Ignorance Might Be Bliss When It Comes To Medical Scans
The increased availability and quality of medical scans is an important and potentially lifesaving advancement in modern medicine, but do we know too much? It is now a common occurrence for a patient to be scanned to rule out a broken bone after a fall, and instead get diagnosed with an assortment of other conditions which that have no symptoms of. With this new-found knowledge the brain becomes more alert and the patient begins to feel pain, and withdraw from activity. Six months later they are having surgery for a problem they never knew they had.
We have started to discover that many bone, joint, tendon and other soft tissue conditions that are seen on scans, are pain free and appear to be a common part of the aging process. The phrase ignorance is bliss, comes to mind here.
Many studies are now being performed comparing the scan findings of a group of people with symptoms of a condition and those with no symptoms, and the results are truly shocking.
Studies have found that in hip scans of older adults with no pain, 69-83% have labral tears, 24% have chondral defects, 11% have rim fractures and 16-23% have bone cysts 1, 2. In scans of older individuals with no knee pain, 5.6-36% had meniscal tears and 34% had signs of osteoarthritis 3, 4, 5, 6, 7.
In no area is this more revealing than in the aging shoulder. In studies of shoulder scans in pain free older individuals, 75% had acromioclavicular osteoarthritis, 33% had subacromial spurs and 23-54% had either tendinopathy, partial tears or full thickness tears of the rotator cuff tendons 8, 9, 10, 11. One particular study by Tempelhof Rupp and Seil in 1999 showed that the percentage of rotator cuff tendon tears increased with age in an almost linear way. In 50-59 year old’s, 23% had tears, in 60-69 years old’s 20% had tears, in 70-79 year old’s 31% had tears and in those over 80 years old 51% had pain free tears.
What do we take away from all this? Medical scans are objective and sensitive. They tell us about every tiny detail of our bones, joints and tendons. No all of this information is relevant, and the finding of a medical problem does not mean we should or will have pain. Most of the time these image findings are incidental and may be part of normal age-related changes.
1. Register, B., Pennock, A., Ho, C., Strickland, C., Lawand, A. & Philippon, M. (2012). Prevalence of Abnormal Hip Findings in Asymptomatic Participants: A Prospective, Blinded Study. The American Journal of Sports Medicine, 40(12), 2720-2724. doi.org/10.1177/0363546512462124
2. Schmitz, M., Campbell, S., Fajardo, R. & Kadrmas, W. (2012). Identification of Acetabular Labral Pathological Changes in Asymptomatic Volunteers Using Optimized, Noncontrast 1.5-T Magnetic Resonance Imaging. The American Journal of Sports Medicine, 40(6), 1337-1341. doi.org/10.1177/0363546512439991
3. Beattie, K. A., Boulos, P., Pui, M., O'Neill, J., Inglis, D., Webber, C. E., & Adachi, J. D. (2005). Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis and cartilage, 13(3), 181-186.
4. Boden, S. D., Davis, D. O., Dina, T. S., Stoller, D. W., Brown, S. D., Vailas, J. C., & Labropoulos, P. A. (1992). A prospective and blinded investigation of magnetic resonance imaging of the knee: abnormal findings in asymptomatic subjects. Clinical orthopaedics and related research, 282, 177-185.
5. Fukuta, S., Masaki, K., & Korai, F. (2002). Prevalence of abnormal findings in magnetic resonance images of asymptomatic knees. Journal of orthopaedic science, 7(3), 287-291.
6. LaPrade, R. F., Burnett, Q. M., Veenstra, M. A., & Hodgman, C. G. (1994). The prevalence of abnormal magnetic resonance imaging findings in asymptomatic knees: with correlation of magnetic resonance imaging to arthroscopic findings in symptomatic knees. The American journal of sports medicine, 22(6), 739-745.
7. Zanetti, M., Pfirrmann, C. W., Schmid, M. R., Romero, J., Seifert, B., & Hodler, J. (2003). Patients with suspected meniscal tears: prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral asymptomatic knees. American Journal of Roentgenology, 181(3), 635-641.
8. Needell, S. D., Zlatkin, M. B., Sher, J. S., Murphy, B. J., & Uribe, J. W. (1996). MR imaging of the rotator cuff: peritendinous and bone abnormalities in an asymptomatic population. AJR. American journal of roentgenology, 166(4), 863-867.
9. Miniaci, A., Dowdy, P. A., Willits, K. R., & Vellet, A. D. (1995). Magnetic resonance imaging evaluation of the rotator cuff tendons in the asymptomatic shoulder. The American journal of sports medicine, 23(2), 142-145.
10. Tempelhof, S., Rupp, S., & Seil, R. (1999). Age-related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery, 8(4), 296-299.
11. Sher, J. S., Uribe, J. W., Posada, A., Murphy, B. J., & Zlatkin, M. B. (1995). Abnormal findings on magnetic resonance images of asymptomatic shoulders. JBJS, 77(1), 10-15.