Gina Kolata had a very interesting article in the New York Times today about the evolving perception of the usefulness of the MRI (magnetic resonance imaging) exam as a tool for diagnosing sports injuries. For somebody who is interested in both sports and health care as I am, the article provided some interesting thoughts that challenge the conventional wisdom about injury diagnosis, particularly for pitchers.
Kolata spoke with Dr. James Andrews, perhaps the most famous and successful orthopedic surgeon in the country, and an expert in pitcher injuries and biomechanics. It is common practice to use an MRI when a person is suffering from pain or discomfort in a muscle or joint, and it is also useful at detecting tumors and other abnormalities. The MRI tends to be very good at detecting these abnormalities, but sometimes, it is even too good. As one of the orthopedic surgeons interviewed in the article described, it is a very sensitive tool (good at detecting abnormalities), but not very specific (ie, the false positive rate is very high).
Andrews gave MRI screenings to 31 pitchers who were perfectly healthy, and had no problems with pain, discomfort, or performance in their pitching arm. However, the MRI picked up problems in the rotator cuff and shoulder cartilage of nearly 90 percent of these asymptomatic pitchers. There are two conclusions to draw from this: either 90 percent of the pitchers scanned were on their way to getting an arm injury, or the detection of abnormalities on the MRI was not very well correlated with actual pitcher injuries.
Abnormal MRI’s can often be the first step in leading an athlete to undergo surgery. As Andrews said in the article: “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.” Since surgery can be a very serious decision for athletes (sometimes requiring many months of rehab with uncertain prognoses), it is important to make sure that the abnormality observed on the MRI is actually the cause of the athlete’s problem, and not the regular wear and tear that apparently shows up in the shoulder of most healthy pitchers. Misdiagnosing an injury is a big problem for a player’s health, but getting an unnecessary surgery is also highly problematic.
The implication in this article is that MRI’s are overused in diagnosing sports injuries, and there are a number of potential causes, which tend to be causes for other forms of overtreatment in the medical field. One is the financial incentive, as scanning patients by MRI and performing surgery are both highly lucrative procedures, whereas a physician who tells the patient that they don’t need an MRI or surgery will get nothing.
Secondly, the expectation among the general public (and many athletes) is that finding and treating abnormalities early is always the best decision, and will lead to the best long-term outcome. However, studies have shown that many abnormalities that have been detected early (with increasingly sensitive technology) are never destined to cause problems for the patient. By performing surgery on these patients, physicians are actually creating a net harm for the patient. However, a player and his team would likely insist on an MRI in pretty much any situation “just to be safe”, even if the MRI might in fact cause more harm than benefit. Physicians will likely acquiesce to this patient demand for fear of being sued for malpractice should an injury occur at a later date.
So how does this go back to the Yankees? The article reminded me (and Mike over at River Ave Blues) about the Phil Hughes mystery injury situation at the beginning of the season. Many people were wondering why Hughes wasn’t immediately given an MRI on his shoulder when they noticed a drop in his velocity, even though Hughes said he had no pain or discomfort in his shoulder. As the article demonstrates, it may in fact have been responsible to wait on the MRI (as the Yankees did) to see if some rest and rehab would help Hughes get back to normal. I’m almost certain that an MRI on Hughes’ shoulder would have come up positive for several abnormalities then, but most of those were likely due to the stressful nature of pitching rather than a specific injury.
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More than with Phil Hughes, the Joba situation is more concerning. I remember that he really didn’t display any of the usual symptoms that comes with needing TJS. Yet after getting an MRI they determined that he needed surgery. From this article, it sounds like it very well could have been a false positive.
I’m curious about the case of John Lackey needing TJ surgery. I don’t recall him ever complaining of pain, or demenstrating any sign of needing surgery either. Yet after the season he somehow needs surgery and is out all next year. If he had a MRI this could’ve been a false positive as well.
I’m hoping with Joba the surgery make his arm stronger, as it has been known to do before. Maybe they will let him try starting again if he shows his old arm strength, though I doubt it.
There’s a certain amount of wear and tear that all pitchers have, so detecting asymptomatic abnormalities doesn’t surprise me. Pitchers can pitch with ligament damage to the elbow, where it tends to show up is in their command. Since the elbow isn’t strong, the arm overextends and pitches tend to go wild. As wild as Ogondo was the other night, it won’t surprise me one bit if he gets diagnosed having a bum elbow.
To illustrate this, there’s a manual test that’s given for elbow ligament damage where the patient’s arm is extended, and the Doctor pushes downward on the his hand. In a normal patient, there will be little to no movement of the forearm past a straight position. In someone who needs TJ, the forearm will move past that position. If the ligaments are totally severed, the forearm can be extended past the straight position another 45 degrees or more.
BTW-I believe Dr Jobe was the one who did the surgery on Tommy John, so he’s the one who revolutionized the procedure, not Andrews.
Whoops, you’re absolutely right. Fixed.