In part one of this three-part series, I discussed the use of xrays in an orthopedic sports medicine practice. In this post, I discuss the basics of magnetic resonance imaging, or more simply, an MRI. What is an MRI? When do I need an MRI? What are the pros and cons of getting an MRI for my knee or shoulder injury instead of an xray? It’s all here.

An MRI is a specialized radiology test that has become much more commonly used in recent years. Avid sports fans who see college and professional athletes get injured in sports often read the next day that the injured player will undergo an MRI to determine the extent of the injury. If you didn’t know better, you’d think that an MRI is essential to making the diagnosis when evaluating a sports injury or pain.

What is an MRI?

An MRI is a test most commonly used for joint injuries in orthopaedic surgery. Like I said in part one of this series, xrays only show bones. An MRI demonstrates soft tissues of the joint, such as tendons, ligaments, muscles, menisci, and articular cartilage. It can also show changes within bone, such as bone bruises and swelling within bone, like what you would see with a stress fracture. The test usually takes between 30 and 45 minutes. Depending on the body part being imaged, it might require the patient to lie on a table inside a tube. Patients who are claustrophobic often request an open MRI, which do exist. Many physicians and radiologists question the quality of the images obtained with an open MRI. Often radiologists can administer some sedating medications to help claustrophobic patients. Unlike xrays, which usually cost between $50 and $150, an MRI can often cost between $1500 and $2000.

When is an MRI necessary?

I think an MRI is best used when an orthopaedic surgeon suspects a specific injury. For instance, when an athlete or athletic individual presents to my office complaining of a shoulder injury, I start by obtaining information about the injury, such as where it hurts, how it happened, etc. I then perform a thorough physical examination of the shoulder to see if I can determine the injured structure or source of pain. Often history and physical examination are all that are needed to make a diagnosis. I do routinely order xrays for the reasons I discussed in part 1 of this series. If I am worried about a soft tissue injury, especially one that potentially would require surgical treatment, and if the xrays are negative, then I discuss the possibility of obtaining MRI with the patient. Often, however, I will try a course of conservative treatment first, such as sending the patient to physical therapy, to see if the patient gets better. If the patient improves with conservative measures, such as anti-inflammatory medications, ice, rest, or physical therapy, it is often unlikely that an MRI will show structural damage. If the patient is not improving despite an adequate trial of these measures, at some point it’s reasonable to obtain an MRI.

MRI showing a rotator cuff tear

Why don’t orthopedic surgeons order an MRI on everyone?

There are a couple of answers to this question. First is the cost, which as I said above can approach $1500-$2000. As I will discuss in part 3 of this series, many MRIs are probably unnecessary, so the potential cost of a large number of unnecessary MRIs could be significant.

More importantly, I think that an MRI is a fantastic test if the physician knows what he or she is looking for. If, based on the history of the injury and the physical examination, the physician suspects a meniscal tear, then an MRI is very good for determining if one exists and is potentially the source of symptoms. The problem is that an MRI can also show findings that may or may not be important. By showing all of the soft tissue structures of the knee, then an MRI might show abnormalities of other structures that are not the source of the patient’s pain. Too often I believe, primary care providers and orthopaedic surgeons overuse MRI’s or order them too quickly. (Part 3 of this series discusses a recent study that found that primary care providers obtained a tremendous number of knee MRIs that the researchers felt were unnecessary.) I don’t pretend that I don’t commit this mistake occasionally. I get a large number of athletes in the middle of a season who get injured but want to get back to the sport right away. Often the athlete or the parents, or even the coach, will want an MRI right away so they can know if the athlete can get back to play and not do any further damage. I have even had coaches of professional tennis players at the Family Circle Cup who demanded an MRI while the player is still injured on the court.

The bottom line here is that there isn’t always an absolute indication for an MRI. My recommendation in general for those of you who suffer aches and pains with sports or even an acute injury in the sport is to discuss the issue with a sports medicine physician prior to demanding an MRI. Often you can get back into the game without needing the test in the first place.

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Read all three part of this series.
X-rays vs. MRI’s, Part 1 of 3: Do I really need x-rays?
X-rays vs. MRI’s, Part 3 of 3: Are primary-care providers ordering too many MRI’s?