Never Have Knee Surgery Based on an MRI Diagnosis
Robert Filice, M.D.

Recently I saw an athlete who had been on a world championship national volleyball team years ago, and remains active in the sport. He complained about an unstable left knee since a minor mishap several months ago while playing basketball, and he also had a history of arthroscopic surgery on that same knee.

The radiologist’s report stated that the new MRI showed a “tear” of the lateral meniscus of the left knee, and one of the orthopedists he consulted immediately said that arthroscopic surgery was indicated again.

It is the opinion of the second orthopedist he consulted that prompted me to write this article. That opinion was this: a “tear” in a meniscus should be diagnosed on clinical grounds, in other words based on the history and physical exam, not on the MRI findings.

It is not often that orthodox physicians openly admit the limitations of its impressive array of high technology diagnostic tools, so I took notice when I heard this story. Prolotherapists, of course, have been warning people for years that MRI’s are often misleading, and that false negatives and false positives abound.  It turned out that this orthopedist had written a study on this very topic, and I summarize this very significant piece of work for my readers below.

Gary Guten, MD and his orthopedic group in Milwaukee had been observing an increasing number of patients with “positive MRI for torn meniscus (the cartilaginous disk between the two bones comprising the knee joint)” being referred for surgery. However, they have found many of these patients do not have the clinical signs and symptoms that support that diagnosis. They looked for knee MRI’s in the medical literature that had been performed on volunteers without ANY knee symptoms. They found 15 articles which they subsequently reviewed. Some of the highlights and the names of the lead researchers are as follows:

1989 Brunner’s results: of twenty athletes with NO knee symptoms, 50% has significant MRI abnormalities.

1990 Kornick’s results: meniscal abnormailities begin to show up in the twenties, and become more common with age. The “posterior horn of the medial meniscus” was an area especially prone to what the radiologists call “signal abnormalities”.. ie, suspicious for some type of problem.

1992 Bronstein’s results: 15 patients free of symptoms were studied 6-12 months after meniscus repair procedures. They found that MRI was unable to distinguish between scar tissue of healed meniscus repair and actual meniscal tears. MRI thus is NOT a useful tool to evaluate reinjury following meniscal repair surgeries.

1992 Boeden’s results: In patients without symptoms, MRI reports of meniscal tears increased from 13% in younger individuals to 36% in those older than 45.

1993 and 1994  Jerosch’s results: MRI shows meniscus lesions in a significant proportion of asymptomatic (no symptoms) patients, especially in those over 50, and athletic activities stress the lateral portion of the front of the knee joint and that athletics correlate with the incidence of meniscal degeneration of the forward disks (anterior horns), and the posterior (back portion) of the lateral disks (posterior horns).

Here are the conclusions that Dr. Guten drew:
1. Young athletes in their twenties have as high as a 50% incidence of positive MRI’s for meniscal tears, yet are asymptomatic.

2. Staring in the thirties, there is an age-dependent degeneration of the meniscus yet the patients generally have no symptoms. Runners often show this pattern.

3. Abnormal MRI of meniscus is common in the 40’s and 50’s especially with old trauma, obesity, and misalignments of the knee joint.

4. He prefers that radiologists change the language of their MRI reports and eliminate reference to “tears” (which is a clinical matter) and substitute a rating of the “signal intensity” (which is the proper radiologic description).

5. Surgical results on degenerative tears are very disappointing compared to results on traumatic tears.

6. MRI imaging is overused in the evaluation of knee disorders, and is not a cost effective way of evaluating knee injuries compared with a skilled examiner.

7. MRI’s present a potential danger when used as the sole basis for determining surgical intervention.

Here’s how I would summarize the situation for you:

1. Never have surgery based on an MRI finding alone. This goes for back, knee, elbow, and every other joint!
2. MRI’s are not infallible. Many people and their physicians think they are, and act accordingly to the patient’s own detriment.
3. MRI should never be used as a substitute for a complete history and physical exam.

4. MRI’s are not a cost effective examination in the evaluation of many knee injuries.

5. Always see a prolotherpist for a second opinion before ever considering surgery.

6. Prolotherapists rely on their clinical skills, and not on imaging results, to guide their recommended treatment.

7. Prolotherapy effectively resolves mensical and most other common knee lesions without surgical intervention.