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Author Topic: Can an accurate diagnosis be made without MRI?  (Read 1650 times)

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Offline kneedeepinpain

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Can an accurate diagnosis be made without MRI?
« on: September 13, 2010, 11:27:36 PM »
Hello.  Iím new here.
 Iím 60 and had a clean-up of a torn lateral meniscus about 4 years ago.  Iíve been doing really well ever since.

  About 5 weeks ago, I woke up and couldnít walk on that leg.  I was really incapacitated for about 10 days. Iím doing better, but still have a lot of pain.  It was very curious that I was fine when I went to bed the night before.

   I got a different doc this time and he only took xrays and said that the osteoarthritis in that knee is really bad.  He said its bone-on-bone, and chose not to do an MRI.  He said that my only options left are Orthovisc injections and a TKR.

  I was determined to heal this myself with ice and physical therapy and positive thinking.  But its not working too well.  At first, I was just having severe muscle spasms around my knee, but now Iím feeling like itís a torn medial meniscus.

   It seems to me that you canít base your entire diagnosis on xrays, and not an MRI.
Iíve heard of people having bone-on-bone and not having much pain.
  What are your thoughts on his basing his decision without an MRI?  In my experience, an MRI tells you much more than xrays.

   Iíve heard heís a really good knee surgeon.  Otherwise, I would be concerned about his judgment.   Iím sure I can talk him into an MRI.  I was hoping to not need one, since they are so expensive.
   What is your opinion about basing his entire diagnosis on just xrays?
   Maybe he thinks my knee is too shot to be even wasting time on an MRI and a meniscus repair.  But Iím thinking I could possibly get another 4 years out of a meniscus repair, instead of assuming I need a knee replacement right now.
Thanks for your input.

Offline arthriticknee

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Re: Can an accurate diagnosis be made without MRI?
« Reply #1 on: September 14, 2010, 08:24:27 AM »
Hi Kneedeepinpain,

MRIs are a part of the range of assessment tools used in diagnosis but the general population probably has a heightened view of their role.
They are good at looking at soft tissue structures like the meniscii, ligaments and tendons. However, the most important part of making a diagnosis is looking at the whole picture.
You have had a (?partial) lateral menisectomy in the past. These tend to have a much poorer prognosis than medial meniscal injuries. Your plain xrays show advanced OA in the lateral compartment. Yes, the correlation between OA on xrays and pain is not as strong as you would think, but the combination of prior surgery, xray findings and a clinical assessment is usually enough in experienced hands to come to a strong diagnosis.
Experienced surgeons quickly screen the knee for ligamentous and meniscal injuries and will order an MRI is more information is needed. If they are fairly sure of the cause of your pain, an MRI is a costly and excessive step. Your history as described is not uncommon - if every case like yours was to have a MRI waiting lists would be very long or we would need a lot more MRI machines.
If you had mechanical symptoms of a further meniscal tear (locking etc) and your surgeon though it likely, again they would probably NOT order an MRI as this would only confirm the diagnosis, he would still need to scope it to trim the flap so most would proceed straight to arthroscopy
To summarise, an MRI is used when there is a margin of uncertainty. Different surgeons will have different confidence levels on their clinical reasoning but as most cases are "very likely to be injury x, and very unlikely to be conditions y & z" an MRI is not needed.


Remember that any advice on an online forum is of a general nature.
You are always advised to be assessed by a medical professional so your individual situation is addressed.

Offline Kaputt_Knee

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Re: Can an accurate diagnosis be made without MRI?
« Reply #2 on: September 14, 2010, 10:39:55 AM »
Push for a good diagnostic MRI and/or limit what the surgeon can do without your consent if they do an exploratory arthroscope. Just because you are 60, it does not have to mean you automatically need a new knee these days!

I had a tear which "moved" and blocked the joint making it impossible to bend or extend the knee. One doctor looked at my age and said arthritis TKR blah, blah........† I pushed for full diagnostics and an exploratory arthroscope with another surgeon and they said there was "little or no arthritis"† and took the photographs to prove it! It happened overnight as well. A small piece of the meniscus had torn off and was trapped in the joint. They cleaned the tear up and washed out the joint, good as new within a couple of weeks.

Some people look at the age of the patient first and base their initial diagnosis on that, rather than hard evidence. Hard to say how to get past prejudices like that to be honest, other than going for more than one opinion if you can. A consensus still does not have to be right though.

Sue  ;)

1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline kneedeepinpain

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Re: Can an accurate diagnosis be made without MRI?
« Reply #3 on: September 14, 2010, 12:15:43 PM »
Thanks Arthriticknee and Sue,

   I am beginning to feel that "senior discrimination" in a number of different situations.
   I'm trying to make sense of the suddenness of this particular problem, and a loose piece of meniscus jammed into my joint seems to be a reasonable assumption.   I am in alot of pain and can't do much, and it seems that if I can buy a few more years without a knee replacement with just a removal of a loose piece of meniscus, then that's what I should do.
   Who knows......maybe in a couple years a TKR will be even more perfected.
  I do like it when a doc has faith in his clinical assessment.  But in this case, I feel that I'm more aware of my knee idiosyncrasies
 than he is at this point.
   If I get an MRI and it shows no tear, then I will accept his diagnosis.

   While I have you both here..........would this debilitating pain have occurred so suddenly, if it were bone-on-bone pain?  It seems like that would have taken awhile to progress and every day would have gotten worse, rather than suddenly over night.

   I know I'm getting a bit obsessive about figuring out what to do, but a TKR is a huge deal.  And yet, so is a meniscus tear surgery if I get no relief from it.
   Another big factor for me is that I have fibromyalgia and my body reacts violently to small things.   Just from this knee problem, I'm getting pain in all my joints (fingers/hands/feet/neck), and pain in all my muscles, so no matter what surgery I end up having, its not going to be easy.

  Also.....the doc was encouraging the orthovisc injections.  Seems like if I have a wedged piece of meniscus that is causing fluid accumulation, the injections could just worsen the pain from having fluid in there by adding more fluid to it.
  Thanks so much for your help!

Offline WestPoint

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Re: Can an accurate diagnosis be made without MRI?
« Reply #4 on: September 14, 2010, 01:13:15 PM »
Hi Kneedeepinpain,

I agree with what Kaputt_Knee has told you. Get a second opinion. Also, why should we knee sufferers submit to TKR when there are other options open to us which could very possibly help us stave off such radical action. Before you even think about TKR, please consider other options such as stem cell treatment. Refer to the Regenexx posts in the injections into the knee section. Savario has just recently posted that he is also almost cured, and he was a TKR candidate too, if I remember properly. Don't fall into despair.

Hope this helps.
« Last Edit: September 14, 2010, 04:27:38 PM by WestPoint »

Offline kneedeepinpain

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Re: Can an accurate diagnosis be made without MRI?
« Reply #5 on: September 14, 2010, 01:32:42 PM »
Thanks Westpoint,

   I had read a little about stem cell treatment.  I will look for that post and read up on it.
Its so difficult to want to trust the "professional", but feel that they might not have the best answer for you.
I've heard great things about this surgeon's abilities, and how all his patients do great after a TKR, but I'm just not ready for that yet.
  It sort of reminds me of that quote": "If you're a hammer, you see everything as a nail".   I think he loves doing knee replacements, and I fear that's clouding his judgment of what's best for me at this point.
  I'm going to push for the MRI and go from there.
  Thanks for your help and encouragement Westpoint!

Offline Kaputt_Knee

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Re: Can an accurate diagnosis be made without MRI?
« Reply #6 on: September 14, 2010, 01:59:26 PM »
Quote
would this debilitating pain have occurred so suddenly, if it were bone-on-bone pain? †It seems like that would have taken awhile to progress and every day would have gotten worse, rather than suddenly over night

That's the way I would read it - sudden onset = something moving into the space and blocking it = pain!

I agree with WestPoint - research all the possible options open before accepting a diagnosis that involves such a radical and irreversible action.

Sue
1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline kneedeepinpain

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Re: Can an accurate diagnosis be made without MRI?
« Reply #7 on: September 15, 2010, 12:10:20 AM »
Thanks Sue,
    I have a call in to the surgeon's physician's assistant.  Hopefully, they'll let me get the MRI without hassle.  I just hope the doc doesn't say that its too much of a waste of time and money to fix the meniscus problem, since he thinks (from the xray) that my knee is very arthritic.
The thing is........I have just as little joint space on my medial side of my other knee, and I don't have any problems with it.   I guess I'm willing to go through with an arthroscopy and take my chances that it is a wedged meniscus problem.
  Sure wish they could just inject some of that expanding plumber's foam into there and it would work just fine.   ;D

Offline arthriticknee

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Re: Can an accurate diagnosis be made without MRI?
« Reply #8 on: September 15, 2010, 04:08:37 AM »
Hi Kneedeepinpain,

Re your question about sudden onset pain, yes it is common for severely arthritic knees to have  a huge pain reaction to trivial events. A minor movement can stir things up so much that people are unable to walk. Other situations that can cause this are loose bodies in the joint (not just meniscal flaps).

An a seperate issue, many people with advanced arthritis have degenerative tears of their meniscus. Older people without arthritis have been found to commonly have degenerative tears in their meniscus and no symptoms at all. An MRI may well show this is the case with you but the relationship with your pain will not be clear from this. Arthroscopies to "wash out" an arthritic knee have been found to be of no benefit at all. Their role in the treatment of arthritis is to treat specific mechanical symptoms e.g. locking of the knee.
In the absence of a symptomatic loose body or locking, a scope is not going to address the pain of osteoarthritis.
Remember that any advice on an online forum is of a general nature.
You are always advised to be assessed by a medical professional so your individual situation is addressed.

Offline kneedeepinpain

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Re: Can an accurate diagnosis be made without MRI?
« Reply #9 on: September 15, 2010, 02:19:23 PM »
Thanks Arthriticknee,
   Since I've had this for about 6 weeks now, I've been able to "define" it better.  For most of that time, I had only severe muscle cramps around the knee.....especially in the lateral calf and up into my lateral hamstring.  I'm not getting those spasms as much now, but something is keeping me from extending my knee, and also I'm getting pain in the medial aspect of my knee.  I am getting occasional locking.  So that has made me think that I have a piece of meniscus wedged in there somewhere.
  I do totally understand that I have a big arthritis problem, with lots of deterioration everywhere.  But I'm thinking if, for now, the problem is a wedged piece of meniscus, then I'd rather have that removed and see how things go for awhile.  The doc suggested Orthovisc injections, and I'm feeling that that would be unwise at this point, considering I haven't had an MRI, to rule out a loose/wedged piece of meniscus.  If the MRI shows no problem in that respect, then I would maybe proceed with the injections.   But I'd hate for the injections to appear not to work, because we didn't deal with that renegade piece of meniscus.  :)
  Thanks for your perspective!