TO THE EDITOR:
Congratulations to Sher et al. on their article "Abnormal Findings on Magnetic Resonance Images of Asymptomatic Shoulders" (77-A: 10—15, Jan. 1995), which revealed a new syndrome: an abnormal anatomy confirmed with magnetic resonance imaging in a clinically normal patient. These are therefore clinically false-positive but anatomically correct magnetic resonance images of the shoulder. The authors' conclusion regarding "the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention" is correct but should be expanded. Not only is there a potential danger in the use of a magnetic resonance image as the basis for determining the need for an operation, but there is also the inherent danger of using a magnetic resonance image that reveals a tear of the rotator cuff or another abnormality to determine a handicap, an impairment, or a disability rating.
I therefore raise the question as to what would be the appropriate handicap determination for an otherwise clinically normal individual who has had slight trauma to the shoulder but who also has a complete tear of a rotator cuff or another abnormality as seen on magnetic resonance images and then alleges a total disability on the basis of the findings on the magnetic resonance images. Also, what about an individual who is involved in a traumatic event, incurs no or a relatively minor injury to the shoulder, and subsequently is seen to have a complete tear of the rotator cuff on magnetic resonance imaging performed for the first time? Would the patient who had normal findings on examination but a complete tear evident on magnetic resonance images after a relatively minor event and who complains of symptoms in the shoulder warrant a determination of disability, handicap, or impairment of the shoulder?
Richard S. Goodman, M.D.: 285 East Main Street, Southwest Suite, Smithtown, New York 11787
Dr. Sher, Dr. Uribe, Dr. Posada, Dr. Murphy, and Dr. Zlatkin reply:
On the basis of imaging studies alone, we cannot currently distinguish which tears of the rotator cuff will be compatible with normal function and an absence of symptoms and which will be associated with a physical impairment. Early data have indicated, however, that normal kinematics of the shoulder are possible in light of a tear of the rotator cuff, as long as sufficient anterior and posterior portions of the cuff remain intact1. The critical amount of preserved tendon or muscle necessary to maintain the normal force couple and function remains undetermined. Our study affirmed that certain tears of the rotator cuff seen on magnetic resonance imaging can be compatible with normal, painless functional activity. Therefore, in light of apparent image abnormalities in patients who have pain in the shoulder, objective physical findings should be sought and matched to the findings on magnetic resonance imaging. We agree with Dr. Goodman's additional conclusion that an abnormality discovered on a magnetic resonance image is not sufficient evidence for a determination of an impairment or disability rating if the clinical findings do not correlate.
Caution is warranted, however, in readily dismissing as malingerers patients who have continued symptoms of pain and apparently normal function of the rotator cuff. Persistent symptoms may not be related to the rotator cuff despite abnormalities on the images that are suggestive of a lesion of the cuff. Frequently overlooked sources of pain in the shoulder include the acromioclavicular joint, the biceps tendon, and the cervical spine. Other potential etiologies worth consideration include angina pectoris, Pancoast syndrome, peptic ulcer disease, diaphragmatic irritation, cholecystitis, and cholelithiasis.
We therefore agree that the findings on magnetic resonance images alone should not be used to determine a handicap or disability rating. Dr. Goodman raises important concerns that encompass not only clinical matters as they relate to disease of the rotator cuff but also social, economic, and moral issues as they pertain to patients who have secondary gain. Despite the clinical situation, the utility of magnetic resonance imaging should be kept in perspective, and this modality should remain as an adjunctive diagnostic aid to confirm or rule out clinical findings.
Jerry S. Sher, M.D.; John W. Uribe, M.D.; Alejandro Posada, M.D.: Division of Sports Medicine, Department of Orthopaedics and Rehabilitation, University of Miami, Doctor's Hospital, 5000 University Drive, Miami, Florida 33146
Brian J. Murphy, M.D.: Department of Diagnostic Radiology, Magnetic Resonance Imaging Center, Doctor's Hospital, 5000 University Drive, Miami, Florida 33146
Michael B. Zlatkin, M.D.: Department of Diagnostic Radiology, Hollywood Memorial Hospital, 3700 Washington Street, Hollywood, Florida 33021