Editor’s Spotlight/Take 5: Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes

Aging stinks.

But the sad truth is that aging is unavoidable. When it comes to the musculoskeletal world, we know that the advent of maturity is accompanied by loss of muscle and bone, with attendant changes in joints and tendons. Muscle mass decreases approximately 3% to 8% per decade after the age of 30, and this rate of decline is even higher after the age of 60 [10]. The blood flow to tendons gets worse with age, stem cells drop away, and the result is an ever-increasing prevalence of tendinopathy [14, 17, 19, 20].

The consequence? We are left with anatomic structures that are less resilient and more injury-prone. Tom Brady notwithstanding, there is a reason why the average NFL player is only 26-years-old [6].

But when should age-related changes be considered normal, and when should they be considered pathologic? This is no mere philosophical question—its answer can be the difference between a recommendation for surgery and one for nonsurgical care. Getting it right is not always easy, and treatment decisions involving older workers are complicated and expensive. Prematurely returning an injured worker to duty can result in permanent impairment, while removing healthy individuals from the workforce has personal, financial, and societal implications. It is no coincidence that those regions of the United States with the bleakest economic outlooks, such as Appalachia, have the highest proportion of working age adults on disability [8].

In this month’s Clinical Orthopaedics and Related Research ^®, coauthor David Ring MD, PhD and his team from the University of Texas at Austin (in collaboration with a colleague from the OccMD Group in Dallas, TX, USA) analyze a unique data set arising from a Texas firm handling workers compensation claims [13]. In brief, companies in Texas can choose not to subscribe to state-run workers compensation, instead purchasing commercial insurance for their employees. In this setting, the commercial insurer handles job-related injury claims as well as other forms of care. Because it was hard to differentiate work-related pathology from normal aging, the firm in question started the routine use of bilateral MRI for all claims related to the shoulder or knee. This resulted in a consecutive set of patients from all over Texas with a work-related claim for the shoulder and knee.

What does this mean for the orthopaedic practitioner? For those who spend a lot of time in occupational medicine, this study provides a useful guide on day-to-day management of patients with work injuries. But even for those who rarely deal with job-related injuries, or who don’t address knee or shoulder problems, the study by Dr. Ring and his team show strong evidence that much of what we regard as disease, and what we call pathology on imaging, is actually normal, albeit aging, tissue. And while the quest for eternal youth and vigor has been a constant since Herodotus in the 5th century BCE, we should avoid the temptation to treat aging as something to “fix,” simply because we have pictures on an MRI.

In our Take-5 interview, Dr. Ring discusses the issues facing individual patients who suffer new onset of knee or shoulder pain on the job, and what this might mean for the larger community.

Take Five Interview with David Ring MD, PhD, coauthor of “Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes”

Paul Manner MD: What should we tell the patient who has new onset of shoulder or knee pain which began on the job? Aside from the issues of causation, what should the patient expect in terms of prognosis for return to function? Does the information that his or her pain is the result of aging rather than a specific make it any easier?

David Ring MD, PhD: The heuristics, or mental shortcuts, that humans use to interpret symptoms and circumstances can increase symptom intensity and magnitude of limitations. In other words, both the physician’s and the patient’s mindset matters. There is mounting evidence that less-effective coping strategies such as catastrophic thinking (preparing for the worst) magnify musculoskeletal illness [7, 15, 18]. And effective coping strategies, such as self-efficacy (the sense that one can achieve one’s goals in spite of adversity), ameliorate illness [5, 16].

Humans are remarkably adaptive to age-related musculoskeletal changes [2, 3]. When age-related problems start to cause symptoms, it’s reassuring and empowering to know that the changes are healthy and appropriate, and that these problems are highly responsive to resiliency. Contrast that with feeling injured, damaged, and vulnerable, which puts the patient into a more-passive role, waiting for and reliant on a “fix” from some powerful other. While it’s not easy to train our reflective/analytical approaches to thinking so as to moderate our automatic thoughts, there is growing evidence that it is an effective health strategy [9].

The key for clinicians is to understand how difficult it may be for a person to evolve his or her explanatory model. Our role is to convey compassion and genuine interest, and to gain a patient’s trust. Once a relationship is established, we can provide expertise in an understandable, concise way and empathize with how counterintuitive expert advice can sometimes seem to a patient [4, 12]. Finally, we can develop strategies that use time, reflection, and support in place of low-value tests and treatments.

Dr. Manner: What should we tell the employer? The employer, presumably, wants the worker to return as soon as possible. What should our role be as physicians?

Dr. Ring: Physicians are society’s experts on health. Our duty is to provide accurate, balanced, dispassionate, scientific information. For the knee and the shoulder, when we see expected, age-related MRI signal changes in the meniscus or rotator cuff tendons, we should not refer to these as “tears”. That misleadingly implies injury and damage. We should be accurate and describe these as normal age-related changes—the expected arthropathy and tendinopathy of normal human development. It is a fact that pathology often goes unnoticed for years and then suddenly comes to our attention, often after a specific event. That doesn’t qualify as an injury. When symptoms increase, there may be small changes in pathophysiology, but for the most part, the pathology is not new. Rather, it is often the person’s relationship to the pathology that has changed.

The key to maintaining both integrity and compassion is to separate the disease (pathophysiology) from the illness (symptoms and limitations). For instance, one could report, “There are newly symptomatic age-related changes in the shoulder that will not deteriorate with work” along with “The patient doesn’t feel capable of returning to work”. This approach avoids reinforcing catastrophic thinking while gently bringing the psychological factors to light.

There is no reason to limit activity for arthritis or tendinopathy (or age-related meniscal and rotator cuff changes), unless there are safety implications. For example, a roofer with advanced hip or knee arthritis shouldn’t climb ladders or walk on slippery, high surfaces because they might be at greater risk for severe injury from a fall. But depending on circumstances, that same worker could do a safe but painful labor job, as many people choose to do every day. Stated otherwise, some patients who have less-effective coping strategies may need some compassionate coaching. What they probably do not need is an anatomic adjustment—like surgery—for incidental findings or age-related changes on MRI examinations. In fact, if we use the wrong language to describe those findings, we may cause the patient more distress. This may potentiate an already upsetting situation, perhaps making a worker more anxious about trying to return to duty because he “has a tear in his rotator cuff”, when people safely and appropriately do that type of work every day with similar symptoms from similar age-related changes in the tendons. I believe the language we choose to use when describing age-related anatomic changes can either support a patient’s self-efficacy, or reinforce a patient’s misconception that he or she “cannot work.”

The next step is for clinicians and insurers to understand the importance of taking a comprehensive approach to musculoskeletal illness: Treating the person, not just the body.

Dr. Manner: There is a lot of pressure to obtain advanced imaging as soon as possible, to “figure out what’s going on.” Clearly, this imaging is sometimes unhelpful, and frankly, can be counterproductive. How do we resist the temptation?

Dr. Ring: Clinicians need to be well-versed in the tools we use to hone probabilities in differential diagnosis and the strong negative influence of low-prevalence scenarios on diagnostic tests. Put simply, unless there is a clear question and a high pre-test probability for a given finding, testing is counterproductive. Surgeons in particular can use symptoms, signs, and circumstances to develop useful probabilities that are unlikely to be improved much by diagnostic tests. For example, a person older than 40 years of age with anterolateral shoulder pain, worse with internal rotation and overhead flexion, and with normal passive motion is highly likely to have rotator cuff tendinopathy. In the absence of a lag or weakness of external or internal rotation, any tendon defects are likely to be small and restricted to the supraspinatus and education and treatments to provide palliation while enhancing self-care and resiliency are appropriate. It’s only when we think there is a more-substantial defect that surgery is considered and an MRI can tell us whether surgery might help (such as if there is limited retraction and fatty replacement of the muscle). If one thinks this through, shoulder pain is extremely common and appropriate indications for a shoulder MRI are quite uncommon.

From the patient’s side, screening is difficult to understand. Why not take a look? This is most energetically discussed in the setting of cancer screening. In a low-prevalence environment, screening leads more people to live under the anxiety of having a potentially deadly disease. They are also more likely to have potentially harmful tests and treatments of limited value for false positives, low-grade cancers that are best left undiscovered, and cancers in older people that will not grow fast enough to be the cause of death. An example of this is the epidemic of thyroidectomy for low-grade thyroid cancer in South Korea that is an artifact of unwise screening practices [1].

When it comes to your shoulder or knee, it can often be more difficult to feel as healthy and forego intervention when one knows that there are changes in the joint, particularly when the radiologist and surgeon describe those changes as “tears”. We may be able to reduce symptoms and limitations more by using crafted techniques for getting people comfortable with the aging process.

Dr. Manner: From a social viewpoint, one of the striking things in the last decade has been the extraordinary rise in the number of workers who receive disability benefits. In some “rust belt” counties, up to 20% of workers are on disability [8]. How might your findings affect that?

Dr. Ring: Our findings add to a large body of evidence that suggests we may be mislabeling a change in symptoms as an injury. I think we can help people to get and stay healthy if we separate illness from disease; treat the psychosocial aspects along with the biomedical; use accurate, hopeful, enabling words and concepts; and plan potential age-based work transitions for people that rely on their body for their livelihood and make sure they have other skills and other options.

Dr. Manner: In 1960, back pain and musculoskeletal problems accounted for 8% of disability claims [11]. Since then, work has become less physically demanding, and American workers are healthier. Yet musculoskeletal problems now account for more than one-third of claims [11]. Is this because there are no objective measures for these problems, or something else at play here?

Dr. Ring: Musculoskeletal problems are a common somatic focus for distress. One interesting development is that my occupational-health colleagues tell me that there is evidence that claims for back pain seem to be decreasing. While it’s difficult to be sure why that is, one potential explanation is all the attention placed on helping people have comfortable backs. This may take the form of training, lifting devices, and other measures. I’m optimistic that a similar focus on the importance of alleviating stress and distress and fostering the most-effective coping strategies will lead to improvements in health.