Putting the Shoulder Surgery Fox in Charge of the Henhouse

By Chris Centeno, MD /

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Shoulder surgery mri

It’s always interesting to read the medical research studies that come by my daily feed. Some are groundbreaking, most are so-so, and a few are downright silly. This morning we’ll look at a silly study about shoulder imaging that seems to have started with a conclusion and worked backward.

My Shoulder Hurts, so I Need an MRI

MRIs are a two-edged sword. On the one hand, they have revolutionized what we can see inside the body. On the other hand, they have likely launched millions of unnecessary surgeries. One of the more startling research studies of the last few years that threw our understanding of what’s important on its head involved rotator cuff tears. For example, instead of showing a direct correlation between patients who had their tears operated on, an improvement on the MRIs, and reports of better function, it demonstrated no correlations  All that was important was the level of an inflammatory chemical inside the shoulder joint.

The Bizarrely Dumb Study

The research was conducted at an urban teaching hospital on all shoulder MRIs ordered. The authors then created an ordered list of the percentage of patients who then went on to get surgery by the department that ordered the study. Since the percentage of patients who got shoulder surgery was highest when an orthopedic surgeon ordered the study, the authors concluded, “Detailed analysis suggests that providers who do not have specific training in shoulder pathology should consider consultation with an orthopedic surgeon before ordering shoulder MRI for patients who may need additional imaging after radiography.” Huh?

Argumentum ex silentio

While the conclusion of the above study likely has a few logical fallacies that apply (circulus in demonstrando and petitio principii to name a pair), an argument from silence (argumentum ex silentio) where the conclusion is based on the absence of evidence rather than the existence of evidence is one. Basically, the authors assume that orthopedic surgeons are infallible in their judgment to operate on a shoulder based on MRI findings. Which, you know if you read this blog, is a nutty assumption. What’s thrown out the window is the opposite possibility that surgeons want to operate; hence, they would have a higher number of surgeries resulting from fewer images than say family doctors. In fact, in this study, the family doctors did have a lower number patients going to surgery, which of course could mean that the patients who never had surgery never needed it in the first place.

For example, if we look at the research above on rotator cuff healing, we’re not even sure that a rotator cuff tear seen on MRI that would lead to a surgery is even all that important for why the patient hurts or recovers. As another example, in this recent study, more than half of asymptomatic men had shoulder labral tears, suggesting that some of these MRI findings leading to surgery do little to explain why a patient hurts.

The upshot? Never put the fox in charge of the henhouse is a truism from my mother’s time growing up in rural Pennsylvania. One that the authors of this study clearly forgot that along with a number of logical fallacies!

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8 thoughts on “Putting the Shoulder Surgery Fox in Charge of the Henhouse

  1. Joan Fugazzi

    My sister’s should is broken in several places. She lives in Pittsburgh. PA.

    Is it possible for her to have stem cells?

    1. Regenexx Team Post author

      Joan,
      It’s possible, and would depend on many different factors. If she submits the Candidate form, we can review her images, medical history and speak to her about her case to see if she’d be a good Candidate for a Regenexx Procedure. Here’s our Pittsburgh, PA Regenexx Provider:http://www.rapsmd.com/

  2. bart tucker

    re: Labral Tears
    I’ve been told that this is somewhat like meniscus and probably won’t ‘re-grow’. I’ve had problems in my right shoulder for years, esp reaching behind me for belt insert or wallet. No problem lifting above my head or moving arm in circles. Also, no pain with pressure applied deeply. Sorry, no MRI just yet.
    Can you please comment and provide studies on Stem Cell for this area? Your L.A. or Oceanside treatment centers have credentials here as well?
    Gracias!

    1. Regenexx Team Post author

      Bart,
      The most important thing is to have the type of exam that will pinpoint your torn shoulder labrum as the actual problem, or not, as labral tears like meniscus tear findings on MRI can often be incidental. Like meniscus surgery, Shoulder labral tear surgery tends to make the joint less, rather than more stable: Please see: https://regenexx.com/blog/shoulder-mri-results/ https://regenexx.com/blog/shoulder-labral-tear-surgery-pros-cons/ and https://regenexx.com/blog/watch-advanced-image-guided-injection-shoulder-step-procedure-suite-dr-schultz/ and https://regenexx.com/blog/shoulder-labrum-surgery-alternative/ and https://regenexx.com/

  3. bart

    thanks, read them all, and then some with all the links …
    this issue has been both better & worse over the years and PT was of no avail.
    bart

    1. Regenexx Team Post author

      bart,
      You’re welcome. Your shoulder likely needs treatment. To see if your shoulder would be a good Candidate for treatment, please submit the Candidte form: https://regenexx.com/the-regenexx-procedures/shoulder-surgery-alternative/

  4. M

    Just went through 3 months ago Fai surgery. I hurt more now than I did before surgery. Physician-patient blame saying maybe you’re one of those people that surgery doesn’t agree with you. I explained to him, I’ve had multiple surgeries and came out feeling fine. Now I’m supposed to have bone spurs removed from shoulder. When I asked to see them on the MRI with it being on the big screen were they were located then he turned around and said maybe you don’t want to have surgery because you may come out worse than you were before or since you have not recovered from hip surgery. What! Sounds like patient blaming. As a test for accuracy to see if this surgery would work I was given marcaine in the shoulder. How is numbing my shoulder a accurate test? And if the MRI report didn’t say I have bone spurs then why does he say I have bone spurs? At this point I am afraid because both Physicians so far have been doing patient blaming like you have fibro ,arthritis or you’re just one of those patients that don’t do well after surgery. So I feel like I’m getting the shutdown. I’m thrown again back to physical therapy.

    1. Regenexx Team

      Hi M,
      Did they say where the bone spurs were? Please see: https://regenexx.com/blog/shoulder-decompression-surgery-no-better-than-fake-surgery/ and https://regenexx.com/conditions-treated/shoulder/ If you’d like us to weigh in on your case, we’d need more information. To do that, please use the “Are You a Regenexx Candidate” button at the last link.

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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