Choosing Wisely: MRI Recommendation
Amy P. Powell, MD

Choosing WiselyTM is an initiative of the American Board of Internal Medicine and supported by multiple medical societies, including the American Medical Society for Sports Medicine. Each Society was asked to contribute five diagnostic tests or treatments that both physicians and patients should question. The highlight this quarter is the AMSSM’s “number four” recommendation: Avoid ordering a knee MRI for a patient with anterior knee pain without mechanical symptoms or effusion unless the patient has not improved following completion of an appropriate functional rehabilitation program. The most common cause of anterior knee pain is patellofemoral painsyndrome. Patellofemoral syndrome (PFS) is the most common cause of knee pain seen by sports medicine physicians and orthopedic surgeons. Classic symptoms include pain around or

under the kneecap (patella), which may become worse with certain activities like running, hiking (particularly down hill), strength training activities like squats and lunges, and daily activities such as kneeling and squatting. It is usually caused by imbalances in strength and flexibility of the muscles that support the motion of the kneecap.

The diagnosis of PFS is almost always made without specific imaging studies, either x-ray or magnetic resonance imaging (MRI). A sports medicine physician will ask the athlete questions about his or her symptoms, the location of pain, what makes the pain better or worse and then perform a careful physical examination of the knee to exclude other potential causes of knee pain. If the history and physical examination support the diagnosis of PFS, x-rays and/or MRI are not necessary. MRI is rarely helpful in managing this syndrome. Treatment should focus on a guided exercise program to correct lumbopelvic and lower limb strength and flexibility imbalances. Knee taping or bracing may also be helpful. If pain persists, if there is recurrent swelling or if mechanical symptoms such as locking and painful clicking are present and radiographs are non-diagnostic, an MRI may be useful.

Visit Patellofemoral Syndrome | Sports Medicine Today for more information about symptoms, prevention, and management of this common condition. Visit Choosing Wisely for more information about this campaign.