Every sports physical therapist remembers the first time they handed a young, anxious athlete an MRI report filled with terms like “partial-thickness tear,” “labral fraying,” or “degenerative changes.” It is a defining moment in a clinician’s career. Instantly, the psychological landscape of the rehab process shifts. The athlete, who might only have mild, intermittent symptoms, suddenly views their joint as a ticking time bomb. As a clinician, it is incredibly easy to let that piece of paper dictate your entire treatment plan, leading to over-protection and a fear-avoidant rehab environment.
The reality of dealing with overhead athletes—especially baseball pitchers—is that structural abnormalities on an image are often just the cost of doing business. If you scan enough high-level shoulders, you are going to find fraying and partial tears in completely asymptomatic arms. The real skill lies in balancing those structural findings with the actual human being sitting on your treatment table. How do you maintain clinical objectivity when the scan says one thing but your manual muscle testing and special tests say another?
On this episode of the podcast, we answer a great question from a listener struggling to navigate this exact scenario with a collegiate pitcher. We discuss how to educate a freaked-out athlete, when to respect the structural pathology, and how to ensure you are treating the functional deficits rather than just chasing a clean image. Check out this week’s episode for our full breakdown and clinical pearls on mastering the physical exam.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 391: Stop Treating the MRI and Start Treating the Athlete
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Show Notes
• Champion Performance Specialist Course
• Champion Baseball Rehabilitation Specialist Course
Transcript
Emma Armstrong:
Today’s question’s from Ken from Florida says, “Hey guys, love the show. I’m working with a college baseball player who has mild but limiting shoulder pain. He can pitch, but doesn’t feel 100% like himself, but his MRI came back showing a partial rotator cuff tear and some labral fray. He actually tests out with deficits and strength, but nothing alarming, and he has mild pain in all the special tests, and he’s completely freaked out by the scan results. As a young clinician, how do you prevent yourself from falling into the trap of treating the scary MRI report instead of the athlete sitting in front of you?”
Mike Reinold:
Awesome. Thank you, Emma. And Carly, you just want to say hi? You got to get your voice on an episode.
Carly Luca:
Hi everyone.
Mike Reinold:
Good job. Perfect. Awesome. Okay. All right. So Emma, great question. Or I should say Ken, great question. Emma, great job reading it. But Ken, great question.
Gosh, I think we all deal with this all the time. And man, is this not one of the more fun topics that we see on social media? I love the emotional, sometimes irrational responses from people, in either direction here, of like, oh, it would be a travesty if you just treat the MRI, or there’s so many asymptomatic findings. Ignore the MRI. I think this is going to be a really great discussion on what we do here.
So… Baseball player, even though I think this applies to everybody. I’m pretty sure Dave can jump in here on what his gymnasts’ backs look like, or stuff like that, or some of our athletes with hip problems and stuff like that.
But what do you guys do here when, in the exam, you have some findings, but you’re certainly not blown away like, “Uh-oh, this kid needs surgery,” but the MRI has some very, let’s call it “inflaming” terminology. How about that? That maybe freaks him out a little bit.
What do you guys do? Who wants to jump in? I want to hear from Mike Scaduto on this one. Because I feel like Mike sees this a lot in his practice between golfers and baseball. I mean, there’s probably nobody that Mike sees that doesn’t have an ugly MRI. Most of our people have ugly MRIs. So I’d love to hear your thoughts, Mike. What do you got?
Mike Scaduto:
Yeah, that’s definitely true. I think, specific to baseball, if we get an MRI of their throwing shoulder, we’re probably going to see something. I think some fraying of the labrum or a slight rotator cuff tear, however that was described in the question, doesn’t necessarily raise red flags for me. They’re probably yellow flags.
So, first thing that we’re trying to do is we’re always trying to correlate their clinical symptoms to their MRI findings the best that we can, knowing that a lot of the tests that we do are not as specific or sensitive as we’d like. But if there’s anything that really does pop up in their clinical exam, we want to address that. We want to speak to them about that and not sweep it under the rug.
I think that if the patient is freaked out, I think we can be reassuring. We can maybe offer some advice based on our clinical experience, like, “Oh, we’ve dealt with people like this before, and this is the outcome that they were able to achieve.”
I think the thing that we really want to avoid in these people is an unnecessary surgery to their throwing shoulder. That can be very detrimental for the long-term health as a throwing athlete. We know that any surgery, whether it’s a large labral repair, or something else where it’s just a shoulder scope, that can have long-term outcomes that are not super favorable for a thrower.
So I always try to mention that like, “Hey, we’re going to do everything that we can to try to avoid a surgery,” whatever that means for that person.
Then from there, I mean if we feel like we’ve addressed the MRI findings, we feel like we’ve got some rapport with that patient, we start talking about what could possibly be contributing to how you’re feeling when you’re throwing a baseball, that’s not necessarily structural damage. So, what are the suboptimal things?
I think the question said that they test out with good strength. I think we would need to be a little more specific. Is it good? Is it excellent strength? Is it within our goal ranges? And I think at Champion, we do a really good job breaking that down for the patient and saying, “These are expectations from you, from a strength perspective, and here’s why, and here’s why we think this is going to help you.” Also looking at range of motion.
So I think going back to those basic things that could be a little bit suboptimal. One, I think we start finding things that help the patient gain confidence because they’re like, “We can address these things. It’s not that difficult.” It’s going to take some work. But if we achieve those goals, I’m fairly confident that we’ll be able to throw with less symptoms or feel significantly better when you throw.
And then, I think it comes down to a whole conversation on workload management and all those things specifically related to their sport.
But that’s typically the strategy that I’m using, especially with a baseball player, where if we… Not allow, but if they end up going down this path towards surgery, that can have significant detriments to their career.
Mike Reinold:
I like that, Mike. I like how you hit that from multiple angles too here, because I do feel like one of our main goals that we need to do here is to pump the brakes a little bit, maybe with their anxiety. And you mentioned that. I think it goes a long way to just, “We do this all the time.” You say, “Look around the room here. If we MRI’d everybody here that’s being treated or all the jerseys on the wall, they probably have very similar MRIs.”
And I think, right there, it’s almost like the air comes out of the balloon a little bit and they start to feel a little bit better. But the other thing you said, Mike, that I thought was really good too, is that it’s not just about the structural changes, it’s about what you find on exam. And there’s always things that we find.
And just commenting, real quick, before others jump in here on Mike’s comment on strength. I cannot tell you how many times, I don’t know the answer to this, people listening, but please listen. I cannot tell you how many times people come to us that have really good strength or they test it out maybe with these apps with these really cheap dynamometer devices, or maybe these other new devices that… We’ll leave it at that. But there’s other devices out there that people come in and they’re like, “No, I’m really strong. My trainers say I’m great,” that sort of thing. And then we test them, and they’re not strong.
That happens almost daily with us. So, something to keep in mind here. To Mike’s point, okay, you’re not that weak, but are you strong enough? Maybe is the right question. So awesome stuff. Anthony, what do you… What’ve you got?
Anthony Videtto:
Yeah, I thought Mike hit the nail on the head there, but just going back to the question, it seems like this pitcher is throwing, but is still experiencing pain on the table. And I think a rule of thumb for us is, you got to experience zero pain on the table before we want you to pick up a baseball.
And so, I think if we can elicit that to them and explain, like, “Hey, maybe these are some things that we can work on in the meantime to get you out of pain first. We’re going to be a lot more confident when you’re getting back and throwing a baseball. And we can address range of motion and strength deficits, and make sure you look 100% ready to take on the stress of throwing that is something that we can’t avoid.” And then when we start that throwing program, maybe we’re starting at 45 or 60 feet instead of going right back to the mounds where they didn’t feel great before.
So then, we’re building some confidence at, let’s say, the 60-foot mark, and then we’re going to go out to 90 feet, and we’ll feel good there, and then 120, so it’s just building rapport from day one and then slowly engaging them in a process that builds confidence throughout the whole time that you’re with them.
I think you can get them back to a point where they’re seeing that, just because they have this really scary MRI doesn’t necessarily mean that all things are bad in the world.
So, of course, not everyone’s going to take that route and feel amazing when they get back, and maybe those cases may need a surgery at some point, but I think if you can outline that rehab timeline for them, they might take a little bit more rapport with you, and I think outcomes will become better that way too.
Mike Reinold:
Yeah. Well said, Anthony.
Dave, I know you want to jump in. I also want to hear your perspective on maybe a back. Maybe it’s the same thing in an MRI on a back or however you want to approach this, but I think you have the same experience. What do you got?
Dave Tilley:
Yeah, I was talking to the students yesterday a lot about, randomly, back pain in the clinic and assessments and evals. And I mean, I’ve probably treated in the last whatever decade, a thousand people for back pain. I treat a lot of baseball players, hockey, gymnastics. I treat a lot of gymnasts, of course, but I think spondies and disc issues tend to come to me from a sports point of view, because people maybe have similar problems.
And I can think maybe if you put it in the youth population, I’ve had 10 kids get surgery from a thousand. Adults are a little bit different if they have long-term issues. But in the sporting population, I can think of a couple of fusions, a couple laminectomies, for really acute sciatica. A pitcher we worked with last year was throwing, felt a pop on the mound, leg went numb, head foot drop. And the leg was like, yeah, this is an easy thing to think about.
But other than that, I’ve had a lot of people who have, on paper, MRIs that look like a bomb went off in their back, and they have no surgery. They have a great clinical outcome. They do really well. They get back to sports. And I was talking to the students about how, early on when I got into the two years of studying the back, pain science was this huge hardcore area of the research. And then there was this huge mechanical side, Stuart McGill stuff.
They both explain the same thing based on the person that’s in front of you. And it’s not just the classic 60-year-old dad who’s worried about his back. If I have a player sit down in front of me, and they’re a PhD level, they want to hear about facets and joints and sciatica and stuff, then yeah, I’m going to go a little bit more in depth and talk about the mechanics of it and the forces of throwing or jumping or whatever, just because that’s where they’re at in terms of education and establishing rapport.
But if somebody comes in and they’re like, “I’ve seen two doctors and these MRIs, they want me to go to shots right now,” and they’re clearly terrified of the long-term outcome of their back, I’m going to avoid all of those mechanical things in their MRI and talk about some pain science stuff, and talk about some more big picture global type stuff.
And, I think if you get more experience in a joint or a condition, one of the best things about Champion is, because we’re specialized, people come to you, and you talk their language, you talk about slow balls, and you talk about innings and what’s your arm slot and this and that. And I can talk about gymnastics and terminology. And that, plus, “Oh yeah, I see this all the time. No worries. We see people, we’re going to give this a couple of weeks, thinking weeks, not days.” And you calm them down.
It’s really all about delivering the type of information they have to hear, based on their symptoms in front of you. But I’ve had people with horrific sciatica come in once a week for six weeks, and they do great. They do totally fine.
So there are some situations where you have to not be… What’s that term, throwing the baby out with the bath water, like, oh, you never need surgery, no injections, you’re totally fine. You don’t want to go that route because there’s people who really do need some oral meds or injections, or a laminectomy eventually, but it’s very, very few and far between if you have a good clinical picture in front of you.
So don’t rule it out always, but also, you got to give it at least four to six weeks minimum before you’re having that conversation about an injection, before you’re having a conversation about a fusion or a laminectomy.
Mike Reinold:
Yeah, great stuff, Dave. I mean, I think we see this all the time. I think one of our big things, you don’t treat an MRI. An MRI is just one part of your diagnostic process, and it’s just a structural part. Big thing, the way we practice at Champion, a big part of our CPS program that we have is, we have a structural valve, and we have a functional valve.
So, structurally we know that you have some damage to some tissue, but it’s not the end of the world. We’re going to work on all the functional things that we find. Like Mike said, that checklist of suboptimal things. We’re going to work on that, and I think the vast majority of time, people do better.
But the only thing I’ll end with, and just reiterate again here is, when you’re in this situation, I think a big part of your treatment program has to address the anxiety that’s probably happening with the kid, the parent, the coach, the agent, whoever you have going on with you. You have to address that.
And some of the strategies we talked about here, I think, will really help them, but it’s going to be hard to get some significant improvements or get them back to a return-to-sport program if they’re still so fearful of the MRI.
So, make that a big part of your evaluation process, that they understand that they’re not unique. They’re not broken. They just have some structural findings that are pretty common, and those are things that we’ll deal with. And over time, I think as they start to progress, that anxiety will get a little bit better.
So thanks again, Ken. Great question. If you have anything like that, head to mikereinold.com. Click on the podcast link and ask away. And please subscribe on your favorite podcast thingamabob, and we will continue to pump out these episodes for you.
