Stop Treating the MRI and Start Treating the Athlete

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 see full show notes and more, head to: https://mikereinold.com/stop-treating-the-mri-and-start-treating-the-athlete/

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Transcript

SPEAKER_01 0:47

On this episode of the Ask Mike Rhinal Joe, we talk about how we deal with MRI findings during our clinical evaluation. The Ask Mike Rhinald Joe. Helping people feel better, move better, perform better. Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training. If you want to learn how to get started optimizing and enhancing performance, this is the course for you. Head to micrennell.com slash performance. Sign up today. Welcome back, everybody. Latest episode, The Ask Mike Reynolds Show. We are here up in Boston, champion PT performance, answering your questions. Anything you want to talk

Why MRI Findings Create Fear

SPEAKER_01 1:37

about, ask away, career advice, sports PT stuff, anything, just let us know. Head to micrunnell.com, click on that podcast link, and you can ask away. Let's see. Today, what do we have? Mike Scaduto, Kevin Coughlin, Dave Tilley, Lenny McCrina, Anthony Vedetto, and Brendan Gates here to answer your questions with an amazing group of students.

SPEAKER_04 1:57

Len, who do we got today? Really good students. Um, even

Free Performance Therapy Course Plug

SPEAKER_04 2:01

better than last week's students. Um, we have Kylie Luca from Northeastern University. Fun fact about Kylie she played Division I soccer at Indiana University, the Hoosiers. Caden Johnson at Belmont University. He played

Meet The Panel And Students

SPEAKER_04 2:18

I don't know. Sorry, Caden, he's a golfer and a passionate PT student. Emma Armstrong from Duquesne University. A softball player from Townsend State First Baseman. Welcome.

SPEAKER_01 2:33

I feel like you better prepare for that episode, Len. Did you just Google them or something? That was not.

SPEAKER_04 2:38

Nah, I mean, which is just existing. Thin profiles. Just conversations, just establishing relationships.

SPEAKER_01 2:44

It seemed it seemed like you had just enough time to Google Carly and Emma, but like Caden was last. I would have to Google Caden. I I knew Carly. That was mapped out. You need to spend some more time with Caden. But all right, what do we have for a question today? Who's up for our awesome question?

SPEAKER_00 3:02

Today's questions 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 in 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?

SPEAKER_01 3:33

Awesome. Thank you, Emma. And Carl, you just want to say hi, just get you got to get your voice on an episode.

SPEAKER_00 3:38

Hi, everyone.

SPEAKER_01 3:40

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,

The Baseball Shoulder MRI Question

SPEAKER_01 3:47

great question. I 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? Like, I love the uh emotional, sometimes irrational responses from people uh 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, like ignore the MRI. I think this is gonna be a really great discussion on what we do here. So, baseball player, even though I don't think I think this applies to everybody, right? I'm pretty sure Dave can jump in here on what his gymnast backs look like or stuff like that, right? Or some of our athletes with hip problems and stuff like that. But what do you guys do here when, you know, in the exam, you you have some findings, but you're certainly not like blown away, like, uh oh, this kid needs surgery. But the MRI, you know, has some very um, 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? Um, I kind of I want to hear from Mike Scaduto on this one. Can I because I feel like Mike sees this a lot in his practice between golfers and and baseball. I mean, there's probably nobody that Mike sees that doesn't have an ugly MRI, right? Most of our people have ugly MRI. So I'd love to hear your thoughts, Mike. What do you got?

SPEAKER_05 4:58

Yeah, that's that's definitely true. Um, I think, you know, specific to baseball, if we get an MRI of their throwing shoulder, uh, we're probably gonna see something. I think, you know, some spraying of the labrum or a slight rotator cuff tear, um, however that was described in the question, um, doesn't necessarily raise like red flags for me. They're probably yellow flags, right? 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 that we like. Um, but if there's anything that really does pop up in their clinical exam, you know, we we want to address that. We want to speak to them about that and not kind of 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 we've dealt with people like this before, um, and this

Match Symptoms To MRI Carefully

SPEAKER_05 5:48

is the outcome that they were able to achieve. You know, I think the thing that we really try to want to avoid in these people is uh is an unnecessary surgery um to their throwing shoulder. That can be very detrimental for the long-term um health as a as a throwing athlete. Um, we know that any surgery, whether it's you know a large labor repair or you know, something else where it's just a you know shoulder scope, um, that can have long-term uh outcomes that are not super favorable for a thrower. Um, so I always try to mention that, like, hey, we're gonna do everything that we can to try to avoid a surgery, um, whatever that means for that person. Then from there, I mean, you know, 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, you know, what it what could possibly be contributing to uh how you're feeling when you're throwing a baseball, um, that's not necessarily structural damage. So what are the suboptimal things? You know, I think the the question said that they test out with good strength. I mean, I I think we would need to be a little more specific. Like, is it good? Is it excellent strength? Like, is it within our goal ranges? Um, and you know, I think at Champion we do a really good job breaking that down for the patient and and saying these are expectations from you first from a strength perspective. Um, and you know, here's why, and here's why we think this is gonna help you. Um, also looking at range of motion. So I think going back to those basic things that could be, you know, a little bit suboptimal. Um, one, I think, you know, we start finding things that help the uh the patient gain confidence because they're like, we can address these things, it's not that difficult. It's gonna take some work. Um, but if we if we achieve those goals, I'm fairly confident that we'll be able to throw um, you know, people with less symptoms or feel significantly better when you throw. Um and then I think it it comes down to a whole conversation on workload management and all those things specifically related to their sport. But um that's typically the strategy that I'm using, especially with a baseball player, where like, you know, if we if we not allow, but if if they end up going down this uh path towards surgery that that can have significant detriments to their career.

SPEAKER_01 7:57

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 um, you know, kind of pump the brakes a little bit, maybe with their anxiety. And you you you know, you mentioned that it's you know, I think it goes a long way to just, you know, we do this all the time. You say liquid 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 like you almost like it's almost like the air comes out of the the balloon a little bit, right? 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 like it's 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 I cannot tell you how many times people come to us that have really good strength, or they test it out maybe you know, with these apps, with these really you know cheap dynamometer devices, or maybe these other new devices that we'll leave it at that. But there's there's other devices out there that um people come in and they're like, no, I'm really strong. My trainers say I'm great, like that sort of thing. And then we test them and they're not strong. Um, that happens almost daily with us. So uh, you know, it's something to kind of keep in mind here. It's to Mike's point, like, are you okay, you're not you're not that weak, but like, are you strong enough? Maybe is is the right question. So uh awesome stuff. Anthony, what do you uh what do you got?

SPEAKER_02 9:22

Yeah, I thought Mike hit the nail on the head there, but you know, just kind of going back to the question, seems like this this picture is you know throwing, but it's still experiencing pain on the table. And I think a rule of thumb for us is like 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 kind of lift it that to them and kind of 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 gonna be a lot more confident when you're getting back and throwing a baseball. And you know, we can address range of motion and strength deficits and make sure you look 100% ready to take on, you know, the stress of throwing that is you know, something that we can't avoid. And then, you know, when we start that throwing program, maybe we're starting at 45 or 60 feet instead of going right back to the mound where they didn't feel great before. So then, you know, then we're building some confidence at, let's say, the 60-foot mark, and then we're going to go up to 90 feet and we'll

Pain Free First Then Throwing Progression

SPEAKER_02 10:12

feel good there, and then 120. So it's just, you know, building rapport from day one and then slowly engaging them in a you know, a process that builds confidence throughout the kind of whole time that you're with them. I think you can get them back to a point where they're they're seeing that, you know, just because they have this really scary MRI doesn't necessarily mean that all things are bad in the world. So, you know, 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 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.

SPEAKER_01 10:48

Yeah, well said, Anthony. Um, 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 an MRI on a back or a hit where a hit, whatever you, however, you want to approach this. But I think you have the the same experience, right? What what do you got?

SPEAKER_03 11:01

Yeah, I was talking to the students yesterday a lot about randomly uh back pain in the clinic and like assessments on a vowels. And um, I mean, I've probably treated in the last whatever decade a thousand people for back pain. You know, I treat a lot of baseball players, hockey, gymnastics, like I treat a lot of gymnasts, of course, but I think spondees and disc issues tend to come to me from a sports point of view because people, you know, 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, right? Adults are a little bit different if they have like uh long-term issues. But in the sporting population, I can think of a couple fusions, a couple um laminectomies for like really acute side. A pitcher we work with last year was throwing, felt the pop on the mound, leg went numb, head foot drop, and this leg was like, yeah, this is kind of an easy thing to think about. But um, other than that, like 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

Back Pain MRIs And Pain Science

SPEAKER_03 11:51

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 like the two years of studying the back, pain science was this huge, like hardcore area of the research. And then there was like this huge mechanical side, Stuart McGill stuff. They both explain the same thing based on the person that's in front of you. So, and it's not just like, you know, the classic 60-year-old, you know, dad who's worried about his back. If I have a player sit down in front of me and they are like like a PhD level, they want to hear about facets and joints and sciatica and stuff, then yeah, I'm gonna 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 shots right now, and they're clearly terrified of the long-term outcome of their back, I'm gonna avoid all of those mechanical things in their MRI and talk about some pain science stuff and talk about some more like 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, right? And you talk about innings and what's your arm slot and this and that. And I can talk about gymnastics and you know terminology and that plus, oh yeah, I see this all the time, like no worries. Like we see people, we're gonna give this a couple weeks, thinking weeks, not days, like, 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 bathwater, 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 oromeds or injections or a laminectomy eventually, but like 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 like 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.

SPEAKER_01 13:50

Yeah, great stuff, Dave. I mean, I think we see this all the time. I think our one of our big things, we you don't treat an MRI, right? You don't an MRI is just one part of your diagnostic process. And it's just a structural part, right? You know, you know, big thing that we the way we practice at Champion, you know, a big part of our like CPS program that we have is like we have a structural vowel and we have a functional valve, right? So structurally, we know that you have some damage to some tissue, but it's not the end of the world. We're gonna work on all the functional things that we find, right? Like Mike said, that checklist of of suboptimal things. We're gonna 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 you know, some of the strategies we talked about here, I think will will

Address Anxiety In The Plan

SPEAKER_01 14:40

really help them, but it's gonna be hard to get some significant improvements or get them back to a return to support program if they're still so fearful of the MRI. So, you know, make that a big part of your evaluation process is that they understand that they're not unique, right? They're not broken. Um, they just have some structural findings that are pretty common. And those are things that we'll deal with. And, you know, 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 microundle.com, click on the podcast link and ask away. And please subscribe on your favorite podcast, Thingma Bob, and we will continue to pump out these episodes for you.