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The Truth About Imaging

Updated: Aug 30

I want to address a common frustration I get from many orthopedic patients. They want to know "Why won't my doctor order me an MRI?". They say "I don't understand how you (a physical therapist) can treat me without knowing what is going on." or even "How will this fix me when there is a structural problem (like a tear, bone spur, etc)?" I am writing this assuming you have an orthopedic issue and not cancer or something serious like this.


Based on your history, age, medical history and physical exam a doctor can tell whether something you have going on warrants an image such as an x-ray, CT scan or MRI. If your doctor doesn't think you have anything super serious, then likely you won't be given imaging.

In the orthopedic world - making sure you don't have a broken bone or pain that doesn't improve despite lots of treatment are great reasons to get an X-ray or other imaging.


In the case that a serious issue is not suspected: imaging can lead to unnecessary surgery, unnecessary

medical costs and fear with certain

movements. Finally, many orthopedic issues can be diagnosed with your history and physical tests.



I would like to open up with how this can lead to unnecessary surgery and medical costs. What if I told you that lots of people have herniated discs (also called bulging discs) in their low back and don't even have pain with them? This table below is from a research study(1) that looked at thirty-three studies together. Look down the left column where I've underlined Disk bulge. Then you can look across the ages to see what percent of people in each decade of life have disc bulges but NO pain or other symptoms. For example 40% of people in their 30s in these studies have bulging discs but no symptoms.

Ok let's think about this. What if your back pain was actually from a muscle strain which MRIs don't always pick up on? But you see your MRI which shows a disc bulge which may have been there all along even when you didn't have pain. You are convinced this is the problem and go have surgery to fix your bulging disc when it was a muscle injury. You may feel better afterwards anyhow because guess what happens after surgery? You rest! Rest is great treatment for a muscle strain too. Alternatively, you may not have any relief. Anyhow, you can see how this quickly becomes messy.


I have no idea how common this above scenario is, however I'm sure it does happen. I have had a patient with hip pain who had a hip replacement and it didn't fix their pain. This could be because the pain was from the back but the doctor saw arthritis in the hip on the x-ray and suspected that this was the culprit. The physical tests are SO important. You can see how this would lead to unnecessary costs and surgery.


Another study(2) was performed where radiologists looked at shoulder MRIs in 45-60 year olds. At least 55% of the people had a labral (thick cartilage in the shoulder joint) tear but no pain or weakness in their shoulder. Most of the other studies I found for shoulder and knee looked at middle aged people. In general I think abnormal findings are more meaningful in young people.


Next, imaging can cause people to be fearful of movement which causes them to avoiding the activities they enjoy. I have many patients through the years who have told me "I have a disc issue in my back so I can't do that exercise." Wait what?! (you'll understand more why I'm baffled later on down!)


A study(3) looked to see if patients who had imaging had better outcomes. This study looked at 421 patients with low back pain and performed imaging on half of them. The patients who had imaging were more likely to report more pain 3 months later and visit the doctor again than the group that didn't have imaging. The group that had imaging also reported overall poorer health scores on their health score questionnaire. Interestingly though, the patients who had imaging were more satisfied with their care. Our population feels that if we are given an x-ray or MRI that the care is better. The general thinking from my experience is that patients feel like you can't properly treat them if you don't know what's going on. If you don't have imaging - how do you know what to do!

It could even be understood that the act of a doctor ordering imaging may make you feel there is something more serious going on. You can image if a bone spur, or other structural issue was found, you might feel hesitant to move into certain directions for fear of aggravating that THING. Avoiding movements perpetuates stiffness and weakness and can lead to inactivity. As a physical therapist, my entire job is to get people back to doing what they love and so this makes me so sad. When patients are prefaced with this information, we then not only have to address the pain but the fear as well.


The kermit picture says "THE TRUTH: Sometimes it is ugly."


Finally, a lot of orthopedic issues can be diagnosed from your history and a physical exam. In physical therapy school we are taught special tests out the wazoo! These are tests we perform on you to see what hurts, what's weak, and what doesn't move well. We cluster them together to help us understand what tissue is giving you an issue. Ha, you like that rhyme? We gather this information and we can treat the actual cause of your pain. In fact, I don't like to look at a patient's MRI because as mentioned above, some things are shown that may not be the cause of the pain and I don't want it to bias my physical exam. If it's available, I'll look at it after. One last study that I hope will give you more confidence in your treatment without having an MRI illustrates that our bodies can heal! How about that?! Have you ever healed from a cut, a burn, a strain, a sprain? Yes it's TRUE!

Some newer research(4) is showing that even those pesky herniated (bulging) discs can reduce or even heal with time!


This study looked at 106 patients with herniated discs AND low back pain. They performed an MRI at the onset of the study and then again 1 year later and found that 76% of the bulging discs had reduced or totally resolved. In the image to the left, pictures A and B are from the start of the study and C and D show how the disc bulge has decreased in a year.



In conclusion, in the absence of a suspicion of something serious, imaging can lead to unnecessary surgery, unnecessary costs, fear and reported lower heath, and finally it is just plain excessive in certain situations. Often you can be treated successfully without imaging.


If you are wondering why your doctor didn't order imaging then you should be saying "Phew!!! I'm going to be just fine."


I'd be interested to hear your comments on this one. Also, references are all the way at the bottom of the page.



If you would like advice on your situation, text me at (512)763-0556. I am happy to find a time we can talk about what is going on and your next best steps.

DISCLAIMER: THIS WEBSITE DOES NOT PROVIDE MEDICAL ADVICE. The information, including but not limited to, text, graphics, images and other material contained on this website are for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.

References:

  1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173

  2. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016 Jan 5;4(1):2325967115623212. doi: 10.1177/2325967115623212. PMID: 26779556; PMCID: PMC4710128

  3. D. Kendrick, K. Fielding, E. Bentley, R. Kerslake, P. Miller, M. Pringle. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ, 322 (2001), pp. 400-405

  4. Yì Xiáng J. Wáng, Ai-Min Wu, Fernando Ruiz Santiago, Marcello H. Nogueira-Barbosa, Informed appropriate imaging for low back pain management: A narrative review, Journal of Orthopaedic Translation,Volume 15,2018,Pages 21-34,ISSN 2214-031X, https://doi.org/10.1016/j.jot.2018.07.009. (https://www.sciencedirect.com/science/article/pii/S2214031X18300883)

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