This is a very common question we get in the clinic: “Do I need an X-ray / ultrasound / MRI?” Patients are often wanting to know more about their injury and get a diagnosis as quickly as possible. This is a very understandable impulse, but is diagnostic imaging necessarily the way to go?
Here are some things to consider:
1. Is it providing you with an accurate diagnosis?
As imaging gets better and better in quality, we are finding more and more “abnormalities”. A 2015 study looking at MRI findings of people with no back pain found that 30% of 20 year olds had disc bulges. This more or less increased by 10% with each decade until 70 years of age, when 77% of people with no back pain had disc bulges. In another study, 22.1% of people in a sample had full thickness rotator cuff tears in their shoulder and only one third of them had any pain. Broken down into age brackets of people with absolutely no pain, 13% had rotator cuff tears in their 50s, 15-20% in their 60s, 25-30% in their 70s and 35-50% in their 80s. It has been the conclusion for some time that many “pathologies” are actually just natural physiological changes most of us will go through as we age, much like grey hair, but inside our bodies.
2. How can we use it to help us?
If you develop pain and go and get some diagnostic imaging, how can you be sure that the findings are the true source of your pain, and not something that has been there for a long time and not a bother at all? This is the tricky part, but what your clinician will do is assess whether your imaging findings marry with your clinical symptoms and history. As we like to say, we are treating a person, not an x-ray. If the imaging reports nothing, but you are clearly in a lot of pain, have a history of trauma or an acute onset, and other symptoms of concern (pins and needles, numbness, weakness), we will not dismiss you based on those results. Conversely, if your pain is not severe and you have no other symptoms, then a significant finding on imaging will be considered but not relied on.
3. Will it change your management?
If the findings of your imaging are the difference between you needing a procedure performed or not, we will probably refer you for imaging early on. An example of this would be a suspected ACL tear in a young athlete which is very often operated on. However, if we are just ordering imaging to confirm what we already suspect, and you are not a likely candidate for any procedure (including surgery or injection therapy), then obtaining imaging has no point or benefit. We will usually hold off to see how your respond to conservative therapy.
4. Are there any downsides?
There seem to be a few downsides from over-reliance on diagnostic imaging. Certainly the cost on the healthcare system and ACC is significant. Furthermore, the exposure of patients to radiation needs to be considered. Of clinical importance to physios is the impact imaging findings has on a patient’s outcomes. Studies have shown that obtaining MRIs has been associated with a greater likelihood of getting surgery and a reduced sense of well being – with no impact on actual outcomes in comparison to people who don’t get MRI. Some studies actually showed that getting MRIs was associated with longer recovery times. In 2012, an American initiative called “Choose Wisely” was launched to discourage unnecessary diagnostic testing from being ordered. A list of commonly-ordered tests that were considered the least important or valuable were compiled along with helpful evidence-based advice for imaging guidelines. X-rays of the lower back were considered unnecessary if the symptoms had been presenting for six weeks or less and no red flags were present. The American Medical Society for Sports Medicine recommended avoiding MRI for knee pain patients with no swelling or other symptoms, unless they have failed to improve following a functional rehab programme.
Diagnostic imaging absolutely has its merits and should be used particularly when we suspect serious red flag conditions like a fracture, cancer, or nerve damage. Within the musculoskeletal and sports domain, try not to be disappointed if your physio, doctor or specialist doesn’t trundle you off for a routine x-ray every time you have pain – they may be saving you a lot of time, money, health risks, pain and anxiety. Take any imaging you do get with a grain of salt – chances are they’ll find something, but it’s been there long before your pain started and it will be there long after it finishes!