So You Have Pain, Should You Go Get Imaging?

Oftentimes, our musculoskeletal injuries can start something like this: You are running, lifting weights, or bending to pick something up and you feel a painful twinge. So you go and get imaging, and the MRI or X-ray demonstrates a “defect” like “degenerative disc disease”, “bulging disc”, “rotator cuff partial tear”, or “torn meniscus”. So it seems pretty straightforward forward this 'defect' is the reason that you have pain in your shoulder, back, or knee.

But what if that isn’t the whole story?

The idea that specific structures in the body are single-handedly and directly causing our pain is something many of us have been taught to believe. And receiving imaging results can seem to confirm this. However, the reality is a bit more complex. 

There are certainly some instances where receiving and reviewing imaging is certainly appropriate. But this isn’t every case. And research shows us that it isn’t warranted in most cases. The biggest indication that an injury requires imaging is described by medical professionals as red-flag symptoms. 

Red flag symptoms is a term that medical professionals (physical therapists included) use to describe symptoms that are emergent - and should be treated by emergency medicine, (depending on the case, this can involve the ER or your primary or orthopedic doctor). 

Some of these symptoms include: 

• Unexplained weight loss

• High fever

• Loss of bowel/bladder control

• Significant trauma (ex. hitting your head or another part of your body, or falling)

• History of cancer

• Loss of feeling or control of the legs or arms (affecting your ability to walk, or to hold items)

• Changes in your reflexes

• Inability to put any weight through your legs/arms

In fact, in your physical therapy session, your PT will likely ask about these symptoms - just to confirm that physical therapy is the right place for you to be and that another member of the medical team is not required! This is why answering these questions candidly to your PT or other medical provider can be extremely helpful.  But generally speaking, these kinds of symptoms are much less common than you might think. 

Take back pain for example research shows that less than 1% of back pain comes from causes that are “red flag conditions” - meaning that they should be managed by something more invasive than physical therapy. Furthermore, research indicates that imaging is not needed with occurrences of back pain unless it is going to significantly change the treatment plan that you and your physical therapist decide on. This rule of thumb applies to pain/injury experienced all over your body. 

If you do decide to get imaging, it’s important to understand what imaging can and cannot tell you. Two helpful things to consider are: 1)  imaging is just a snapshot in time and 2) damage to a particular tissue doesn’t tell the whole story. 

To demonstrate this point, a study that looked at imaging of hundreds of people with low back pain, found that there was not a correlation between the number of “defects” found on their imaging results and the degree of pain that they were experiencing. In short, while changes like “osteoarthritis”, “meniscus tear”, and “spinal stenosis” “anterior pelvic tilt”  can contribute to the issue, they are only one piece of the puzzle. Some of the other factors that science shows can drive pain include genetics, comorbid health conditions, psychosocial influences, movement patterns, and neurological processing. Imaging cannot always tell us when these changes developed. In many cases, physical therapy can help you feel better and get back to whatever activity is most important to you without imaging or needing to change these “defects”. 

The biggest thing we’d love for you to realize is that almost no matter what your imaging shows, you don’t have to always be in pain or be limited in what you can do. We’ve had hundreds of people with MRIs that show something like a herniated disc or a tear who can get back to working out and living life without pain.

In summary, physical therapists are trained to listen to the nature of what caused your injury, consider the other contextual factors, and help you determine if what you are experiencing requires imaging or the assistance of another medical professional, or if it can be addressed with physical therapy treatment, including appropriately dosed exercise. Anatomical issues alone do not tell the whole story nor dictate recovery potential. If you have an injury (new or old!) and you are considering getting imaging, please give us a call! We would love to hear from you and help you make an informed decision.

References: 

Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust. 2017;206(6):268-273. doi:10.5694/mja16.00828

Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75. doi:10.1007/s00586-017-5099-2

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.A417