And so, the saying goes ‘a picture is worth a thousand words.’ And in so many situations I would wholeheartedly agree. A picture can strike a range of complex emotions in our heart.
But in the world of musculoskeletal imaging, it’s quite simple: a picture is far from 1000 words. Scans often do not convey the complexity of an injury, are highly inaccurate, often oversimplify and can potentially cause more harm to the patient. And as a Physiotherapist, I have very strong opinions towards imaging because I spend a great deal of my treatment time dealing with the confusion and possibly harm they cause.
So instead of me starting off today’s blog hating on scans (which is not what this is meant to be), I’m going to do the opposite and explain the many valid and clinically appropriate reasons to seek investigations. So let’s start with when I believe it’s appropriate to undertake musculoskeletal imaging:
When there is genuine cause by your doctor or treating practitioner that the cause of pain is non-musculoskeletal. I.e kidney stones, cancer, migraines etc.
When there is concern of a fracture, dislocation or concussion that can’t be managed without imaging
Where there is concern of neurological compression associated with complete loss of muscle strength including sudden unexpected urinary or bowel incontinence (medical emergency)
Unexplained persistent headaches that differ to a patient’s usual headaches
Unexplained vertebral artery symptoms including dizziness, double vision, trouble speaking, trouble swallowing, loss of co-ordination, numbness, nausea, and/or vertigo
And when the patient has undergone GOOD conservative physiotherapy management for at least 6-8 weeks and there has been ZERO sign of improvement. And when I say good management, I’m not talking about a bit of poking and prodding. I’m talking about dedicated tailored strengthening x 3-4 times a week provided by a knowledgeable Physio.
And yep that’s it. Just those reasons.
We could finish the blog there, but I promise it’s much more interesting to read the solid evidence behind why scans are not helpful in the practice of musculoskeletal and sports medicine and in many cases very harmful.
Not all good things are good for us
Ok, so you’ve booked an appointment with your Physio to be assessed for your shoulder injury. Please, I beg you, do not get a scan done prior to that appointment unless any of those first 5 points are of genuine concern by your doctor. Regardless of your level of pain. Your physiotherapist has undergone extensive musculoskeletal training to clinically determine the underlying cause of your pain. A scan will rarely provide additional assistance in this matter. You’re probably wondering why this is such an issue because scans aren’t harmful, right?
Well unfortunately, musculoskeletal imaging can be incredibly harmful for a variety of reasons.
We are exposed to ‘natural’ radiation daily without too much concern, but when it comes to certain imaging our radiation exposure significantly increases. Ultrasounds and MRIs do not expose us to increased radiation, however X-rays, CT and bone scans do.
The important facts to know surrounding imaging radiation are this:
Our annual recommended limit for radiation is 20mSv for medical workers exposed to radiology
An Australian worker is exposed to 1.5-3.0mSv of radiation per year
A lower back X-ray carries 1.5mSV radiation dose
A bone scan carries up to 6mSv radiation dose
An abdominal and pelvis CT scan can carry up to 15-30mSv radiation dose
In fact, the radiation from one CT scan is equivalent to the radiation in:
1400 dental X-rays
240 x 5-hour flights
Smoking a pack of cigarettes per day for a whole year
And high doses of radiation have a definite link with sinister pathology. A study released in 2012 by a group of international researchers, which took place over 23 years, found that otherwise healthy children who received CT scans after falls or accidents or to diagnose infections were three times as likely to develop brain cancer and four times as likely to be diagnosed with leukemia as those who opted out of the scans (Pearce et a., 2012).
Now I’m not saying to never undergo a X-ray or CT scan ever again because of cancer risk. The number of children who actually went on to develop sinister pathology was small. However, these pathologies may have been preventable and this is something to keep in mind when requesting imaging. For a variety of purposes imaging is required for clinical benefit, but I would always encourage radiation doses from CT scans to be kept as low as possible and alternative procedures, which do not involve ionising radiation, to be considered by the health care provider if appropriate.
In Australia we are quite fortunate with our health care system and most scans referred by GPs are bulkbilled. However, just because the patient doesn’t pay out of pocket doesn’t mean there is no expense to the individual. Imaging and all other bulk billed medical expenses come out of tax payer’s well-earned dollars.
Currently, just over 80% of tax payer dollars are going to our welfare services. The government contributes $199 million annually on diagnostic imaging items from the Medicare Benefit Schedule (per the 2019-2020 Australian Budget).
So as a society from a monetary perspective, we should be trying to minimise unnecessary imaging (Webster et al., 2014), and instead funnel some of that money into preventative medicine and rehabilitation to deal with the current pain pandemic Australia is experiencing. But that’s a whole different blog in itself. If you’re interested in learning more about the world’s pain pandemic check out the Global Burden of Diseases Study by Cieza et al (2020).
Ok, when it comes to imaging this is the cause of harm that irks me and what I would consider to be the most important. The psychological and emotional harm caused by scans runs deep and this is the most common issue I have to address when treating patients. I could tell you a million horror stories, but let’s pick one from a patient I saw last week and roll play you as the patient.
So, you’ve had 2 weeks of unrelenting shoulder pain after injuring it in a handspring. The pain has not settled down with rest, so you’ve had an ultrasound on it to figure out what’s wrong. You’ve stopped pole. You come to see me in a very distressed state because the doctor has, in basic terms, told you your shoulder is stuffed and you should stop all forms of exercise. They have said you will require an injection first and probably surgery to remove a whole bunch of things if the injection fails and you’ll never be able to pole again in your life. But you’ve been told to see a physio to prepare you for surgery anyway.
Just let that all sink in and then answer, how does this make you feel? Angry? Scared? Not in control?
Now what if I told you that I see this happen on average 10-times per week. And no, I’m not exaggerating.
You’re probably thinking ‘the scan shows my shoulder is stuffed so it is and then there’s nothing I can do about it’. And I’m happy to report in this case you would be wrong.
Because if the radiologist had scanned your non-painful/injured shoulder they are likely to find the exact same issues in that one too. Don’t believe me? Well check out the results of this study by Barreto et al (2019, JSES). 123 people with unilateral shoulder pain lasting for 1 month to 3 years in duration had both shoulders scanned.
There are just as many findings seen on MRIs in pain-free shoulders as there are in painful shoulders. There is the exception being in full thickness tears and osteoarthritis. However, those numbers were too low in that particular study to draw conclusions.
So you might be thinking this was a once off study, there needs to be more evidence than that to convince you. Great! I appreciate that way of thinking. And I won’t disappoint you because there is a ton of research out there on this.
Another great study by Guermazi et al (2012) in the British Medical Journal (BMJ) scanned 206 patients with knee pain and 504 patients without knee pain. Both knees were scanned in this study. And similar to the shoulder study, they found just as much pathology in the pain free knees as they did in the painful knees. Again, this demonstrates the pain and disability is not correlated to scan findings. And furthermore, these scans do not predict future pain.
So now you’re probably thinking that both of your shoulders are going to need surgery and that would be wrong again. How and why?
Because imaging does NOT correlate to pain!
Just let that sink in because for to accept this fact we need to re-write incorrect and deep-seated beliefs in our brain. It can be a tough one to process. I have seen countless people post-surgery, done to correct a scan related issue, that then realised later this issue wasn’t actually the cause of their pain.
Here are some more studies:
Brinjiki et al showed a high prevalence of ‘pathology’ in lower back MRIs in well over 3000 people without any pain or issues in ages from 20 to 80 years old
Nakashima et al showed similar results in over 1200 neck MRIs in subjects again with NO pain or issues.
In just the shoulder alone:
Grisih et al found a staggering 96% of subjects with no pain or issues had at least one so-called pathology on their US scans.
Teunis et al showed an increasing prevalence non-painful cuff tears with age and with up to 65% being non-symptomatic
Schwartzberg et al demonstrated 72% of middle-aged subjects had non-symptomatic SLAP lesions,
Le Goff et al showed that over 50% of calcific deposits seen in cuff tendons are non-symptomatic,
Lesinak et al highlighted nearly 50% of young elite level professional baseball pitchers have cuff tears and SLAP lesions with no effect on their performance.
In fact, here are some on the whole body:
We could definitely go on, demonstrating pain-free individuals with considerable pathology on their scan with no history of pain or any disability!
So what is the explanation for all of these changes then because we are not born like this?
Instead of saying image results are degenerative, worn out or torn and that they require surgical intervention, it’s about time patients understand that many of these scan results are considered normal changes as we age. A frequent analogy I use is that we wouldn’t expect to look the same at the age of 50 as when we were 20, so why would we expect to look the same on the inside. Now, not that there’s anything wrong with aging, but just like we begin to show signs of wrinkling on the outside, these tears and extra bone growth are like wrinkles on the inside. And some people will just naturally wrinkle more than others due to a variety of factors including genetics and use. But it’s not a bad thing! In fact, exercise and muscle use helps to keep our body strong and resistant to injury. So don’t be afraid to move your body!
Can scans be helpful?
Now not to contradict myself, but yes, in many cases they can. When clinically reasoned and appropriate they can be helpful in ruling out/in secondary causes of pain. But the common belief held by patients and many clinicians that a scan 100% of the time shows the cause of pain needs to be thrown out the window. And in particular, dependence on imaging needs to be questioned when clinicians may in reality need to use their clinical training a lot more.
One more brilliant (case) study for today’s blog (Herzog et al 2017): one patient with low back pain visited 10 different medical centres and had ten MRI’s done within the space of three weeks. These MRIs were then reported on by ten different radiologists. And the results are astounding. 49 different issues were reported across the scan. But none of the same issues were reported in all 10 scans.
So, whilst we don’t usually place great weight on case studies in the medical field, this was a great one that showed there is considerably HIGH variability in reported imaging findings in the same patient. And this is where scans can cause great harm. Without the presence of serious or sinister pathology, MRIs can be inaccurate and too often lead to over- and mis-diagnosis.
Key take home message – scans are there to exclude the worst possible findings. And beyond that, they often do not tell us where pain is coming from.
Clinicians – if you’re reading this, then this is for you
Our health care system needs some work. I’m sure we would all agree on that. But there are a few things we can do as individual healthcare professionals to improve it for the better:
Doctors & HCPs - Don’t send patients for scans just as a reassurance if there is no clinical indication. Just stop it. You are not helping anyone here. You are the clinician and it is your job to provide your patient with reassurance, not a scan that may show up non-painful pathology! Most of the time this will freak a patient out unnecessarily! (van Ravesteijn et al., 2012)
If you believe a patient has a decent injury, before sending for a scan to confirm ask yourself ‘how would this imaging change my management of this condition?’. i.e. if you think it’s a muscle tear, would getting imaging actually change how you manage the condition. In most cases no, so there would be no need for a scan.
If you don’t know what’s going on with the patient, don’t send the patient for a scan because you think it’s a mystery and a scan will solve it. Instead, refer the patient onto the right practitioner that can help, because if you have no clinical hypothesis of the cause then you’re not the person to help!
Stop scaring patients with imaging results. Do not underline or highlight words on scan results. It is mentally scarring for patients, and patients hold onto these incorrect diagnoses unnecessarily. Instead, please reassure patients as to what normal results entail per the studies listed above. Use lots of helpful analogies like the one on wrinkles on the inside.
Radiologists & medical technicians are incredibly valuable in their interpretation of the scans and are experts in their field, however they do not ‘see’ the patient and the clinical assessment that’s undertaken in a clinical room. So do not let a radiologist’s recommendation soley guide your treatment. It is my firm belief that a good radiologist will never recommend an injectable in their report. I would even go so far to suggest it is a conflict of interest as the radiology clinic will benefit financially from the injectable. You are the clinician, and you decide what’s best for the patient. Treat the patient in front of you and not the scan results.
Radiologists, radiographers & technicians - despite this blog being on why I discourage imaging of every patient, I would actually like to take the time to say that we do actually appreciate you & all the work you do. It’s very technical & not easy. This blog is not trying to poo poo all over your work, but instead bring the imaging evidence to the fore. And from a clinical point of view there are still a few things that you can all do to help a patient that does require imaging. Firstly I suggest that instead of telling patients what’s wrong with their injury in the radiology room (which should not be done anyway), take the time to reassure an anxious patient when you see one. It’s their body and they are going through a challenging time, so they are likely to feel a bit frightened & unsure. A smile and a simple ‘it will all be ok’ or ‘you’re in good hands with your doctor or physio’ is all a patient needs to hear sometimes. And with a persistent patient you can say a simple ‘it’s not too bad at all but the doctor or physio explain will explain it to you at your next appointment’ to reassure them. If we can avoid inciting fear in the patient early on it can considerably speed up the resolution of their symptoms. Secondly please please please don’t inject a patient without a referral, despite your clinical reasoning. Unfortunately I still see this happening too often.
So this blog ended up being a tad longer than I initially anticipated, but as you can see I have many strong and evidence-based opinions on imaging. And as healthcare professionals we are advocates for our patients and should do all we can to minimise harm, particularly when it comes to imaging. And patients, you are advocates for yourself and your own health. I’m hoping that those who read this, both patients and clinicians alike, see that imaging definitely has a role in musculoskeletal practice, but the way it’s used needs to change to a more sensible implementation.
Are you recovering with an injury and it’s getting in the way of your pole?
Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'.
Until next time, train safe.
The Pole Physio
van Ravesteijn H, van Dijk I, Darmon D, van de Laar F, Lucassen P, Hartman TO, van Weel C, Speckens A. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012 Jan;86(1):3-8. doi: 10.1016/j.pec.2011.02.003. Epub 2011 Mar 6. PMID: 21382687.
The Cascade of Medical Services and Associated Longitudinal Costs Due to Nonadherent Magnetic Resonance Imaging for Low Back Pain Barbara S. Webster , BSPT, PA, * † YoonSun Choi , MA, * Ann Z. Bauer , MPH, ‡ Manuel Cifuentes , MD, MPH, ScD * ‡ and Glenn Pransky , MD, MOccH * SPINE Volume 39 , Number 17 , pp 1433 – 1440
Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. doi: 10.1016/S0140-6736(12)60815-0. Epub 2012 Jun 7. PMID: 22681860; PMCID: PMC3418594.
Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, Aliabadi P, McLennan CE, Felson DT. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339. doi: 10.1136/bmj.e5339. PMID: 22932918; PMCID: PMC3430365.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8. doi: 10.1097/BRS.0000000000000775. PMID: 25584950.
Girish G, Lobo LG, Jacobson JA, Morag Y, Miller B, Jamadar DA. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971. PMID: 21940544.
Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014 Dec;23(12):1913-1921. doi: 10.1016/j.jse.2014.08.001. PMID: 25441568.
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.
Le Goff B, Berthelot JM, Guillot P, Glémarec J, Maugars Y. Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine. 2010 May;77(3):258-63. doi: 10.1016/j.jbspin.2010.01.012. PMID: 20434387.
Lesniak BP, Baraga MG, Jose J, Smith MK, Cunningham S, Kaplan LD. Glenohumeral findings on magnetic resonance imaging correlate with innings pitched in asymptomatic pitchers. Am J Sports Med. 2013 Sep;41(9):2022-7. doi: 10.1177/0363546513491093. Epub 2013 Jun 17. PMID: 23775245.
Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017 Apr;17(4):554-561. doi: 10.1016/j.spinee.2016.11.009. Epub 2016 Nov 17. PMID: 27867079.
Cieza, Alarcos & Causey, Kate & Kamenov, Kaloyan & Hanson, Sarah & Chatterji, Somnath & Vos, Theo. (2020). Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 396.
Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg. 2019 Sep;28(9):1699-1706. doi: 10.1016/j.jse.2019.04.001. Epub 2019 Jul 3. PMID: 31279721.