The truth about Imaging…
This post isn’t just about MRIs and X-rays (Radiograph is the correct term for an “X-ray”). It’s about ALL FORMS of imaging in general, including CT Scans, contrast-dye imaging, ultrasounds, etc.
Imaging assists medical professionals in diagnosing injuries, diseases, disorders, or other underlying pathologies. It can help identify ACL tears, fractures, muscle strains, ligament sprains, and more sinister pathologies like cancer. However, imaging is likely relied on too often in the medical profession. And, despite its usefulness, imaging can be quite MISLEADING.
What imaging doesn’t tell you…
As a therapist, I hear it all too often, statements along the lines of, “My doctor told me my X-ray showed that I have disc degeneration” or “My MRI showed I have a bulging disc.” Patients believe that these “abnormalities” seen on imaging are the CAUSE of their pain…but it isn't that simple.
Commonly, diagnoses like bulging discs, rotator cuff tears, arthritis, etc. are present in people who DON’T have pain or disability. That’s right, there are thousands of people walking around with large, protruding disc bulges that don’t even know they have them. According to some research, more than 50% of people aged 65 and older have rotator cuff tears, yet half of those people don't even know they have them. This goes against the popular belief that rotator cuff tears are always painful and disabling. The question you might then ask is…“why do I hurt and others don’t?”
To be honest, we don’t know why. NO ONE DOES. Pain is multi-factorial, unpredictable, and hard to treat. So many things impact how or what you feel and your imaging results CAN’T give you that information.
For example, below are some questions that represent factors that can affect how we feel:
What did you eat today? Yesterday? Over the last week? Month? Years?
How many hours do you sleep on average? Was it quality sleep? How often do you wake up each night?
What are your cultural beliefs?
How do you manage your stress? What things contribute to your stress? Work? Kids? Health?
Exercise regularly? What type? How long? What intensity?
Do you smoke? Drink regularly?
How many co-morbidities do you have? Diabetes? High blood pressure? Anxiety? Depression?
Have you spent time with family, friends, etc., and socialized?
The list could continue almost indefinitely, but you should get the point by now.
Did my doctor order a “Code Red”?
Let us be very clear…your MD likely interpreted your imaging results correctly. Though imaging results are misread or interpreted differently at times, you likely do have the pathology your MD mentioned when they interpreted your imaging results. Your doctor isn’t out to get or misinform you, and they certainly aren’t ordering a “code red”.
But here’s the problem…many bodily anomalies and abnormalities will show up on imaging that AREN’T the cause of your pain. Could they be? Possibly. But they might not be as well. I’ll make a case as to why anomalies and abnormalities aren’t the cause in many cases.
And the Research Says???
Disc Herniations/Bulges
One paper studying 587 people showed that 62 – 80+% of people who had disc herniations had spontaneous reabsorption of said herniations (quick reduction in size back to normal) with conservative treatment…NOT surgery or prescription medication. (M. Zhong et al. Pain Physician 2017)
Take-home points = The belief that disc bulges don’t heal and are “here to stay” isn’t true. If my bulge has reduced back to normal then why do I still hurt? Maybe it wasn’t the CAUSE in the first place? Conservative treatment should ALWAYS be sought out FIRST.
Imaging Errors
One patient with a history of low back pain and radiculopathy was sent to 10 different MRI centers over 3 weeks to see if she would receive variable diagnoses. 49 DIFFERENT findings were reported that related to some type of pathology among the 10 MRI’s performed and only ONE finding was consistently reported between them. (R. Herzog et al. The Spine Journal 2017)
Take-home points = You may have received the INCORRECT diagnosis. There’s a poor overall agreement in imaging interpretation between interpreters. A HIGH amount of ERROR exists with MRI imaging interpretation in general. The methodology of image “grading” isn’t consistent amongst interpreters.
Knee Abnormalities
A study involving 710 participants, 504 of whom DID NOT have knee pain, underwent MRI imaging. At least one pathological finding was present in 86 – 88% of the 504 people who DID NOT have knee pain. (A. Guermazi et al. BMJ 2012)
Take-home points = Abnormal findings in imaging results are common, even in people who DON’T have pain. Even if you DO HAVE PAIN, your imaging results can’t tell you the CAUSE of your pain. What tends to be considered abnormal might be more normal than most people believe.
Complete Rotator Cuff Tears & Spinal Pathologies
A study showed that 147 (22.1%) people out of 664 had complete tears of the Supraspinatus and/or Infraspinatus (2 of the 4 Rotator Cuff Muscles) and 65.3% of the 147 people had NO SYMPTOMS (H. Minagawa et al. Journal of Orthopedics 2013).
A systematic review was performed looking at the imaging findings of 3110 people between the ages of 20 and 80 who had NO PAIN OR DISABILITY. Look at the image below for some mind-blowing percentages based on age. Notice how the prevalence of common pathologies like disc bulges and degeneration were present at young ages and increased as people got older. This shows that these changes are normal, age-related changes AND that they aren’t always as painful as many believe (W. Brinjikji et al. American Journal of Neuroradiology 2015).
Take-home points = abnormalities and pathologies are common in people who don’t have pain or disability. Pathologies seen on imaging might not necessarily be the CAUSE of your pain or limitations. Imaging can provide valuable information about anatomy and pathology but shouldn’t be completely relied upon to determine WHY you're experiencing symptoms.
Hip Impingement (FAI)
A meta-analysis of 2,114 people were imaged using either MRI or radiographs (x-rays) or both to determine if hip pathology was common in people WITHOUT hip pain. It was found that a CAM deformity was present in 37%, a Pincer deformity was present in 67%, and labral tears were present in 68.1% of the participants imaged. (J. Frank et al. The Journal of Arthroscopic and Related Surgery 2015)
Take-home points = At this point, I think you get where I’m going with this…
To be completely transparent…
These are just a few of the many research papers that illustrate these common occurrences with imaging. Many research papers show that pathology seen on imaging results is positively correlated to pain. So, maybe that labral tear in your hip is the cause of your pain…but maybe it isn’t too.
This blog’s primary purpose is to illustrate to you that imaging is a diagnostic tool that should be used appropriately. The results your doctor sees from imaging should ASSIST in the diagnosis they give you. They SHOULDN’T be the “end-all-be-all” in the complex equation that is your diagnosis and/or pain.
The secondary purpose of this article is to help ease the fear you may have while waiting or receiving imaging results. It’s natural to be concerned or fearful about the results of imaging. But, as you can see, your results shouldn’t scare you as they might not mean anything significant. Also, there’s research that shows that imaging can have negative psychological effects, which can further worsen your experience of pain…yet another reason to be cautious surrounding imaging.
A Personal Story Showing How Imaging Can Be Vital…
A few years ago I noticed a large mass developing in the side of my lower leg. The mass never hurt but the tissue around it did now and then making it difficult to walk. And even though I’m a physical therapist, like many people, I didn’t get it looked at immediately to make sure it wasn’t anything serious. This mass was present for over 6 months before I saw an MD…yikes!!! (see, we therapists are human too)
After finally going to see an MD, they ordered an MRI and the results showed there was a large mass that appeared to be coming from my proximal tibiofibular joint (the higher joint where your large shin bone connects to your smaller lower leg bone).
Since he was an orthopedic doctor he wanted me to see a tumor specialist as he wasn’t sure if the mass was sinister. Understandably, I was nervous that he made this recommendation. I saw the tumor specialist and he ordered a contrast-dye MRI which would tell us whether or not the mass was fluid-filled or solid. Fluid-filled would mean that it’s a harmless ganglion cyst and solid would require me to get a biopsy…and we all know what that likely meant (the dreaded “C” word).
Luckily, upon review of the MRI, it was determined that it was a ganglion cyst…PPHHHEEWWW!!! He recommended that as long as it doesn’t cause significant pain, I leave it alone and avoid having it surgically removed. This is because the cyst was near my common peroneal nerve and removing it might cause foot drop, which can be very difficult to rehabilitate.
In Conclusion…
An MRI helped me rule out something potentially serious. Imaging was intended for this type of use. It’s meant to HELP you understand what’s going on in your body and determine if further steps are necessary. However, it ISN’T capable of telling you the cause of your pain, when the pathology happened, or many other factors surrounding your present condition. Now the question is…can you handle the truth?
