by Jason Schexnadyer, PT, DPT, CMTPT


First of all…

This post isn’t just about MRI’s 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 the diagnosis of an injury, disease, disorder, or other underlying impairment. They can help identify ACL tears, fractures, tendinopathies, muscle strains, ligament sprains, and more sinister pathologies like cancer. However, imaging is likely relied on too often in the medical profession. And despite their usefulness, imaging can be quite MISLEADING.

 

Before I continue, if you haven’t seen “A Few Good Men” do me a favor and take the time to watch it…but I digress…back to the main topic.


What imaging doesn’t tell you…

In our profession, we hear it all too often. Statements along the lines of, “My doctor told me my X-ray showed that I have degenerative disc disease” or “my MRI showed I have a bulging disc.” Patients believe that because their imaging shows an abnormality that it’s the CAUSE of their pain…but this isn’t always true.

Commonly, diagnoses like bulging discs, shoulder impingement, arthritis, etc. are present in people who DON’T have pain or limitation. That’s right, there are thousands of people walking around with large, protruding disc bulges that don’t even know they have them. And almost all human beings have “impingement” in some joints of their body and don’t know it because they don’t experience pain or limitation with movement. The question you might then ask… “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…

  1. What do you eat?
  2. How many hours do you sleep on average?
  3. What are your cultural beliefs?
  4. How do you manage your stress?
  5. Exercise regularly?
  6. Do you smoke?
  7. How many co-morbidities do you have? Diabetes? High blood pressure?
    • Just because you take blood pressure medication, doesn’t mean you don’t have high blood pressure anymore
  8. Your fears about what’s going on?

These are only a few examples of the LIKELY INFINITE variables that contribute to the pain you feel.

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 incorrectly at times, you likely do have arthritis in your knee or a tendinopathy in your shoulder. Your doctor isn’t out to get you 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? Sure. But they might not be as well, and we’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 587 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
        1. The belief that disc bulges don’t heal and are “here to stay” isn’t true.
        2. If my bulge has reduced back to normal then why do I still hurt?!?! Maybe it wasn’t the CAUSE in the first place?!?!
        3. 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 a 3-week period 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
        1. You may have received the INCORRECT diagnosis.
        2. There’s a poor overall agreement in imaging interpretation between interpreters.
        3. A HIGH amount of ERROR exists with MRI imaging interpretation in general.
        4. The methodology of image “grading” isn’t consistent amongst interpreters.
  • Knee Abnormalities

    • A study involving 710 participants, 504 of which 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
        1. Abnormal findings in imaging results are common, even in people who DON’T have pain.
        2. Even if you DO HAVE PAIN, your imaging results can’t tell you the CAUSE of your pain.
        3. What tends to be considered abnormal might be more normal than most people believe.
  • Complete Rotator Cuff Tears

    • 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)
      • Take-home points
        1. Once again, abnormalities and pathologies are common and might not necessarily be the CAUSE of your pain or limitations.
        2. Imaging can provide valuable information but shouldn’t be completely relied upon to determine WHY you hurt.
  • Hip Impingement (FAI)
    • A meta-analysis of 2,114 people were imaged using either MRI or radiographs (x-rays) or both in order 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
        1. At this point, you get where I’m going with this…

To be completely transparent…

These are just a few research papers of the many that illustrate these common occurrences with imaging. There are also many research papers that show that pathology seen on imaging results are 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 and the results your doctor sees from imaging should ASSIST in the diagnosis they give to you. It SHOULDN’T be the “end-all-be-all” in the complex equation that is your diagnosis and/or pain. The secondary purpose of this blog 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 clearly see, your results shouldn’t scare you as they might not mean anything significant.

A Personal Story Showing How Imaging can be VITAL…

Over a year-and-a-half ago I noticed a large mass developing in the side of my right lower leg. The mass never hurt itself, but the tissue around it did every now and then making it difficult to walk. I tried treating it thinking it was a muscular issue since it hurt intermittently when I walked. And even though I’m a physical therapist, like many people, I didn’t take the appropriate steps to make sure it wasn’t anything serious. This mass was present for over 6 months before I saw an MD…yikes!!!

I finally went to an MD I’ve seen patients for in the past. He 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 tibia connects to your fibula).

Since he was an orthopedic doctor he wanted me to see a tumor specialist as he wasn’t sure if the mass was sinister in nature. 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 reviewal 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 that I leave it alone and avoid having it surgically removed. This is because the cyst was in close proximity to 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 very serious. Imaging was intended for this type of use. It’s meant to HELP you understand what’s going on in your body and to determine if something very serious is present. However, IT’S NOT capable of telling you the cause of your pain. Now the question is…can you handle the truth?