They say a picture is worth a thousand words… but do they tell the entire story? Medical images like x-rays and MRI are pictures of our bodies, and can tell us lots important information. But sometimes they tell us details which aren’t important to the story, and might not tell us the entire story.

Does Your Image Show Something Scary?

Arthritis, Bulging Discs, and Torn Rotator Cuffs… OH MY!

When most people experience musculoskeletal pain, they want to know what is “wrong”. This leads to visits with doctors, specialists, and in many cases, some form of medical imaging such as x-rays or MRIs. While these images are definitely appropriate in certain situations involving musculoskeletal symptoms, many times these costly images are not necessary and can lead to increased fear and unwarranted medical procedures.

The below information will cover some misconceptions of medical imagining for musculoskeletal symptoms, what a “normal” image is, how reliable these images are, and some examples of when images are appropriate for musculoskeletal symptoms.

What is “Normal”?

According to the dictionary, “normal” is the usual, average, or typical state or condition. When someone is in pain and receives diagnostic medical imaging, they expect the image to reveal somethings which is NOT in the typical state or condition. For example if they are experiencing low back or neck pain, they would expect the image to show disc degeneration or bulging “slipped” discs. If they were experiencing shoulder pain, they would expect the image to possibly show a torn rotator cuff. If they were experiencing knee pain, it would seem reasonable that the image would show arthritis or a meniscus tear. Likewise, if someone is feeling perfectly healthy and without pain, they would expect these images to show nothing “wrong” with the discs, rotator cuff, bone, meniscus, etc.

Research in the medical field, however, is showing us this is not always the case. It is becoming clearer that some of these imaging findings may be misleading, and that having “abnormal” findings on an image is actually normal.

Abnormal is Normal

A couple of studies by Brinjikji et al. and Nakashima et al. in 2015 looked at MRI images of 3110 low backs and 1211 necks, respectively. Each of the images were taken on individuals WITHOUT back or neck pain. I repeat… NONE of the individuals which were imaged during these studies had ANY pain in the areas being imaged.

They found “abnormal” findings such as disk degeneration and disk bulges in a large number of these people who had no pain at all. In fact, 37% of people in their 20’s, 68% of people in their 40’s, and 88% of people in their 60’s had disk degeneration in their low back. As well as 30% of people in their 20’s, 50% of people in their 40’s, and 69% of people in their 60’s having disk bulging in their low back (1). Likewise, 73.3% of males and 78% of females in their 20’s had disk bulging in their necks, and the frequency of these findings increased with age from the 20’s to the 50’s (2).

Studies also report similar findings in the shoulder (3):

-          Sher et al. 1995: “54% of people over the age of 60 years without shoulder symptoms demonstrated a partial or full thickness rotator cuff tear”

-          Girish et al. 2011: “shoulder abnormalities including: subacromial bursal thickening, supraspinatus tendinosis and tears, and glenoid labral abnormalities, were identified in 96% of men who did not have shoulder symptoms”

-          Miniaci et al 2002: MRI findings in asymptomatic professional baseball players have demonstrated; rotator cuff abnormalities in the throwing shoulder (79%) and non-throwing shoulder (86%) and labral abnormalities (79%) in both shoulders”

And in the hip (4):

-          Frank et al. 2015: pincher lesions were found in 67% and labral injuries in 68% of asymptomatic individuals

And in the knee (5):

-          Bhattacharyya et al. 2003: 73% of asymptomatic 65 year old participants had a meniscal abnormality

I think you get the point. A majority of the population has “abnormalities” on images, without having symptoms associated with those abnormal findings. It is NORMAL to have these ABNORMALITIES! Based on the above information, it would be more of a surprise if an image found NO abnormalities. These abnormal image findings are a natural part of aging, and unfortunately none of us are getting younger. As we age, our body tissues slowly break down, or degenerate. This is the reason skin gets saggy, and we get wrinkles on our faces. We get these same “wrinkles” on the inside of our bodies. I don’t know about you, but I’m not walking around with face pain as I get more wrinkles, and the same is true about my inside wrinkles.

Findings ≠ Symptoms

So what does this mean? What is the significance of abnormal findings being seen on images of asymptomatic people?

This shows that the findings on an image, do not correlate to pain. We know this because there are LOTS of people walking around with those abnormal findings, who have NO PAIN at all.

An image of a body part does not take an image of pain. Pain cannot be seen on an image, it can only be felt by the person feeling it. An image is used by a medical professional to assist in the attempt to diagnose what is causing an individual’s pain. And the diagnosis all depends on which person is reading the image.

A Story

Consider this example: A 63 year old woman with low back pain goes to get an MRI. For some reason, over the course of 3 weeks she decides to get 10 MRIs of her low back at 10 different imaging centers which are read by 10 different radiologists. She then takes the 10 reports written on the 10 MRIs taken at 10 imaging centers by 10 radiologists and compares the results. What does she find? Ten reports which are pretty similar? Not even close…

I know this because this is not just a story. This was a research experiment done by Herzog et al. (2017), and when they compared the 10 MRI reports they found “marked variability in the reported findings.” There were 49 different findings across the 10 reports. NONE of the 49 reported findings were unanimously reported in all 10 MRI reports, and only ONE of the 49 findings appeared in 9 out of 10 reports (6).

Their conclusion: “where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome.”(6) Yikes… so where I get an image and who reads it primarily determines: what they find, whether or not I have surgery, and how well I do afterwards, for a finding which most of the population my age might also have, but who don’t necessarily have pain from the same thing? That’s kind of scary!

A Time and A Place

Now don’t get me wrong. There are definitely instances when imaging is appropriate and needed for musculoskeletal symptoms.

One of these instances is when a clinician observes a cluster of “red flags” or warning signs and symptoms that something more severe may be involved. As well as if an individual fails to improve with conservative treatment, or their condition worsens.

Another example is when there was a significant trauma associated with the injury. Trauma alone may not be the deciding factor, as there are sometimes established rules in place to guide decision making on obtaining images for certain body regions to rule out fractures such as the Canadian Cervical Spine Rules, Ottowa Knee Rules, or the Ottowa and Bernese Ankle Rules.

Any well-trained physical therapist will be familiar with these signs, symptoms, and rules, making appropriate referrals for imaging or to the most appropriate specialist when the situation is warranted.

Recommendations for Care

As well as recommendations and rules being in place for when imaging should be obtained, there are also recommendations for when imaging for certain situations is not appropriate.

For example, the American College of Physicians’ Clinical Guidelines state that “clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific” (atraumatic) “low back pain (7).” This was also reiterated in a recent online series of recommendations about low back pain published by the Lancet Low Back Pain Series Working Group in 2018 (8).

Research states that “an exercise based approach produces equivalent outcomes when compared to surgery for those diagnosed with… rotator cuff tendinopathy, and those with atraumatic partial and full thickness tears (3).” So is imaging necessary in individuals with pain from expected diagnoses which a majority of the population has, and which respond favorably to conservative treatment?

Likewise, Azam and Shenoy (2016) recommend a new algorithm for treating meniscus tears, in which surgery is reserved for those individuals with traumatic injuries, locking of the knee, and those who fail conservative treatment (9). So if there is no trauma and no knee locking, is an image needed in order to initiate conservative treatment (which, by the way, is the recommended “first-line treatment of degenerative meniscus tears” by Azam and Shenoy)?

So please, before blindly agreeing to be x-rayed or being placed in an MRI tube, understand why the image is necessary, and how the findings of the image will potentially change the recommended course of treatment for the particular condition or symptoms.

Resources:

(1)    Brinjikji, W., 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.A4173.

(2)    Nakashima, H., et al., Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. SPINE, 2015; 40(6): 392-398.

(3)    Lewis, J., Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, 2016; 23: 57-68.

(4)    Lubowitz, J.H., Editorial Commentary: Hip Imaging Studies Suggest Significant Pathology in Asymptomatic Individuals. The Journal of Arthroscopic and Related Surgery, 2015; 31(6): 1205-1206.

(5)    Troupis, J.M., et al., Magnetic resonance imaging in knee synovitis: Clinical utility in differentiating asymptomatic and symptomatic meniscal tears. Journal of Medical Imaging and Radiation Oncology, 2015; 59: 1-6

(6)    Herzog, R., et al., Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 2017; 17: 554-561.

(7)    Chou, R., et al., Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med, 2007; 147: 478-491.

(8)    Foster, N.E., et al., The Lancet Series- Low back pain 2: Prevention and treatment of low back pain: evidence, challenges, and promising directions. http://dx.doi.org/10.1016/S0140-6736(18)30489-6

(9)    Azam, M. and Shenoy, R., The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature. The Open Orthopaedics Journal, 2016; 10: 797-804.