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When Should I Get A Scan?

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“We’ll get a scan so that we know exactly what is going on.” This is a common phrase we hear as clinicians, as patient’s and practitioners’ alike search for a diagnosis or “label” to their condition, ultimately as a way of helping to guide appropriate management.

As Adam Meakins pointed out in his recent blog on The Sports Physio, ‘there is still a commonly held belief by both patients and many clinicians that an MRI or Ultrasound image of a herniated disc, or degenerative joint or a torn tendon can explain why things hurt or are not functioning properly.” As Adam explained, “in a lot of cases it isn’t as simple as this, and the planning of interventions and treatments using medical images alone needs to be questioned and challenged a lot more.”

At times it can be simple – we have a fall and break our ankle or wrist. The resultant acute trauma and pathology (broken bones and soft tissue damage) will cause pain and disability, and help to guide appropriate treatment and management of the injury.

What about the instances where you have not had an incident of trauma though? Or if enough time for healing a structure has occurred but pain is persisting. This is where things get a little more complicated and grey, and it is not as simple as attributing particular findings on imaging as the specific cause of a patient’s pain.

This has come to light with significant evidence in recent years to demonstrate that many worn out, degenerative or torn structures seen on scans (such as MRI’s and Ultrasound) are also commonly found in people who aren’t suffering any pain or disability.

So, as you can see, it’s not as simple as attributing a ‘defect’ found on imaging to a particular painful presentation. It would appear that in many cases, these so called structural defects are in fact normal signs of aging.

This has been highlighted in many studies, across many different anatomical regions.

Guermazi et al found that many common pathologies seen in knee scans - such as meniscal lesions, synovitis and articular cartilage damage are found equally, if not more in people without pain as those with pain.

Brinjiki et al showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.

Nakashima et al showed in their study of over 1200 subjects, that many pathologies were reported on neck MRI in people without pain or dysfunction.

In the shoulder, many studies have painted a very similar picture. Grisih et al found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. Teunis et al also showed an increasing prevalence with age of rotator cuff tears that actually don’t result in pain or dysfunction. They showed that up to 65% of subjects with a rotator cuff lesion on imaging were found to be asymptomatic.

We can see from all of these studies that it is becoming increasingly evident that we simply cannot rely on medical imaging alone to accurately determine the reasons for a patient’s pain and dysfunction.

While it is important to note that medical imaging clearly does have a role to play in aiding diagnosis and management of patients, it is equally as important to make sure we are using this in the most sensible and appropriate way. Essentially, we should never use a scan alone to guide a patient’s diagnosis and management. They should always be used in combination with a thorough clinical assessment, to ensure consistency between the findings.

In the majority of cases, a thorough, objective, clinical examination is going to provide much more reliable information to help ensure appropriate management of a patient’s presentation. In many of these cases, this can then negate the need to undertake a scan at all, saving both the patient and the health care system significant time and money, without compromising the outcome for the patient. At times a scan may be ordered purely with the rationale of reassuring the patient about their condition. This can in fact be counter-productive to patient outcomes, with evidence suggesting that patients undergoing unnecessary scans that aren’t clinically indicated, often to help reassure the patient about their condition, actually “can cause more fear, angst and harm.” (Meakins, 2017)

In many patients that we see at NWPG, the primary contributing factor to their condition is often a different structure to a reported pathology that has been identified on imaging – findings that appear consistent with the research outlined above, as well as current neuroscience research on pain. This further validates why we use the approach we do – the Ridgway Method - (link to why do a whole body assessment) – which utilises a thorough, whole body assessment for each patient to help solve the underlying cause of their pain and dysfunction.

References:

Meakins, A; https://thesports.physio/2017/01/10/a-picture-is-not-always-worth-a-thousand-words/. The Sports Physio blog. Jan 2017.

Guermazi A et al; 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.

Brinjikji W et al; 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.

Nakashima H et al; Abnormal findings on magnetic resonance imaging of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8. doi: 10.1097/BRS.0000000000000775.

Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971

Teunis T et al; A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014 Dec;23(12):1913-21.