Debunking the Myth That Imaging Is Essential for Pain Treatment

Firstly, what is musculoskeletal (MSK) pain?

This is a broad term that refers to discomfort or pain that occurs in the muscles, joints, bones, tendons, ligaments, and other parts of the musculoskeletal system. The symptoms of musculoskeletal conditions may include localized or widespread pain, stiffness, limited range of motion, swelling, and muscle weakness. For example, maybe you feel a strain in your shoulder after moving boxes all weekend to your new home. Or, your knees hurt during a long run. Maybe you’re not entirely sure when, how, or why your pain started, but you decided it’s time to seek answers. In your recovery journey, read along to understand why early imaging is often not the best place to start.  

Why NOT Imaging First?

Early imaging can lead to unnecessary surgery - yes, surgery 😧:

There is a strong association between early imaging and surgery for those with low back pain. Receiving an MRI early on led to a 3-times increase in surgery. For the patients who underwent surgery, unfortunately, there were no differences in outcomes after one year. For many MSK conditions, imaging can lead to over-diagnosis and over-utilization of medical services, including a risky surgery!

Decreased radiation exposure:

Images have differing levels of radiation exposure, for example, an x-ray has less exposure to radiation while CT scans use higher levels. In specific scenarios, the benefits of receiving an image outweigh the radiation exposure, but why not avoid this if possible? For context, approximately 5% of patients at Aware Health are referred for imaging, and the other 95% can improve pain and function without imaging, ultimately minimizing radiation exposure.

Imaging does not tell the whole story:

Imaging actually tells us very little in most MSK cases. There’s a very high incidence of images showing abnormalities in asymptomatic people. One study found that while 37.4% of adults over age 60 showed knee osteoarthritis (OA) on an x-ray, only 12% of these adults had knee pain. This means more than 20% of this population did NOT have knee pain or OA symptoms, but based on their x-ray, they would be diagnosed with knee OA. This diagnosis often fast tracks patients towards an unnecessary knee surgery.

Additionally, pain does not necessarily equal tissue damage. The root cause of pain is often not reflected in the diagnosis, such as osteoarthritis. Rather, the cause of pain often goes alongside impairments in mobility or strength, movement patterns, or activity level - all of which can improve with non-surgical treatment! Imaging only shows the passive structures, but does not show the whole picture (pun intended). Also, pain can be complex, involving factors and psychosocial elements that imaging cannot capture.

Cost effectiveness:

An MRI can cost up to $2,000 or more out of pocket, even with insurance. And, if you haven't met your deductible, these costs may be even higher. Even for a 'simple' x-ray, you can expect to be billed for the primary care visit, the x-ray referral, the x-ray itself, and all follow-up care to discuss results, adding to hundreds once all is said and done. Though you will likely be referred to physical therapy for your pain, in the absence of a fracture, x-rays often do not change the physical therapy treatment plan.

As you can see, imaging is more complex than initially thought, and there are many factors to consider before receiving imaging for your musculoskeletal pain. 

What Steps Should Be Taken Instead?

See a Doctor of Physical Therapy!

Physical therapists are specialists in diagnosing orthopedic and musculoskeletal conditions through clinical evaluation rather than imaging. Your specialist will gather information about your medical history, symptoms, and perform physical examinations to get to the source of pain. If imaging is needed, your physical therapist will work with your healthcare team to order the proper imaging. And, Aware does this all through telehealth!

Do not fear movement:

Imaging can give patients a false sense of being “broken” or “abnormal” and lead to fear of activity and movement. Instead, your physical therapist will focus on your symptoms and impairments and create a treatment plan centered around movements, stretches, and pain management techniques that improve your function and pain. The musculoskeletal system loves movement, so movement is the best thing you can do to help pain! It’s about finding the right treatment plan unique to you.