FAQ Series - "Do I need an X-Ray or scan?"

Technology in medical imaging has improved in recent times but does this actually help clinicians to make a better diagnosis, and more important, effective manage pain, dysfunction or injury.

X-ray, CT scans, ultrasounds and MRI scans are among the more common types of imaging orders by GP’s, specialists, physio’s or chiro’s. Depending on what we are looking for, they allow for imaging of the body’s bone and soft tissue.

People suffering for a problem are often extremely keen to see exactly what is going on in an area affected by pain, swelling and reduced movement.

When Should scans or X-rays be requested?

A scan should be ordered by a clinician if it is likely to influence the treatment that is to be given. Examples include suspected:

• Fractures

• Tumours

• Blood clot

• Infections (Blood test)

• Significant neurological symptoms eg weakness, incontinence

• Significant musculoskeletal damage that requires urgent attention eg ruptured tendon, anterior cruciate ligament.

As a physiotherapist, we ask specific questions and perform tests that help differentiate between problems that are standard everyday complaints and those that require an exact diagnosis or further investigation with the assistance of imaging.

Can imaging be harmful?

Besides exposure the to radiation with a number of imaging methods, many of the changes that a seen in scans are actually very normal and may not at all be contributing to someone’s pain.

Example 1

Lower back disc bulges (slipped disc) - this is often a dreaded diagnosis and anything to do with a disc strikes fear into the back pain sufferer. There is a belief that any “damage”

The reality is though, disc bulges can be completely normal. Kupaswamy et al (2017) found that 37% of normal, pain free subjects had disc herniations and another 33% had degeneration of discs. So over two-thirds of the people had detectable lesions with their discs but none of them actually had pain.

Example 2

Rotator cuff tears - Ultrasound or MRI scans often show tearing of the tendons that connect around the shoulder joint. Again, these can be quite normal.

A study by Minagowa et el (2013) found that around 22% of subjects had rotator cuff tears but two thirds of these had no shoulder pain.

Example 3

Meniscus tears in the knee. Englund et al (2010) found that 61% percent of people in the study group had meniscal tears but no pain.

In these cases, people can be so concerned about a “tear” or a “herniation” that they stop doing things all together for fear of making it worse or increasing the size of the lesion. The reality is that the changes have likely been there for a considerable period of time and there is no reason why someone can regain normal function and have no pain.

By avoiding painful movements and activities all together, all that generally happens is increased sensitivity and reduced strength. This leads to further tolerance of load - the result - increased pain and reduced function.

With the help of a skilled physiotherapist, you can begin moving at a suitable level and then progress your load to get back to many things that you love - despite having a bulge, tear or herniation.