Debunking Common Misconceptions about Imaging

Myth #1: Imaging cannot always show the cause of pain

When you experience pain and undergo imaging, such as an MRI, to identify the cause, it is important to consider that certain abnormalities detected in the imaging may actually be common in people without symptoms. For example, a study conducted by Horga et al in 2020 found that nearly all knees of asymptomatic adults showed abnormalities in at least one knee structure on MRI, including meniscal tears in 30% of cases. Similarly, a study by Barreto et al in 2019 concluded that most abnormal MRI findings were not significantly different in frequency between shoulders with and without symptoms. Therefore, many of these imaging findings are now considered normal, age-related changes similar to the natural aging process of the skin or hair. So, if you were to be in a car accident, develop low back pain, and receive imaging that reveals an abnormality, it is important to understand that this finding may have been present before the accident and may not be directly related to your current symptoms. It is crucial to remember that while your pain is real, it may not always be visible through imaging. When it comes to imaging, if you actively search for a connection, you are likely to find one.

Myths 2# : Imaging results may not accurately predict your outcomes

Just because your symptoms are correlated with your x-ray or MRI doesn’t necessarily mean that the worse the imaging looks, the worse your symptoms, function, and long-term recovery will be.For example, having bigger disc herniations or greater nerve compression doesn’t automatically mean that you won’t recover as well. It is possible to have a large disc herniation and still experience quicker improvement compared to someone with a smaller disc herniation.

Likewise, symptoms associated with osteoarthritis may not always align with the degree of change observed on imaging. You can have minimal-to-no pain or loss of function, even if significant bone spurs and joint space narrowing are present.

This is why it is important for medical professionals to avoid telling patients that their knee is “bone-on-bone” or that their hip x-ray is the “worst I’ve ever seen.” Often, the impact of such words can be more harmful than the actual findings on the imaging.

Myth #3: Addressing the appearance will resolve the discomfort

Despite previous discussions, it is logical to assume that if you have symptoms and corresponding imaging findings, addressing those imaging findings would resolve the symptoms. However, the reality is not always that straightforward.For instance, a systematic review conducted by O’Connor et al in 2022 concluded that arthroscopic surgery for degenerative meniscal tears offers little to no significant benefit in terms of pain relief or improved function. It is also unlikely to enhance knee-specific quality of life and may not achieve better treatment outcomes compared to a placebo procedure.

Another study by Persson et al in 1997 compared the effectiveness of surgery, physical therapy, and cervical collar use in treating cervical radiculopathy (a condition characterized by neck-related nerve pain, muscle weakness, and sensory changes). The study found no significant differences in outcomes between surgical and conservative therapies after one year.

It is worth noting that I have intentionally provided only a few examples per section to keep this blog concise. However, numerous studies have shown similar findings across various diagnoses and body regions.

As imaging does not always reveal the underlying cause of pain or predict long-term outcomes, it is crucial to carefully match your clinical presentation with your imaging findings to determine the most appropriate course of action. It is important to note that this may not always be possible.

Similar to a cut on your skin, many conditions can heal or improve on their own. Although a visible scar may remain, it typically does not cause lingering issues and may even fade away over time.

Myth #4: Rehabilitation is solely determined by imaging results

Treating someone with a disc herniation typically involves performing repeated extensions or repetitive arching of the low back. Physical therapists and those who have researched this question often consider these methods effective.

However, I didn’t mention where the disc herniation occurred – in the lower back or the neck. Nor did I mention if the person had any symptoms. If they did have symptoms, what if they experienced relief with repetitive flexion or bending forward? Let’s consider the context!

Two individuals may have the same diagnosis based on their imaging results, but this snapshot of their anatomy doesn’t provide information about their age, lifestyles, goals, sleep habits, what alleviates their symptoms, or what exacerbates them, and so on.

Focusing solely on an image and its perceived implications can lead to a situation where the expectations set by that image become fulfilled. For instance, someone may believe that they cannot run because their knee is bone-on-bone, or that they should stop going to the gym because of a herniated disc at L5-S1. Another example is someone giving up golf due to a pinched nerve in their neck. However, it is important to keep in mind these four points:

1. Many so-called “abnormalities” are commonly found in individuals who do not experience any symptoms.
2. Imaging results do not always accurately predict long-term outcomes.
3. Some changes identified through imaging can resolve on their own without any intervention.
4. Even in cases where imaging changes persist, symptoms and overall function can still improve.

Imaging plays a role in rehab similar to how a compass aids in navigation. When functioning properly, it can guide us towards our intended destination, but it cannot provide us with the most optimal route or help us overcome obstacles. Do not allow a single image to hinder your progress in your rehabilitation journey.

Myth #5: The Importance of Imaging is Negligible

Imaging is important when used and explained correctly. After an injury to the ankle and foot, the Ottawa Ankle Rules, an evidence-based guideline, helps doctors decide if x-rays are necessary to check for fractures. A similar set of rules exists for the neck. These guidelines help doctors avoid excessive imaging while identifying those who require specific medical treatment for their injuries.

In most cases, low back pain is not caused by serious issues. However, there are rare instances when it may be linked to conditions like cancer or infection that need immediate medical attention. X-rays and MRIs are crucial in such situations. There are also times when imaging plays a role in rehabilitation or is used to make decisions about the suitability of surgery.

In summary

There are 5 common misconceptions about MRIs and x-rays:

• Misconception #1: Imaging reveals the cause of pain

The truth is that many of these “abnormalities” are actually common in people without symptoms and are considered normal age- related changes, similar to wrinkles or graying hair.

• Misconception #2: Imaging predicts your outcomes

The reality is that imaging doesn’t necessarily determine your future, especially if it doesn’t align with your current symptoms and function.

• Misconception #3: Fixing the image fixes the pain

The fact is that we don’t always need to find something to fix because our bodies have the ability to heal and improve on their own.

• Misconception #4: Imaging dictates rehab

Actually, you, as an individual, have a greater influence on the rehabilitation process than a single, detailed picture of your anatomy.

• Misconception #5: Imaging never matters

While imaging can be important in certain cases, when it’s not used or explained properly, it can result in higher costs and worse outcomes.

References

1. Horga LM, Hirschmann AC, Henckel J, Fotiadou A, Di Laura A, Torlasco C, D’Silva A, Sharma S, Moon JC, Hart AJ. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol. 2020 Jul;49(7):1099-1107. doi: 10.1007/s00256-020-03394-z. Epub 2020 Feb 14. PMID: 32060622; PMCID: PMC7237395.
2. Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg. 2019 Sep;28(9):1699-1706. doi: 10.1016/j.jse.2019.04.001. Epub 2019 Jul 3. PMID: 31279721.
3. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010 Mar;92(2):147-53. doi: 10.1308/003588410X12518836438840. Epub 2009 Nov 2. PMID: 19887021; PMCID: PMC3025225.
4. Karppinen J, Malmivaara A, Tervonen O, Pääkkö E, Kurunlahti M, Syrjälä P, Vasari P, Vanharanta H. Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine (Phila Pa 1976). 2001 Apr 1;26(7):E149-54. doi: 10.1097/00007632-200104010-00015. PMID: 11295915.
5. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019 Apr 27;393(10182):1745-1759. doi: 10.1016/S0140-6736(19)30417-9. PMID: 31034380.
6. O’Connor D, Johnston RV, Brignardello-Petersen R, Poolman RW, Cyril S, Vandvik PO, Buchbinder R. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev. 2022 Mar 3;3(3):CD014328. doi: 10.1002/14651858.CD014328. PMID: 35238404; PMCID: PMC8892839.
7. Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J. 1997;6(4):256-66. doi: 10.1007/BF01322448. PMID: 9294750; PMCID: PMC3454639.