Hint: It might not be what you think.
Anybody that has dealt with an injury has likely come across the idea of imaging at some point or another. Most people get some type of imaging done very quickly after their pain starts. Whether being referred by a healthcare professional or pushing for one yourself, the general idea is that imaging will give you answers about what is going on, what is causing your pain, or how your pain can be fixed.
But how much does imaging actually help? How reliable are the results from medical imaging? Read on to find out.
Does this sound like you?
“I can’t do that anymore. I have arthritis in my back.” “Doc said I have the knees of a 75-year-old and I’m going to need a replacement in the future.” “…worst shoulder they’ve ever seen!” “I have a disc bulge at L5-S1…”
I hear these types of things on a daily basis in my line of work. You get imaging to hopefully find out what is “wrong with you.” What needs to be “fixed.” You hope that after going through the long process of finally getting into that MRI machine, that it will give your healthcare team a road map to what to do.
But then your results never actually get explained to you in a way that you can comprehend. You just get told a bunch of big, scary-sounding words and then get sent out of the door. No explanation of what those words mean, or how it may affect your life moving forward. Or even worse, they offer you some things you can do... pills, surgery, and you have to stop doing that activity that you love.
Now you associate all of your aches and pains to the things that showed up on your image. Just like those quotes up above.
What if they images don’t have all of the answers? That the diagnoses you received might not be as bad as it sounds? Because that very much may be the case. Let’s go over what the research says about how much imaging findings correlate to pain. Let’s start at the top.
Finding non-existent problems with the neck...
In 2015, Nakashima et al (1) put together a study that looked at a total of 1211 healthy volunteers. "Healthy", meaning these people had no pain, numbness, or tingling of any kind. No history of brain or spinal surgery either. The volunteers varied in age from 20-79 years old, so your age group was likely covered. There was also a very wide range of jobs represented, from office workers to teachers and students, to construction workers, to people that were unemployed. All of these volunteers had an MRI performed on their neck between 2006 and 2008.
They found that 87.6%of the volunteers had disc bulges. The frequency and severity of the disc bulges increased with age. They also found that 5% of the volunteers had narrowing of their spinal canal (spinal stenosis). One individual had a 75%reduction in the spinal canal area. That means that there wasn’t very much space left in there. Remember, none of these people had any type of symptoms related to these findings.
And the lower back...
In 2015, Brinjikji et al (2) compiled 33 different studies looking at 3110 people. Again, all 3110 people included in the study were pain-free. Here were their findings:
Okay, so you don’t have to try to figure out what all of that means—this table shows all of the different “diganoses” present in a large amount of the people studied, with it being more and more common as you age. “Disc degeneration” (or degenerative disc disease) was present in 37% of people in their 20’s and 96% of people in their 80s. So…are these things really a cause of pain, or just a normal age-related change to our tissues?
A more recent study was done in 2019 by Rahyussalim et al (3) that had similar findings. Was the degeneration they found in the spines of the people studied completely irrelevant? No. But could it predict the amount of low back pain somebody was in? No.
So maybe you are more worried about those disc herniations that you keep hearing about. I feel that it is common sense to think that the larger the bulge, the more severe the symptoms that you get, right? Nope. A study by Gupta et al (4) followed 368 patients with confirmed disc herniations to see if the size of their disc herniation could predict the ones that needed surgery. Out of 368, want to take a guess at how many needed surgery?
It was 32. The average size of herniation between those that didn’t have surgery and those that did was 31.2% of the spinal canal and 31.5% of the spinal canal, respectively (so not different at all). Other studies have shown that 90% of disc herniations heal on their own over time. So are we maybe jumping the gun on looking at surgery and injections immediately after getting your image results?
Let's keep moving.
Horga et al (5) looked at the knees of 115 sedentary adults in 2019. None of these people were injured or had any pain going on at the time of study. They took an MRI of both knees for all 115 people, that’s 230 knees if you aren’t great at math. Out of all 230 knees…..97%had an abnormality show up on the MRI. Yes, you read that right, 97%. Almost all of them. Showed some type of finding, including: meniscus tears, cartilage breakdown, and tendon issues, among others. None of these people had had knee pain, a knee injury, or a knee surgery of any type, ever. They did have one thing in common though….none of them were meeting the physical activity guidelines of 150 minutes of moderate-intensity exercise per week.
I get so many patients that come in telling me about their shoulder arthritis or torn rotator cuff that was found on imaging….my first question: did they image the other (the pain-free) side?
Barreto et al (6) did in 2019. They took an MRI of both shoulders on people that were dealing with shoulder pain in only one of those shoulders. Do you know what they found? Almost no difference between the two shoulders on imaging (see table). Rotator cuff tears, arthritis, and other things. Nearly equal on both sides, but only one side had pain. How could that be?
The truth about the accuracy of medical imaging
Okay, so this is all interesting, but imaging has to at least be accurate, right? They can see everything that is going on and at least have a direction to go?
A study by Herzog et al (7) in 2017 showed that this may not exactly be true either. They took one person (a 63-year-old woman with a history of back and right leg pain) and had her get an MRI at ten different local MRI centers. What they found was that across the ten MRI reports, there were 49 distinct findings. Not a single one of the reports fully agreed on any of these findings, and there was only one finding that made it onto nine of the ten reports. They concluded that your imaging results may depend on who was working that day, what location you went to, and if your GP or surgeon reviewed the images (and how experienced they are with reviewing imaging).
So what do I need to know?
Imaging does, and always will, have a place in medicine. It is amazing technology that can give us an enormous amount of information. The problem is that imaging has become the first step in healthcare to diagnose conditions and find the reasons behind pain. There is one enormously huge thing that happened as everybody began to rely on imaging for answers… they stopped thinking about you as a human being. Everything was based on those pictures. They saw a picture of a telephone, and assumed that the telephone was ringing. But as we can see in the studies that I referenced above... sometimes it’s just a picture.
I did not write this so that you completely disregard what your imaging says. But maybe we tend to run to imaging a little too early, and get stuck on what was found. Maybe we get sucked into the idea that we need surgery or some type of procedure done to us in order to “fix us,” when in reality there is nothing to be fixed. I’m not saying that whatever was found on your image is irrelevant, but also that it may be less associated with your symptoms than you think. I have seen countless people that have avoided specific activities for years due to what was found on their imaging, and after working together for a few weeks or months, they were back to doing those exact activities. This has included things like squatting, lifting overhead, running, and even something as simple as bending over (yes, I mean any type of bending, at all). We need to step away from relying on imaging and trying to get fixed. We need to focus on the things that matter: sleep, diet, stress management, and proper training.
If this has struck a chord with you, please reach out. If this sounds like someone that you know, send them this post and get them in touch with me. You do not have to be sentenced to a life of pain and misery because of a picture. I’d love to help you get back to into the gym or on the court.
Thanks for reading,
Jacob Erbes PT, DPT, CMFA, CF-L1