Sometimes we get so used to something we take it for granted or we expect it to always be a part of our lives. When an expectation has not been met, it can lead to frustration or questioning.
Health care is no different, it is a service provided to the public and just like any service it comes with expectations. When you see your doctor for an injury you might expect to get an x-ray or be sent for an MRI to help your doctor or other health-care provider make a clinical decision. Recent research has changed the role and use of certain interventions and The Choosing Wisely Campaign has been leading the change since 2014.1
The mission of this campaign is to reduce the use of unnecessary tests and treatments using scientific evidence. The overuse of diagnostic imaging is a major topic that the Choosing Wisely Campaign has focused on.
Diagnostic imaging has undeniably changed health service delivery and can be a powerful tool. However, the ability to see these things with diagnostic imaging also comes at a cost. As we will see later, we are just learning now that many of the “abnormalities” on imaging are actually the norm for our population.
As physiotherapists, imaging is a tool that can be used to confirm a diagnosis or to help decide the appropriate treatment plan or referral. However, unnecessary diagnostic imaging has the potential to cascade into further unnecessary testing and treatment.2 This can lead to increased anxiety, potential time away from work and other unintended costs to you as a patient. In relation to the cost to our publicly-funded health-care system it can result in billions of dollars of unneeded tests and increased wait lists to those that really require imaging.3 A paper published in 2019 outlaid some of the issues surrounding diagnostic imaging and stated:
“Steep increases in imaging can be attributed to technical improvements, physician and patient demand, and strong financial incentives. Medical imaging contributes to accurate disease diagnosis and improved treatment; however, imaging can also increase costs and potential harms, such as incidental findings, overdiagnosis, anxiety, and radiation exposure associated with increased risk of cancer. It has been estimated that 30% or more of imaging examinations may be unnecessary, costing approximately $30 billion annually in the United States.”2
Dr. Mike Evans has a popular YouTube channel that discusses the worth of screening tests you can view here. In the meantime, we will continue more specifically about diagnostic imaging as it relates to musculoskeletal injuries and pathology.
- Fractures: To some it might be surprising that you don’t get an x-ray after a fall or an injury even if you see swelling and other signs that make you think it might be a broken bone. There are many things that come before ordering an x-ray, such as watching you move the joint around the injured site, tenderness to touch, whether you can put weight on it, etc. All these questions and tests are part of established guides such as the Ottawa Ankle and Knee rules which help doctors and physiotherapists determine when an x-ray or CT scan should or shouldn’t be ordered. There are obvious times when diagnostic imaging is needed and times where they are not. So don’t panic if your ankle is the size of a grapefruit and the doctor decides not to x-ray it. It is most likely to avoid unnecessary testing and reduce your exposure to radiation. It is important to remember to follow up with your physiotherapist or doctor if you feel you aren’t recovering as expected whether you got an x-ray or not.
- Tendons and Muscles: Shoulder, hamstring, Achilles, and other tendons and muscles can all have tears in them. You may find it surprising to know that some tears found on imaging could have been there for years already without any symptoms or recognition of a previous injury. Depending on the situation, diagnosis can often be easily made through your history and some hands-on tests in clinic. If there are questions around whether or not you need surgery or some other intervention, you may be sent for a diagnostic ultrasound or MRI as those are most likely used for confirming tendon or muscle tears. However, in many cases, tendon and muscle injuries can be managed without surgery, meaning that imaging has limited value to helping you get better.
- Ligaments: Ligaments attach bones to other bones and damage to these can create instability in our joints. Sometimes it can be easy to tell if ligaments have been injured by the amount of extra movement you have in a joint. Again, if it looks like you might be heading for surgery, there is a good chance imaging will be done prior to surgery to confirm the extent of damage. Most often though the clinician will tell you what is injured, and you will be given a brace or splint to immobilize the ligament so it has a chance to heal on its own, without surgery.
- Back pain/neck pain: We know that back or neck pain can be disabling. It is tempting to try to use an x-ray or MRI to try and discover the cause of that pain and hopefully create a better treatment plan. When MRIs were first developed, they were constantly being used to try to discover the cause of the pain, which is the main reason why the use of imaging in health care has escalated so much. However, when MRIs were introduced there wasn’t a clear appreciation for what a normal spine looked like on MRI. So, when we saw all these “abnormal” findings on those images, we attributed those to be the cause of the pain. Fast forward to the present and research has shown that disc bulges, arthritis, etc. are quite common in those who are pain free.4 In truth, imaging and MRIs are not all that helpful for the vast majority of back injuries and should only be used when it would affect the management of back pain such as need for surgical intervention or suspicion on more serious pathology like a cancer.
But what about arthritis and degenerative disc disease?
This is one of the more frequently asked questions by patients when they receive their imaging results. Degenerative disc disease is a terrible name for the natural aging process in the spine as its name can invoke fear and anxiety in patients. Osteoarthritis is also a normal aging process that occurs as our cartilage thins out. We all age physically at different rates and our cartilage breaks down eventually but the severity of the changes seen on imaging does not necessarily correlate with severity of pain or other symptoms.
For example, recent studies have shown 97% of healthy, pain-free individuals have some sort of abnormality in their knees on MRI.5 The British Journal of Sports Medicine published an infographic that outlines common areas of abnormalities found on imaging for each part of the body.6 So, if you are discussing arthritis, or degenerative disc disease with your health-care provider or your neighbour remember that it is not always a big deal. You should focus on how you feel and deal with the aches and pains that matters most to you.
Regardless of the scenario or injury, as a patient considering whether you should agree to diagnostic imaging, you should be asking your health-care provider:
- Why do I need the test?
- How will the test help me?
- What are the risks to me if I do get the test?
- What are the risks if I choose not to get the test?
- How do I follow up to get my results?
Whether your family doctor, physiotherapist, or other health professional is suggesting you get an x-ray or other diagnostic imaging, they should be aware of the Choosing Wisely campaign and the risks of overuse of diagnostic imaging, and should be able to answer these questions.
- Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open. 2019 Oct 2;2(10)
- Smith-Bindman R, Kwan ML, Marlow EC, et al. Trends in Use of Medical Imaging in US Health Care Systems and in Ontario, Canada, 2000-2016. JAMA. 2019;322(9):843–856. doi:10.1001/jama.2019.11456
- Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.
- Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol 49, 1099–1107 (2020).
- Culvenor AG, Ferraz Pazzinatto M, Heerey JJInfographic. When is abnormal normal? Reframing MRI abnormalities as a normal part of ageing. British Journal of Sports Medicine 2021;55:761-762.