Medical Imaging: The Good, Bad and Ugly

Medical Imaging for this article’s purposes consists of MRI, xray, CT scan, etc (there are a plethora of other tests, but these are the most common for musculoskeletal conditions). 

These are typically seen as the gold standard for diagnosing musculoskeletal injury and conditions. They’re very valuable because they provide a much deeper look at what's going on. They also provide significant insight that we couldn’t receive without surgically going in and looking.

For instance, If I fall and twist my knee, and am having instability, pain, swelling, etc. The MRI will do a fantastic job at ruling out an meniscus or ligament tear. This would help the provider and patient in decision making on surgical or non surgical outcomes. THIS IS A GREAT TOOL for many instances. 

However, it’s not all peaches and cream with imaging. 

Here’s where it gets tricky. 

Some conditions are completely normal for most people and medical imaging doesn’t give us the whole story. This is a fact and we know this through the research. A study by Yamamoto (2011), proved that of the 283 subjects, 65.4% showed rotator cuff tears and had no symptoms involving the shoulder. 

Another study by Nakashima (2015), analyzed 1,211 HEALTHY volunteers with NO PAIN ages 20-70 years for presence of disc bulging. “Most subjects presented with disc bulging (87.6%), which significantly increased with age in terms of frequency, severity, and number of levels. Even most subjects in their 20s had bulging discs, with 73.3% and 78.0% of males and females. (See the visual below for more examples in the study. Remember, these percentages were people WITHOUT pain/symptoms!​

Another study done by Herzog (2017) took ONE single patient. The patient had 10 MRIs done in 3 weeks taken by 10 different radiologists. What they found might surprise you! 49 different issues were reported…. but ZERO findings were reported across all 10 reports! This goes to show the degree of high variability in the reported findings of the SAME patient within a short time period. 

As you can see, it is extremely important to match up clinical findings with the imaging. This gets even more important with chronic conditions that just gradually came on over time. So if a 50 year old presents with generalized low back pain across both sides of the lower back and wants to get an MRI, a bulged disc  is more likely than not going to be present on the MRI ! The conversation quickly can move to discuss surgical options (discectomy or even fusions) when in reality we don’t know for certain if the bulged disc is causing the pain. Especially because there were no signs of radiculopathy (pain down into the leg, numbness, tingling, etc)

This is why it’s critical to match clinical signs and symptoms with the MRI. 

MRIs help exclude serious and sinister issues, but they don’t always tell us exactly what is causing pain. This has led much of the medical community to simply call these common conditions “wrinkles on the inside.” When you hear words like “degenerative disc disease, arthritis buildup, spondylosis, bone on bone” don’t panic. Some amount of this is completely normal with aging! 

To recap: medical imaging as a GOOD THING. And it provides us with many answers we would otherwise wouldn’t have. However, we need to use caution especially with decision making on more chronic conditions and conditions that don’t match up clinically!

Cheers!

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