"Do I Need an MRI or X-ray Before Physical Therapy?"
Some wonder if they should get an X-Ray or MRI before beginning physical therapy so they'll know what's wrong first. Others can't understand how orthopedic manual physical therapy can help them when their imaging reveals "something wrong" inside their body - a bulging disk, arthritis, degenerative disc disease, a pinched nerve, and so on.
Both lines of reasoning are logical. However, understanding the limitations of imaging may help. While the technology is quite impressive, and it certainly has its place in health care, no form of imaging (X-rays, MRIs, CT scans, etc) has the ability to correlate the picture to the pain. In other words, imaging cannot tell you why you hurt. Therefore, it is not reliable in guiding treatment. While it may be necessary in the presence of red flags, following severe trauma, and when no improvement of the pain is experienced after comprehensive and competent conservative care, it typically has limited utility in diagnosing pain.
According to several studies, a large percentage of pain-free people have "something wrong" in their imaging; there may be bulging or degenerative discs, arthritis, labral tears, stenosis, spondylolisthesis, degenerative joint disease, and the list goes on. [i],[ii],[iii],[iv],[v],[vi],[vii],[viii],[ix],[x],[xi],[xii]
A study by Nakashima et al in 2015 considered MRI findings of the necks of 1,211 volunteers. Of these volunteers, 87.6% had bulging disks. What percentage of these volunteers do you think had pain or required surgery? None. Not one of them. Zero. To qualify for this study, every volunteer had to have no neck or arm symptoms of any kind. Again, 87.6% had bulging disks; 0% had pain. Zero. None. [xiii]
Similar studies have also concluded that imaging cannot differentiate the patients who have pain from those who do not have pain. The majority of patients will have a positive finding, or "something wrong", whether they have pain or not.
Frank et al in 2015 published a systematic review on the prevalence of imaging findings suggestive of hip impingement. There were a total of 2,114 subjects. The prevalence of a cam deformity was 37%, the prevalence of hips with pincer deformity was 67%, and the prevalence of hips with labral injury was 68.1%. Guess what percentage had pain? Zero percent. [xiv]
Weber et al questioned if there is an association between radiological severity of lumbar spinal stenosis and disability, pain, or surgical outcome. The answer was simply, "no".
The study reported: "Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI, NRS back pain, or NRS leg pain scores. There were no differences in ODI, NRS back pain, or NRS leg pain scores after 1 year. The radiological severity of stenosis was not associated with change in ODI, NRS back pain, NRS leg pain, duration of surgery, length of hospital stay, or perioperative complication rates. Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making." [xv]
What about knee arthritis? A study by Culvenor et al in 2019 found that up to 43% of individuals 40 years of age and older have knee osteoarthritis in MRI findings - when they have no pain. [xvi]
To further elucidate the limitations of imaging, this study found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists' reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period. As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome. [xvii]
Another consideration are the outcomes after imaging. A study by Jarvik et al in 2003 noted that while patients and physicians preferred MRIs over X-rays for diagnosing low back pain, the only difference in outcomes was that patients were more likely to have surgery after getting an MRI. They conclude: "Rapid MRIs and radiographs [X-rays] resulted in nearly identical outcomes for primary care patients with low back pain. Although physicians and patients preferred the rapid MRI, substituting rapid MRI for radiographic evaluations in the primary care setting may offer little additional benefit to patients, and it may increase the costs of care because of the increased number of spine operations that patients are likely to undergo." [xviii]
Imaging can be valuable in the presence of red flags, following severe trauma, and when no improvement of the pain is experienced after comprehensive and competent conservative care. However, a thorough and comprehensive orthopedic physical examination - seeing the individual in action and performing a hands-on assessment - is the most valid way of examining a patient's pain and guiding effective treatment.
Further Information on Orthopedic Manual Physical Therapy
Click on any of the following links for more information:
Would you like a brief overview of the basics of orthopedic manual physical therapy?
Are you curious about the scientific mechanisms behind how orthopedic manual physical therapy works?
Have you ever wondered how pain works?
What should you consider when choosing a physical therapist for an orthopedic condition?
What's an evidence-informed approach to the examination and treatment of sacroiliac joint pain?
How should one perform manual therapy for spondylolisthesis?
Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit https://www.napervillemanualphysicaltherapy.com.
[i] Twomey L, Taylor J. Age changes in the lumbar spinal and intervertebral canals. Spinal Cord. 1988 Aug 1;26(4):238-49.
[ii] Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British journal of sports medicine. 2007 Nov 1;41(11):836-41.
[iii] Videman T, Battié MC, Gibbons LE, Maravilla K, Manninen H, Kaprio J. Associations between back pain history and lumbar MRI findings. Spine. 2003 Mar 15;28(6):582-8.
[iv] Taylor JR, Twomey LT. Age Changes in Lumbar Zygapophyseal Joints: Observations on Structure and Function. Spine. 1986 Sep 1;11(7):739-45.
[v] Kjaer P, Leboeuf-Yde C, Sorensen JS, Bendix T. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine. 2005 Apr 1;30(7):798-806.
[vi] Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after Rotator Cuff Repair: MR Imaging Findings in Asymptomatic Individuals—Initial Experience 1. Radiology. 1999 Dec;213(3):705-8.
[vii] Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan 1;77(1):10-5.
[viii] Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJ. Dead men and radiologists don't lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. The Annals of The Royal College of Surgeons of England. 2006 Mar;88(2):116-21.
[ix] Milgrom C, Schaffler M, Gilbert S, Van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. Bone & Joint Journal. 1995 Mar 1;77(2):296-8.
[x] Munk B, Lundorf E, Jensen J. Long-term outcome of meniscal degeneration in the knee Poor association between MRI and symptoms in 45 patients followed more than 4 years. Acta Orthopaedica Scandinavica. 2004 Jan 1;75(1):89-92.
[xi] Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC musculoskeletal disorders. 2008 Sep 2;9(1):116.
[xii] Major NM, Helms CA. MR imaging of the knee: findings in asymptomatic collegiate basketball players. American Journal of Roentgenology. 2002 Sep;179(3):641-4.
[xiii] Nakashima, Hiroaki, et al. "Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects." Spine 40.6 (2015): 392-398.
[xiv] Frank, Jonathan M., et al. "Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review." Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.6 (2015): 1199-1204.
[xv] Weber, Clemens, et al. "Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study." Spine 41.2 (2016): E78-E83.
[xvi] Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British journal of sports medicine. 2019 Oct 1;53(20):1268-78.
[xvii] Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal. 2017 Apr 1;17(4):554-61.
[xviii] Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, Robinson D, Staiger T, Wessbecher F, Sullivan SD, Kreuter W. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. Jama. 2003 Jun 4;289(21):2810-8.