To image or not to image? That is the question.

Many people believe that they need to have an X-ray, MRI, CT scan or ultrasound in order to “find out what’s wrong” and obtain a diagnosis. These questions can be answered however with a good clinical history and physical examination by your physiotherapist, saving time and money on unnecessary imaging. Imaging should only be performed if it will improve the health outcome of the patient and influence treatment.

Incidental degenerative lesions are common and are expected to increase as we age. In many areas of the skeletal system (lumbar spine, cervical spine, knees, tendons), structural changes have been shown not to correlate well with symptoms. 30-40% of young to middle-aged people have degenerative changes in their cervical spine that are asymptomatic. Abnormal changes in the Achilles tendon were found in 32% of asymptomatic tendons assessed by ultrasound and 65% of rotator cuff tears have been found to be asymptomatic. Many “abnormalities” are not clinically relevant and won’t progress. This needs to be explained to patients to avoid unnecessary anxiety regarding their imaging findings.

Patients and medical personnel can be led astray by incidental imaging findings that may not actually be the source of the patient’s symptoms. This can result in an inappropriate treatment regime being pursued. A good history and physical examination are usually all that is required.

The Royal Australian College of General Practitioners (RACGP) recommends that imaging should not be used as a first-line diagnostic tool and should only be considered if it will influence treatment and impact on the health outcome of the patient. An example here would be utilising imaging for a suspected stress fracture which would determine how a patient’s weight-bearing status and activity levels are managed.

In the end, we need to be realistic and patient when it comes to the rehabilitation of our musculoskeletal aches and pains. “Getting better” is influenced by our age, the structure involved, work/life/sporting commitments, physical characteristics (strength/mobility/flexibility) and compliance with a rehabilitation programme. Medication may ease our symptoms but does not address the healing of tissues or cause of the symptoms.

Imaging has its place in musculoskeletal care but has its limitations and should not be relied upon heavily for diagnosis.