You're in pain and would like a prescription for an X-ray or MRI to 'see what's wrong.' This is a perfectly natural request. After all, how can you treat something if you don't know exactly what's broken? This logic seems obvious, but the reality is more nuanced.

Good news: For the vast majority of musculoskeletal pains, a clinical examination with your physiotherapist is enough to make a diagnosis and establish an effective treatment plan.¹ Undergoing imaging would often not change the treatment. What science tells us about medical imaging:

• MRI 'findings' are extremely common in people who don't experience any pain
• What the image shows doesn't always correspond to what is causing the pain
• Imaging can sometimes cause more worry than it provides answers
• In most cases, imaging does not change the recommended treatment plan

This guide helps you understand when imaging is truly useful. To learn more about the relationship between what is seen and what is felt, read our article on osteoarthritis and pain.

Imaging doesn't always show what is causing the pain

When we have an injury or pain, it's in our nature to want to know the exact structure that is hurting us.

After all, not knowing what hurts is like not knowing why you have a water leak in the basement: it's anxiety-provoking!

We often place a lot of hope in X-rays, ultrasounds, scans, and magnetic resonance imaging (MRI). We think that by taking a picture of the area where we feel pain, we should be able to find the culprit causing it.

But that's largely untrue ! In the vast majority of musculoskeletal injuries and pains (pains in joints, muscles, tendons, nerves, menisci, etc.), the clinical examination (assessment) with the physiotherapist is enough to make the diagnosis AND to determine the best course of action.

Moreover, undergoing a medical imaging exam will not change the treatment plan to heal the injury. What does that mean?

Physio assessment

=

Diagnosis Y and treatment plan X

______________

Physio assessment + undergo an imaging exam

=

Still diagnosis Y and still treatment plan X

Therefore, a large portion of the imaging exams that are done are completely useless in helping you. It's quite disappointing when we feel like we're getting them precisely to improve our situation!

Even worse, recent studies show that simply receiving a medical imaging result is enough to increase anxiety and negative perception of the injury, in addition to increasing the time it takes to get better. Who would have thought that getting an X-ray for our back pain could be enough to significantly delay our recovery?

So, how can we explain that medical imaging doesn't always help us? There are three fundamental concepts to understand to answer this question:

Firstly, NO technology to date can visualize pain. Pain is an invisible phenomenon that can only be felt and experienced by an individual. Pain can be compared to an emotion. No one can 'see' sadness. We can see someone who is sad, just as we can see someone who is in pain, but sadness and pain are only experienced by the person suffering from them. Secondly, the things we see on medical imaging (wear and tear, osteoarthritis, tears, etc.) are, in part, normal findings associated with aging. The older we get, the more we have small tears here and there and wear and tear throughout our bodies. So it's normal to see these things, and they don't necessarily explain why we are in pain. Thirdly What we see on medical imaging is often just as present (and sometimes even more so) in people who don't experience any pain. For example, lower back osteoarthritis is found just as frequently in people with back pain as in those without it. This suggests that something other than what appears on scans explains why we feel pain. Nevertheless, medical imaging should not be completely dismissed. In cases of trauma or injuries that might require surgery, imaging can be necessary and very helpful! Physiotherapists are trained to determine if medical imaging is needed to create the best treatment plan for your injury.

To summarize, the vast majority of pain and injuries can be treated without the need for medical imaging. The treatment plan will rarely be modified following medical imaging. Pain is never visible on imaging, and its cause is rarely visible. However, when we suspect a fracture or another more serious injury, we will use imaging to rule out serious causes.

To learn more

To learn more on medical imaging, listen to the podcast « Talk to me about health » created by one of our physiotherapists, Alexis Gougeon. Episode #27 discusses this topic. 

Episode #27 of Parle-moi de santé (medical imaging)

You can also find the podcast episode on the following platforms:

Sources:

• Jarvik (2002). Diagnostic evaluation of low back pain with emphasis on imaging. Annals of internal medicine.
• Murphy L (2008). Lifetime risk of symptomatic knee osteoarthritis. Arthritis Care & Research: Official Journal of the American College of Rheumatology.
• Van Tulder (1997). Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies. Spine.