Have you had long standing pain in any area of your body? Chances are you have had some form of imaging done or have been recommended to do so. Whether x-ray, MRI, ultrasound, or CT, many people have imaging done for painful conditions that just don’t seem to resolve over time. As a chiropractor, I am often not the first healthcare professional that is sought out for a painful condition and in reality, I am one of the last professionals that someone turns to in these cases. Due to this, many patients have had imaging done to investigate their condition or are scheduled for some form of imaging by the time they see me. I often get questions about imaging findings or whether it is necessary, so I hope to shed a bit of light on some common answers I give to many of my patients.
First off is the question of what certain imaging findings mean for a patient and their condition. Many patients receiving imaging will simply receive a report after their imaging study and will rarely have a follow-up with their family doctor to discuss what was found. These reports are written by medical radiologists who have little to no clinical information on the patient and are simply writing out what they see. The reports themselves are written in terms that are far from plain language and typically contain terms that may be alarming to some if not explained properly. This creates a scenario where a patient has no hope of fully understanding exactly what their results are actually saying which can negatively contribute to their pain experience. A patient receiving an X-ray may see terms on their report such as “degenerative”, “narrowing”, or “spurring”. A patient receiving an MRI may see terms on their report such as “bulging” or “nerve effacement”. These can be concerning things to see for someone who is in pain; even more so if they have nobody to explain these terms to them. However, studies have consistently found that there is little to no correlation between a patient’s symptoms and these findings on imaging1,2. That is to say, someone with a “bad” looking image has just as good a chance to experience no pain as they are to experience pain, just as someone with a “good” looking image could be perfectly fine or could be in debilitating pain. These findings that are commonly seen on images have historically been called “degenerative changes” but in light of the current state of the research, they are now being seen more as “age-related changes” that are typical of almost anyone over the age of 30, regardless of pain. In addition to these age-related changes, other imaging modalities have also had similar issues with correlation to symptoms. A study found that 40% of people over the age of 50 had evidence of full-thickness rotator cuff tears despite having no shoulder pain and no history of shoulder pain3. These types of studies may leave some confused and unsure of what to think about any imaging they may have had done, but it simply serves to tell us that what we see on an image is not always what is causing pain.
This leads us to the question of whether imaging is warranted or necessary for some patients. The answer to this, as with most things, is: it depends. Every injury is different just as every person is different and each case must be considered on its own. However, the general rule in most cases is that a reasonable trial of conservative care (chiropractic, physiotherapy, massage, kinesiology) is indicated before any imaging is needed. Typically, guidelines recommend images be taken only if the clinician has reason to suspect a serious pathology or if a patient has undergone a reasonable trial of conservative care with no progress4,5. Current best evidence shows that despite imaging having a limited role in the management of low back pain, it is still widely overused5. Overall, imaging can be useful but it is best to wait until after an initial trial of care unless clinical suspicion overrules this.
In the end, imaging is necessary at times and can be helpful in guiding management. Additionally, many patients will already have imaging studies done and have access to their reports when they come in to see a chiropractor. However, I would encourage all patients to not worry about any potentially scary sounding words on their imaging reports until they have had a chance to discuss with a healthcare professional. As we can see, there are many cases where a report that sounds concerning could have no correlation with a patient’s pain. So, if you are experiencing pain and have an imaging report that you were given, I encourage you to book an assessment with one of our practitioners who can discuss what these findings mean and whether they are playing a role in what you are feeling.
Dr. Cory Niedjalski
- Rudy IS, Poulos A, Owen L, Batters A, Kieliszek K, Willox J, Jenkins H. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study. Chiropr Man Therap. 2015 Feb 9;23:9. doi: 10.1186/s12998-015-0052-0. PMID: 25671078; PMCID: PMC4322563.
- van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976). 1997 Feb 15;22(4):427-34. doi: 10.1097/00007632-199702150-00015. PMID: 9055372.
- Worland RL, Lee D, Orozco CG, SozaRex F, Keenan J. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South Orthop Assoc. 2003 Spring;12(1):23-6. PMID: 12735621.
- Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. doi: 10.1016/j.jmpt.2007.11.003. PMID: 18308153.
- Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 Jun 9;391(10137):2368-2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21. PMID: 29573872.