When do I need imaging scan to check my pain?

 

When patients come to physio for the first time or with a new pain or problem a common thought or belief is that scans are important to set you up on a treatment plan. Conversely, some patients want to avoid medical imaging due to the risks and exposure that comes from some types of scans at the expense of their best clinical management. This blog will hopefully provide some insight regarding when and why your health care profession will order imaging and how that fits in our assessment to improve your pain.

 

Firstly, in healthcare, the following conditions that could arrive in the physio clinic need a diagnosis including imaging: (Mayfair, 2022)

• Fractures
• Dislocations
• Narrowed joint spaces/Cartilage loss
• Specific Spine or Nerve injuries
• Significant damage to ligaments, tendons, muscles and cartilage, such as:
• Meniscal tears
• ACL injuries
• Other tendon or ligament injuries
• Other medical conditions i.e. Joint inflammation from Rheumatoid Arthritis, cysts or tumours.

 

Often guidelines suggest that we only send for scans in the suspicion of these injuries/conditions to reduce the effects of unnecessary imaging. Studies have shown that unnecessary imaging can lead to poorer outcomes for some musculoskeletal disorders such as low back pain (Cuff et al, 2020) as well as possible radiation exposure – a chest XR for example is an exposure to radiation roughly equivalent to three days worth of background radiation for context (Mendelson, R. & Montgomery, B., 2016). So, how do we make these decisions to scan or not?

Often in clinic we are asked very pointed questions about your pain and issues, how long will this take, what could be the outcomes of my injury/illness, or do I need to skip the game of footy or netball on the weekend – these are usually answered well by our clinical assessment of your problems. This is the same with the decisions to order or avoid medical imaging below are some thoughts used in practice to decide the best course of action for you.

 

1: What you tell us –

Your story or history of what brings you in is often the reason we send for scans is linked to the specific mechanism of injury or what we call red flags in your history. Red flags relate to the things you report that could be related to serious pathology. Was there an episode of trauma, do we need to exclude fractures in your assessment. Do you have pins and needles or horrible night pain. These are examples of how your story may lead us to send for scans to rule out serious pathology we want to miss, and your physio may send you to your GP or straight for scans to remove doubt.

 

2: What we see –

Clinical assessment and tests are the tools we can use to find the most likely cause of your pain. A battery of tests or specific screening tools to find the most likely cause of your symptoms and guide our decision making for your care. Great examples can be found all over the body but examples like Ottawa ankle rules can help us rule in the need for imaging with 97.5% accuracy if used correctly while reducing the exposure to unnecessary imaging for ankle fractures.

 

(image – Daş, M., Temiz, A., & Çevik, Y., 2016)  

 

3: How is it progressing? –   

When we set your plan, we are constantly monitoring your pain and progress to keep an eye out for changes that may cause a change to your plan. this will vary depending on your area and likely injury, but we may decide to image some injuries as they haven’t changed, not improved how we would have hoped, or your signs and symptoms have progressed to bring new light to red flags in your history or changes on testing causing your physio to require more information.   

 

4: If it’s likely to improve or alter your outcomes –   

In some injuries imaging can help assess the severity and provide information regarding the treatment plan you may need. Examples could be the severity of a medial ligament sprain in the knee and the decision to put you in a hinged knee brace for your long-term knee health. In this scenario your story, clinical testing and imaging are all used together to make an informed decision related to a handful specific injuries and treatments based on Sports medicine research.  

The bottom line is that many conditions may or may not need imaging depending on the presentation and all the clinical information at hand. If you are not sure what to do for your pain or musculoskeletal condition, Physio is a great place to start as the clinical skills and assessment can set you on the right path without the need for imaging for all.  

 

 

Written by James Craig, Senior Physiotherapist at myPhysioSA Marden

 

 

 

References:  

Cuff, A., Parton, S., Tyer, R., Dikomitis, L., Foster, N., & Littlewood, C., 2020, Guidelines for the use of diagnostic imaging in musculoskeletal (MSK) pain conditions affecting the lower back, knee and shoulder: a scoping review. Musculoskeletal Care, 18 (4). pp. 546-554. ISSN 1478-2189.  

Mayfair, 2022, ULTRASOUND VS. MRI: DIAGNOSING MUSCLE AND JOINT SYMPTOMS, accessed online at [https://www.radiology.ca/article/ultrasound-vs-mri-diagnosing-muscle-and-joint-symptoms/#:~:text=Your%20health%20care%20practitioner%20may%20request%20this%20scan,joint%208%20Sports-%20or%20trauma-related%20injury%20More%20items] on 30/04/24.  

Mendelson, R. & Montgomery, B., 2016, Towards appropriate imaging: Tips for practice, Australian Family Physician, RACGP, 45 (6), Accessed at [https://www.racgp.org.au/afp/2016/june/towards-appropriate-imaging-tips-for-practice] on 30/04/24.  

Image reference – Daş, M., Temiz, A., & Çevik, Y., 2016, Implementation of the Ottawa ankle rules by general practitioners in the emergency department of a Turkish district hospital. Turkish journal of trauma & emergency surgery: TJTES, 22 (4), pp.361-364.