Do I Need an MRI?
So… you’ve sustained an injury in a game or at the gym, or you’re dealing with a pain that’s been bothering you for weeks or months. You’re constantly wondering what could be causing your pain and why it won’t go away, which leads to the thought “I think I need an MRI to know what’s going on”.
But… do you really need that MRI?
The answer: probably not.
When it comes to musculoskeletal injuries, it is almost always a good idea to begin addressing pain with some type of physical therapy, whether that is independently or with a physical therapist, before running to a physician to get an x-ray and MRI. This may sound counterintuitive to the thought “don’t you need to know what’s wrong with me in order to fix it?”, so let’s discuss why this is not necessary.
Typically, a physical therapist will begin addressing your pain and limitations based on how you present to them clinically, or right then and there in front of them, versus what your x-ray or MRI says. The reason for this is because we have a lot of evidence that shows there is no correlation between the results of your imaging and why you are having pain.
A lot of studies looking at the correlation between MRI findings and pain have been focused on low back pain since this is one of, if not the most, common complaints regarding musculoskeletal injury. In a study that assessed lumbar MRIs in subjects without low back pain, they found that 64% of these people had an intervertebral disk abnormality (including disc bulges, protrusions, and extrusions) and 38% had an abnormality at more than one level of the lumbar spine. There was also a trend of these findings being more prevalent with increased age as 67% of the people who were 50 years of age or older had multiple abnormalities, as compared with 27% of the younger participants. These people without low back pain were actually more likely to have an abnormality at some level of the lumbar spine as only 36% of these subjects had normal findings at all levels (5).
These same findings have been replicated in other studies that look at other areas of musculoskeletal pain. Regarding professional rugby players, dancers, and age-matched controls without hip pain, there was an 80-90% prevalence of labral tears, 60-80% prevalence of impingement deformities, and 40-60% prevalence of acetabular (socket) cartilage loss (3). Another interesting study looked at subjects with one painful shoulder and one pain free shoulder and performed MRIs on both sides. When looking at the pain free shoulder they found an 88% prevalence of rotator cuff tendinopathy, 89% prevalence of AC joint degeneration, 56% prevalence of subacromial bursitis, 41% prevalence of labral lesions, and 20% prevalence of partial thickness rotator cuff tears (2). A similar study was performed on individuals without knee pain and found that 62% had cartilage lesions, 52% had bone marrow edema, 48% had meniscal lesions, 46% had tendon abnormalities, and 38% had ligament lesions (4). It would be easy to assume that someone having pain who gets an MRI that shows abnormalities is experiencing pain due to that finding. However, now that we know it is very common for pain free people to have similar findings, we can safely assume that there is a good likelihood these abnormal findings may have been present for some time prior to the onset of pain, and therefor may not be contributing to pain at all.
Some people make the argument that “if I got an MRI and knew what was going on, then I’d feel better about it”, however this does not seem to be the case. When comparing those with low back pain that have received an MRI and were informed of the results, to those who had an MRI but were not informed of the results, there was no difference in clinical outcomes including function, pain scale, perceived health status, and fear avoidance behavior (1). This then suggests that just knowing the results of an MRI does not actually improve patient outcomes with conservative management of low back pain. Rather, it has been observed in other studies that ordering an MRI and informing patients of those results may actually have a negative effect on their physical and mental health.
So, what does all this evidence tell us?
The presence of an abnormality on an MRI does not tell us why that person is having pain, and even getting an MRI and being informed of the results does not make you more likely to have a successful outcome with conservative treatment, such as physical therapy.
MRIs are very useful tools to diagnose musculoskeletal and non-musculoskeletal pathologies and are often the “gold standard” to assess the accuracy of clinical tests. However, when performed early in the management of someone experiencing pain, they can often lead to over-diagnosis, over-treatment, and over-complication of patient management. There is a time and place to have an MRI when you’re experiencing musculoskeletal pain, such as when symptoms are progressively worsening or neurological changes are observed, but the majority of the time it’s a better idea to start addressing your pain with skilled physical therapy to improve strength, stability, neuromuscular control, flexibility, and mobility.
If you’re someone that finds yourself being limited or unable to stay active due to pain, we are here to help! Email us at connect@toptierphysicaltherapy.com, or head here to get started today!
References:
1. Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008 Jun;29(6):1098-103. doi: 10.3174/ajnr.A0999. Epub 2008 May 8. PMID: 18467522; PMCID: PMC8118825.
2. Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg. 2019 Sep;28(9):1699-1706. doi: 10.1016/j.jse.2019.04.001. Epub 2019 Jul 3. PMID: 31279721.
3. Blankenstein T, Grainger A, Dube B, Evans R, Robinson P. MRI hip findings in asymptomatic professional rugby players, ballet dancers, and age-matched controls. Clin Radiol. 2020 Feb;75(2):116-122. doi: 10.1016/j.crad.2019.08.024. Epub 2019 Sep 30. PMID: 31582172.
4. Horga LM, Hirschmann AC, Henckel J, Fotiadou A, Di Laura A, Torlasco C, D'Silva A, Sharma S, Moon JC, Hart AJ. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol. 2020 Jul;49(7):1099-1107. doi: 10.1007/s00256-020-03394-z. Epub 2020 Feb 14. PMID: 32060622; PMCID: PMC7237395.
5. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73. doi: 10.1056/NEJM199407143310201. PMID: 8208267.