A Painful Myth
In a recent chat with Dr. Kelly, he went on an awesome rant about one major myth/misconception when it comes to pain. I will give the cliff notes here with some of my thoughts as well. This is a myth: “Imaging (MRI, x-ray, ultrasound) is needed to diagnose and direct treatment” First off, we order x-rays and MRIs on patients all the time. That being said, in most cases imaging is not needed unless there’s a specific exam or history finding indicating something specific. Therefore, diagnostic imaging is better at ruling out, than ruling in. We use it to confirm our suspected diagnosis versus making our diagnosis. The phrase Kelly likes to quote to his patients: “I care more about what it is not than what it is”.
Here are a few conditions where we should pump the brakes on jumping to diagnostic imaging right away:
Headaches Imaging for Headaches is used to rule out severe pathology. There’s a cluster of signs and symptoms we look for indicating something significant. In the absence of these historical or examination findings, an MRI or CT scan is not indicated.
Degenerative meniscus tears A meniscus tear without trauma in the presence of arthritis has the same long-term clinical outcome as somebody receiving arthroscopy according to several studies the most famous study dating back to 2011. Guidelines have changed over the last 10 years in light of the new evidence. A meniscectomy can accelerate arthritis, in some cases by 9 fold. Avoid going under the knife if you can and jumping to imaging early with knee pain in the absence of trauma is usually the first step down that road.
Shoulder pain *A high percentage of overhead athletes have asymptomatic labral tears. *Upwards of 50% of patients over the age of 60 will have partial-thickness rotator cuff tears without symptoms.
Hip pain We’ve seen labral tears in asymptomatic runners and the diagnosis via x-ray of FAI is very common. If we suspect a stress fracture or we need to differentiate between a couple of diagnostic options we will certainly order imaging but in most cases, again it’s a waste of money and time to jump down that road right away.
Spine pain Dr. Kelly makes an excellent point during our discussion. He remarks that almost everyone will have the diagnosis of degenerative disc disease at some point. In fact, in the book back in control by orthopedic spine surgeon David Hanscom, he noted that 100% of patients over the age of 65 have x-ray evidence of degenerative disc disease. Is aging a disease? Maybe, but labeling it this way is proven to inhibit progress with conservative treatment. Chiropractors are notorious for taking x-rays on patients for postural assessment. This is an old-school approach not backed by the latest guidelines. If I suspect something specific I will order an x-ray immediately but it is for confirmation and to narrow down a specific diagnosis versus a cookie-cutter routine approach. I hope this brief post is helpful. If you have any questions for us feel free to reach out.
Alex Tapplin, Sports Medicine Specialist Chiropractor