Clinical Conversations

“Should I get an x-ray or MRI before physical therapy?” This is a common question, and the answer is – NO. Why not? I hope to clarify that in this article, and give you a convincing reason to try physical therapy first.

First, physical therapists can make an accurate clinical diagnosis that will most likely match the radiological diagnosis. A 2005 study published in the Journal of Orthopedic and Sports Physical Therapy compared the agreement between what the physical therapist thought the imaging would show, and what doctors thought the imaging would show. “Clinical Diagnostic Accuracy and Magnetic Resonance Imaging of Patients Referred by Physical Therapists, Orthopedic Surgeons, and Non-orthopedic providers.” Physical therapists could predict the correct imaging diagnosis 74.5% of the time! That’s almost as accurate as orthopedic surgeons, and over twice as good as general practitioners!

• Physical Therapists = 74.5% (108/145)
• Orthopedic Surgeons = 80.8% (139/172)
• Non-orthopedic = 35.4% (86/243)

So, only in a small number of cases, will you need an x-ray or MRI to help determine your condition if it cannot be determined clinically.

False positives

Second, there are a lot of “false positive” findings associated with imaging. A false positive is when the test (radiologic image) shows you have the disease or condition, when you actually don’t. Some of you readers may know of people who were freaked out by a “finding” on their mammogram that turned out (luckily) to not be cancer. How often does this happen in the joints or spine that a physical therapist treats? If you are talking about the neck, quite a lot of people with NO NECK PAIN have a “major finding” on MRI. It is broken down below. (From The Journal of Bone and Joint Surgery 1990 “Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation”)

For people less than 40 years old:

• Major abnormality in 14%
• Herniated disc = 10% (of subjects)
• Foraminal stenosis = 4%
• No “major” bulging discs were seen
• Narrowed disc space / degenerated discs = 25%
• Cord abnormalities = 9%

For people older than 40 years:

• Major abnormality in 28%
• Herniated disc = 5%
• Foraminal stenosis = 20%
• Only 1 subject “major” bulging disc was seen
• Narrowed disc space / degenerated discs = 57%
• Cord abnormalities = 1%

Remember, these are findings in people with NO NECK PAIN. If you have neck pain, there is a good chance that you might have one of these findings, but it would not be the source of your pain. The study authors conclude: “The prevalence of cervical spine pathology in asymptomatic (pain free) individuals of a wide-range of ages, points out the danger in ordering surgery or invasive procedures, or even giving the patient an ominous-sounding diagnosis, without first correlating these MRI findings with clinical signs and symptoms.”

Imaging the lumbar spine can also lead to errors as there is even greater incidence of false positive MRI findings in asymptomatic subjects in the lower back as compared to the neck…

“Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.” J Bone Joint Surg Am. 1990

• 33% had a “substantial” abnormality

60 years old:

• 36% had a disc herniation
• 21% had spinal stenosis

Accurate Diagnosis with your Physical Therapist

If you are still reading this article, then you must be interested in getting an accurate diagnosis of your problem, and you might think a physical therapist could be the one person who can do that. You would be right. Plus, a physical therapist will offer you treatment for your condition, not surgery or drugs. I have been convinced beyond a doubt in my 20 plus years of practice that one should start with a good physical therapy evaluation and possibly treatment before turning to x-ray or MRI. A good physical therapist knows when the clinical diagnosis is complete and correct and when imaging is needed to help fill in the blanks. Don’t get an x-ray or MRI first. It might point you in the wrong direction and bias the clinician trying to arrive at the correct diagnosis and treatment. If you truly need imaging, your physical therapist at Nick Rinard Physical Therapy can help guide you in that decision.