A Picture is Worth a Thousand Diagnoses?

PT Blog   •   January, 2019

shoulder x-ray

“Believe nothing you hear, and only half that you see.” – Edgar Allan Poe

Not all things are what they seem. When was the last time the Big Mac meal looked like the commercial, the slightly used car turned out to be a winner, or your online date’s profile picture was a spot on match? Did I mention that wrestling (aka ‘wrastlin’) and the Easter bunny aren’t real, and I’m still waiting on that free iPhone upgrade. All jokes aside, believing most things at face value is a fool’s errand with skepticism and investigation offering a higher return on your investment. Edgar Allan Poe had a point when he penned the phrase above, highlighting the lunacy in blindly believing what you see and even worse, believing everything that you hear. Discovering the answers for yourself through research and experience offer the greatest rewards and often reveal answers that would have otherwise been overlooked.

Let’s ponder a familiar healthcare scenario: A friend visits the doctor after an insidious onset of low back pain. The doctor orders an MRI revealing a mild disc herniation and “degenerative disc disease.” The patient is started on pain medication, anti-inflammatories, and a muscle relaxer and referred to physical therapy for treatment. The therapist evaluates the patient and prescribes stretches and core strengthening exercises, which help while in the clinic, but the pain returns an hour later. This continues for 4 weeks concluding with increased back pain. The primary care physician refers the patient to a neurosurgeon for surgical consultation.

This is a common scenario that happens thousands of times all across the United States, and unfortunately, patients are never empowered with the proper education and knowledge needed to make informed decisions concerning their care. They are left to blindly believe the healthcare professionals, and they are not included as an active participant in their recovery. This post seeks to restore hope in the midst of this uncertainty.

Medical images and pain levels are not directly proportional. Meaning that the extent of tissue damage does not always correlate to the amount of tissue injury.
Many cases exist where patients with significant radiographic or MRI findings of tissue damage have ZERO symptoms. The vice versa is also true: severe pain cases exist in the presence of ZERO tissue damage (i.e. phantom pain, sunburns). The following is a summary of studies where MRIs were performed on patient that were asymptomatic:

  • Spine: The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge: 30% (20-year-old) v. 84% (80-year-old). Disk protrusion: 29% (20-year-old) v. 43% (80-year-old). (1)
  • Hip: Among pain free hockey players, 70% had abnormal pelvis or hips MRIs; 54% had labral tears.
  • Knee: 86-88% of patients with pain-free knees, age >50 years old, had “at least one type of pathology (“any abnormality”)” on MRI. (2)
  • Shoulder: In one study, 23% of asymptomatic shoulders had a rotator cuff tear; in asymptomatic overhead athletes, 40% had a partial thickness or full-thickness rotator cuff tear in the dominant shoulder. (3)

Abnormal imaging findings do not always indicate that something is wrong or damaged, but rather may be coincidental or normal, age-related changes associated with the joint in question. This does not change the fact that the pain exists or downplays the extent to which it is felt, but rather it exposes the myth that all pain generators are located at the site of pain. The patient given a bleak outlook based on imaging now has hope that their situation can improve despite what may appear to be an insurmountable obstacle.

Not only is imaging not 100% accurate or useful for determining causes of pain, but also it can actually be detrimental to the recovery process. MRIs facilitate “medicalization” of low back pain and unintended harm due to labeling of specific injuries (4). In a study of acute low back pain in which MRIs were performed on all patients, “patients randomly assigned to routinely receive their results reported smaller improvements in general health than those who were blinded to their results.” (5) In another study, “patients with back pain of at least 6 weeks’ duration who had routine radiography reported more pain and worse overall health status after 3 months than those who did not have radiography.” (6) Other potential harmful effects include radiation and iodinated contrast exposure and increased surgical rates.

Medical imaging is a great tool that has allowed healthcare professionals to treat and cure diseases and pathologies that left physicians baffled only a few decades ago. The importance of such imaging cannot be overstated and no intention is made to devalue their importance; however, musculoskeletal injuries and pain is complex and often not the result of specific pathoanatomical “abnormalities.” Patients deserve the most evidence-based approach to treating and abolishing their pain so proper attention must be given to ensure that misleading information is not perpetuated. Guidelines establishing proper criterion for imaging is a useful stepping-stone to improving this. The American College of Physicians and the American Pain Society have established a joint clinical practice guideline recommending when to have patients undergo medical imaging: “Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions (i.e. vertebral infection, cauda equina syndrome, or spinal cancers causing cord compression) are suspected on the basis of history and physical examination; also if surgery or steroid epidural injections are indicated.” (7) Shedding light on misleading health information is difficult and often met with resistance, especially when disrupting the status quo; however, educating patients and providing avenues for them to become active participants in their care and establishing a therapeutic alliance is crucial for optimal patient outcomes. Educating your patients on image findings and how the picture does not tell the whole story can provide hope for a future that many people felt was lost.

Contributing Author Credit: W. Evan Stringfellow, PT, DPT, CSCS, Cert. DN

Edited by: Ashley Theobald, DPT


  1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.
    AJNR Am J Neuroradiol. 2014;36(4):811-6.
  2. Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012;345:e5339. Published 2012 Aug 29. doi:10.1136/bmj.e5339
  3. Hargrove, Todd. A Guide to Better Movement: The Science and Practice of Moving with More Skill and Less Pain. Seattle, WA: Better Movement; 2014.
  4. Flynn T, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-846.
  5. Ash, LM, Modic MT, Obuchowski, Ross JS, Brant-Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient putcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29:1098- 103.
  6. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322:400-5.
  7. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491.

About the Author:

Ashley Theobald, D.P.T. – Ashley was born and raised in a small town in Alabama. She attended the University of South Alabama and was an advanced undergraduate student completing her Bachelor of Science degree in pre-professional health sciences in 2012. She then graduated with her doctorate in physical therapy in 2014. During her first year of PT school she met and married her husband, Ben. They moved to Nashville, TN where she worked for 3 years in an outpatient clinic full time and at Vanderbilt Stallworth Rehabilitation Hospital PRN. She is now working for ATI Physical Therapy full-time in Greenville, SC. She has been an avid health and fitness fan playing softball growing up, tennis in high school, and completing 2 half-marathons in college. She enjoys traveling overseas and has completed 2 short-term medical mission trips for physical therapy in the Dominican Republic (2013) and Haiti (2015), with intentions of returning yearly.
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