The Brutal Honesty On Injury Imaging: To Image or Not to Image, That is the Question!

Do I need injury imaging before I come to see you?

Should I go pay for imaging?

What does my imaging mean?

There is controversy over whether to order imaging or not. There are definitely pros and cons. I hope to go over some of them. I am going to start off by saying that I have a strong bias to NOT ordering imaging. That’s right, I don’t want my patients to order imaging or to even tell my what their imaging results are (at least before I get to assess them first).  I feel like imagining should be ordered as a last resort. Here is why….

Imaging is HIGHLY sensitive. It picks up on the smallest “abnormalities”. These “abnormalities”  could be things that you were born with and you didn’t even know you had. Now that you have shoulder pain and get an ultrasound, the image reports this “abdomormaility”: automatically we assume it is this discrepancy that is causing your pain, even though you had been living with it all your life. 

When Imaging Results Can Increase Pain

It’s hard to take back what is seen. I was talking with another health care professional and they had some imaging done on their knee. She had been having trouble with her knee for sometime but she was able to manage it. Then she got imagingin and it showed some fraying of her meniscus. She said, after she knew her results, it was like her pain tripled. She was no longer able to manage her pain like she was able to previously even though no further damage/injury had been done. With her knowledge of anatomy and rehabilitation she was amazed how her mind was able to change her pain levels with a flick of a switch or in this case by reading a simple sentence. She said “it was like my mind wanted me to have more pain once it had a diagnosis; even though I was able to manage before”. I am a believer that knowledge is power BUT sometimes too much knowledge can be harmful.

Injury Imaging is only a glimpse

Let me ask you this: if you look at a picture of a telephone, do you know if it is ringing? Let’s not over analyze this question either and questioning if you could see if the lock screen light up or if the notification light came on. Think of an old school house phone. The answer is: you can’t. The same is said about our bodies. A static picture of any body part doesn’t tell us how you are able to move, how strong you are or if there are any tight or unstable structures. Patients are often disgruntled when imaging comes back unremarkable but in reality that is a good thing.A physical assessment to analyze your movement will point you in the right direction. 

I personally don’t like to know the results of my patients’ injury imaging until after I get to assess them. By having all the additional information prior to my physical assessment it clouds my judgment and puts a bias to my thinking. As mentioned before: imaging is highly sensitive and sometimes the findings are not related to the injury. They are a static picture of a moment in time. It doesn’t necessarily give us a clear picture. Once I have completed my assessment, it can help compliment my findings. 

Injury Imaging or Physical Assessment

DON’T GET ME WRONG: injury imaging has it’s place!!! Don’t think I HATE diagnostics!! Here is when I recommend my patients get imaging:

When there is trauma and potential for further injury: this one is pretty self explanatory. If someone has fallen or a football player who has been hit and has extreme pain and isn’t able to move; we’ll send for an x-ray as there is a potential for a broken bone. If this bone isn’t casted, then it can cause additional damage.

If conservative therapy isn’t working: this is when I’ve been working with a patient and they aren’t getting better in the suspected timelines. Then we would send for imaging to rule in/out anything else.

When there is a drastic change in function and/or pain: this one is a bit harder and a bit more complicated. There are going to be times that patients flare up while recovering from an injury that will not warrant imaging as it is a part of the rehabilitation process. Sometimes patients “over do it” because they are feeling good, and that’s normal. It delays recovery times but doesn’t require imaging. BUT if suddenly a patient has lost strength or maybe their pain has become unmanageable with no cause: then I would send for imaging. 

Imaging is complicated. It is often evaluated on a case by case basis. It has its place when prescribed appropriately but something used too soon in the recovery process. 

Deciding whether to image or not requires carefully weighing the pros and cons based on your specific symptoms, history, and progression through conservative treatment. There’s no one-size-fits-all rule, which is why having an experienced physiotherapist guide you is invaluable.

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