To Image or Not to Image…That is the Question.

Many clients come to the clinic wondering if their pain may be caused by “something serious” like a degenerating or bulged disc, heel spur, or rotator cuff tear, to name a few. Often they are upset because their doctor chose not to do any imaging or they are still waiting to have their test completed. Let us tell you now…it usually doesn’t matter. Don’t get us wrong. It does matter that you are in pain, that you can’t lift your grandchildren, or that you struggled through the big game yesterday. But what often isn’t particularly helpful, is the results of your imaging.

Lets begin by talking about low back pain…The idea of degeneration, spurs, or bulged discs really makes you worry doesn’t it? In fact, many of you reading this article with have at least one of these things and just don’t know it. Does this mean something is wrong with you? Certainly not! More than likely, it just means this is normal for you and if you’re functioning pain-free, why think twice about it? Just because you have a “bulged disc” does not mean you will have pain. And just because you have pain, does not mean a bulged disc is causing it, even if it shows up on imaging.

This was confirmed by a systematic review in the American Journal of Neuroradiology (Brinjikji et al, 2015) which shows that a large number of people who have no pain still have significant findings on imaging.

The study found “disc degeneration” in:

  • 37% of 20 yr olds
  • 80% of 50 yr olds
  • 96% of 80 yr olds

It also found “bulging discs” in:

  • 30% of 20 yr olds
  • 60% of 50 yr olds
  • 84% of 80 yr olds

This is telling us that in people over 50, the majority will have both bulging discs and disc degeneration. And these are people who have absolutely NO pain! All this means, is that “abnormal” findings on x-ray, CT, or MRI are often just the opposite…normal for you.

Another study in the Journal of Radiology (Modic et al, 2005) tells us that “In typical patients with low back pain or radiculopathy, MR imaging does not appear to have measurable value in terms of planning conservative care. Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well-being.”

This means, if you have low back pain or pain radiating down the leg, an MRI does not help with the therapy plan, and in fact, knowing you have “something wrong” will actually make you feel worse.

So, ask yourself…why are you in such a rush to have imaging completed? If you have an x-ray/ MRI/CT it will very likely show something wrong which may or, even more likely, may not be relevant to your pain. This can feed into a bigger problem, using these findings as a reason you can’t get better and an excuse—not to seek therapy, not to work on mobility, not to be active. These findings are not a life sentence for pain, but doing nothing about it is!

The spine is not the only area where imaging is often not necessary. Plantar fasciitis, for example, is an inflammation of soft tissue of the foot. The soft tissue is what causes the heel pain and cannot be shown on x-ray. Instead, what will often show up are “heel spurs.” The public often isn’t made aware of the fact that heel spurs are present in 1 out of every 10 people (pain or no pain). Of that 10% of people with heel spurs, only 1 out of 20 (5%) will have foot pain (Kadakia, 2010). Having a “heel spur” diagnosis does not indicate heel pain and makes absolutely no difference in a treatment plan for those people with heel pain. So instead of rushing out for an x-ray, give us a call at STRIDE. A thorough assessment by your physical therapist, will differentiate between other sources of heel pain and allow for an accurate diagnosis and treatment of plantar fasciitis—no imaging necessary.

Wondering about your sore shoulder? The same principles apply. The study, “Ultrasound of the shoulder: asymptomatic findings in men” (Girish et al, 2011) took men with no shoulder pain and completed a diagnostic ultrasound. They found “abnormalities” in 96% of subjects. This included things such as bursal thickening, arthritis, tendinosis, and even rotator cuff tears. Again, this shows that in almost all of us, pain or no pain, imaging will find something wrong. And all too often, it isn’t at all relevant to the current situation. Not a very convincing reason to rush out for imaging!

Don’t get us wrong, imaging can be a powerful tool. There are countless times when therapists lobby for certain tests on their client’s behalf; if the client is not responding to treatment or if warning signs are present on testing. Imaging would then become appropriate and extremely useful. These are findings your STRIDE therapist screens for during your initial assessment and continually re-evaluates during treatments.

No doctor visit or referral is required to begin Physical Therapy. But if you did see your physician and they skipped the x-ray and sent you straight to the therapists at STRIDE, good on them. Shake their hand, give them a pat on the back, and start your journey to feeling better!


Brinjikji et al.. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology2014, 36(4), 811-816. Retrieved 8 June, 2016, from

Girish et al.. (2011). Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology, 197(4), 713-719. Retrieved 8 June, 2016, from

Kadakia, A.R. (2010). Plantar Fasciitis and Bone Spurs. Retrieved 8 June, 2016, from

Modic et al.. (2005). Acute Low Back Pain and Radiculopathy: MR Imaging Findings and Their Prognostic Role and Effect on Outcome. Radiology, 237(2), 597-604. Retrieved 8 June, 2016, from