Do Ultrasound & MRI Results Matter? Thoughts from a Physical Therapist
I wanted to write this because over the past 8 years we’ve noticed a belief that imaging like MRI, Ultrasound and even nerve conduction tests provide a “clear” diagnosis for repetitive strain injuries of the wrist & hand.
This is likely associated with the way doctors may be describing imaging in their discussion with their patients.
There is a big difference between
“The Imaging will tell us what is going on”
“Lets get some imaging to figure out what’s the problem”
“I’ll order an MRI and we’ll get some answers” etc.
and
“well see what we find in the imaging but know that we have to use that information on top of what we know about how your injury behaves to determine the right diagnosis”
It should always be approach #2 but unfortunately due to our healthcare system & how behind many primary care providers are in their recommendations (1), it is almost always #1.
And there are some real consequences with that.
Imaging & ultrasound doesn’t matter as much as we think and I'm going to prove it to you through this thread
Let’s first talk about what imaging is typically ordered for RSI issues at the wrist & hand.
Most typically we hear X-rays, MRIs, & Ultrasounds. Each imaging technique has their benefits in visualizing certain types of tissues. And in many cases we see an overutilization of things like X-rays.
X-Rays: Good for seeing fractures, dislocations, misalignments, and narrowed joint spaces. X-rays can't show soft tissue problems. These are generally ordered since they are more affordable. But honestly many healthcare providers overutilize them.
Magnetic Resonance Imaging (MRI): Good for seeing muscles, ligaments, tendons, organs, and other soft tissues. A majority of our patients seem to have had MRI’s ordered (60% of our patients this year who have been dealing with their problem for > 3 months). There are different techniques that can emphasize different tissues (T1 vs. T2 vs. Proton density imaging).
The contrast between the tissues and the presence of certain coloring (white for example) can indicate if there is water present (suggesting some swelling). Above shows a complete achilles tendon tear.
Ultrasound: Typically the most cost effective option for soft tissue issues, especially if you are trying to visualize more superficial tissues. There are less layers at the wrist & hand so this is often the best option for wrist & hand RSI issues. Ultrasound also providers greater detail compared to an MRI for the more superficial structures. Similarly with ultrasound presence of excess fluid can be indicative of tendon pathology. The image below shows a left and right comparison of a tendon with swelling present and thickening of the tendon.
If imaging is ordered ultrasound should be the first option due to its accessibility. Generally imaging is best utilized to rule out more serious conditions than “rule in” a tendon being the cause of the problem. Basically, they aren’t always necessary.
There are mountains of research over the past two decades that have shown that imaging for not only wrist & hand conditions but issues at the shoulder, neck, back, foot do not provide enough information for a diagnosis.
In this study done in 2016, 19 NONSYMPTOMATIC professional baseball pitchers went through a detailed clinical examination and three MRI’s of their dominant shoulders were taken before contract signing. (2)
- 68% (13/19) of the baseball draft picks showed tendinopathy
- 32% (6/19) had a partial thickness tendon tear of the supraspinatus
- 21% (4/19) had AC joint OA
And many other small lesions were found in the subjects. Yet none of them had any pain.
This was repeated in 634 runners, 3110 individuals for the lower back, and at least 20 other studies including several systematic reviews & meta analyses which have shown that altered tissue states in imaging does not always correlate to pain. (3-5)
I’ll leave some more references at the end of this article. But the research is clear.
What we know is that changes in the tendon tissue can be present with imaging. But BY itself it does not mean anything.
Instead only when you layer on the results of a comprehensive clinical exam taking into all of the details of the patient, patient’s history, activity & behaviors can you really make a decision with the results.
In some cases imaging can make things worse! (reference) There are many reasons why this can happen but one of them being the altered behavior and beliefs about your pain and injury.
One study found that for work-related acute LBP, MRI within the first month was associated with more than an eightfold increase in risk for surgery and more than a fivefold increase in subsequent total medical costs compared with propensity matched control patients who did not have early MRI. (6)
What we believe about our pain and our experience around the injury can influence what we feel and how sensitive our bodies might feel.
If we believe we are unable to move because we have a “herniated disc” or “disc degeneration” then we tend to move less, perceive that our bodies are fragile and that leads to real physiologic changes that are detrimental to back pain.
If we believe we have to “rest” because our nerve is being compressed through “carpal tunnel syndrome” then we will avoid the activity that is actually beneficial to us.
Imaging is not as useful as we think for orthopedic conditions. For other medical conditions absolutely.
But for musculoskeletal injuries and more specifically those at the wrist & hand associated with tendons? They don’t offer much value as can be shown through all of the research referenced. Abnormal imaging has been reported in various tendons in as many as 59% of asymptomatic individuals. (7)
Which means that even if they found your tendon to be pathological, it provides no predictive or diagnostic value.
And many cases, when tendons are appropriately loaded through rehabilitation, there is often MORE healthy in the tissue than there is pathological in the tendon. (8)
More healthy tissue when you perform exercises appropriately for the tendon to allow it to positively adapt.
Which means the focus should not be on trying to change the pathology within the tendon, but instead focus on the tolerance to capacity.
All of the tendinopathy research has continued to support this and this has been exactly what we have seen in all of our cases. We only need to focus on
- Performing endurance-based protocols to improve the tendon tissues capacity
- Minimize overstressing the tendons
- Make changes based on how you are responding to the exercises (increased pain & stiffness, etc.)
This again does not mean imaging is useless. It needs to always be placed in the context of the overall clinical picture to help guide decisions. What we have seen is that it is better as a tool for ruling out problems than ruling in.
It can better tell us if there IS NOT a problem than confirming if there is one.
What can you take away from this?
Don’t worry about the imaging results. If you have a doctors appointment, make sure there has been a thorough examination that has been performed:
- Physical tests to assess your muscle endurance & capacity of specific muscles you are using
- Clear identification of pain pattern and pain behavior with activity
- Assessment of your lifestyle, daily movement patterns & behaviors that could lead to increased stress on your hand
If your clinician wants imaging make sure the diagnosis provided includes the context of the examination details above.
If it is not taken into account, then you should find a better clinician.
And most importantly…
Understand that for a majority of wrist & hand issues the tendons are involved. The best approach with the evidence we have and the current research on tendon recovery is to manage how much stress is being applied. (load)
References:
- Ebell MH, Sokol R, Lee A, Simons C, Early J. How good is the evidence to support primary care practice? Evid Based Med. 2017 Jun;22(3):88-92. doi: 10.1136/ebmed-2017-110704. Epub 2017 May 29. PMID: 28554944.
- Del Grande, Filippo MD, MBA, MHEM*†; Aro, Michael MD*; Jalali Farahani, Sahar MD, MPH*; Cosgarea, Andrew MD‡; Wilckens, John MD‡; Carrino, John A. MD, MPH*. High-Resolution 3-T Magnetic Resonance Imaging of the Shoulder in Nonsymptomatic Professional Baseball Pitcher Draft Picks. Journal of Computer Assisted Tomography 40(1):p 118-125, January/February 2016. | DOI: 10.1097/RCT.0000000000000327
- Hirschmüller A, Frey V, Konstantinidis L, Baur H, Dickhuth HH, Südkamp NP, Helwig P. Prognostic value of Achilles tendon Doppler sonography in asymptomatic runners. Med Sci Sports Exerc. 2012 Feb;44(2):199-205. doi: 10.1249/MSS.0b013e31822b7318. PMID: 21720278.
- Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
- McAuliffe S, McCreesh K, Culloty F, Purtill H, O'Sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med. 2016 Dec;50(24):1516-1523. doi: 10.1136/bjsports-2016-096288. Epub 2016 Sep 15. PMID: 27633025.
- Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9):900-7. doi: 10.1097/JOM.0b013e3181ef7e53. PMID: 20798647.
- Docking SI, Ooi CC, Connell D. Tendinopathy: Is Imaging Telling Us the Entire Story? J Orthop Sports Phys Ther. 2015 Nov;45(11):842-52. doi: 10.2519/jospt.2015.5880. Epub 2015 Sep 21. PMID: 26390270.
- Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper's knee). J Physiother. 2014 Sep;60(3):122-9. doi: 10.1016/j.jphys.2014.06.022. Epub 2014 Aug 3. PMID: 25092419.
- Maffulli, N., Nilsson Helander, K. & Migliorini, F. Tendon appearance at imaging may be altered, but it may not indicate pathology. Knee Surg Sports Traumatol Arthrosc 31, 1625–1628 (2023). https://doi.org/10.1007/s00167-023-07339-6
- Jensen, M. P., Turner, J. A., Romano, J. M., & Fisher, L. D. (1999). Comparative reliability and validity of chronic pain intensity measures. Pain, 83(2), 157–162. https://doi.org/10.1016/S0301-5629(19)31173-1
- Khan KM, Forster BB, Robinson J, et alAre ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective studyBritish Journal of Sports Medicine 2003;37:149-153.
- Bley B, Abid W. Imaging of Tendinopathy: A Physician's Perspective. J Orthop Sports Phys Ther. 2015 Nov;45(11):826-8. doi: 10.2519/jospt.2015.0113. PMID: 27136288.
Posted Nov 25, 2024, 7:08 PM UTC