Limitations of MRI: When the Diagnostic Gold Standard Falls Short

In the world of musculoskeletal pain, the quest for accurate diagnosis and effective treatment strategies is never-ending. For many years, magnetic resonance imaging (MRI) has been considered the gold standard for diagnosing musculoskeletal issues. However, it's essential to recognize that MRI imaging isn't always the most helpful tool, and in some cases, it can even hinder patient care. In this blog post, we'll explore the limitations and drawbacks of relying too heavily on MRI imaging in the field of physical therapy.

I recommend watching the YouTube video linked with this blog for a greater understanding of how MRI can have limitations.

Limited Clinical Correlation

MRI scans are a remarkable technological advancement, providing detailed images of soft tissues, bones, and joints. However, it's crucial to remember that not all findings on an MRI directly correlate with a patient's pain or functional limitations. In fact, a study performed on individuals 60 years or older who had no symptoms of low back pain found that 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc (Flynn, 2011). The important part to recognize here is that these subjects had NO PAIN.

The over-reliance on MRI findings can lead to unnecessary treatments and surgeries, often without addressing the true source of pain or dysfunction. Physical therapy has an advantage over imaging as physical therapists use their clinical expertise and consider the patient's history, physical examination, and functional assessment alongside imaging results to make an accurate diagnosis and create an effective treatment plan.

False Positives and Over-Diagnosis

MRI scans can detect even minor abnormalities, and this can sometimes lead to false positives and over-diagnosis. The presence of an abnormality doesn't necessarily mean it's the cause of a patient's pain or problem. For instance, age-related changes in the musculoskeletal system are common and may be unrelated to the patient's symptoms. Another study involving 991 subjects had an MRI performed on their right knee. The study found that 61% of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month. (Englund, 2008). This is an over-diagnosis. Even though the meniscus does show some pathological abnormalities, it is not impacting the subject’s function and they are not having pain.

This over-diagnosis can lead to unnecessary interventions, such as surgery, injections, or other treatments that may not provide any real benefit to the patient. A thorough clinical evaluation can help differentiate between clinically significant findings and incidental abnormalities.

High Cost and Limited Accessibility

Another drawback of relying too heavily on MRI imaging is its cost and limited accessibility. MRI scans can be expensive, and in some regions, patients may face long waiting lists or lack insurance coverage for these tests. This can lead to delayed diagnosis and treatment, causing unnecessary suffering for patients with acute or chronic musculoskeletal conditions.

In contrast, a skilled physical therapist and other practitioners can provide an assessment and develop a treatment plan based on clinical evaluation and diagnostic tests that are more cost-effective and readily available, such as X-rays or ultrasound.

Psychological Impact

The psychological impact is without a doubt the greatest strain that I see firsthand when it comes to advanced imaging. MRI results can have a profound psychological impact on patients. If a scan reveals abnormalities, it can create anxiety and fear about their condition, even when the findings are unrelated to their symptoms. This psychological distress can hinder the healing process and make it more challenging for patients to engage in rehabilitation.

Often patients will say, “It will give me peace of mind getting an MRI to know what’s going on” or “I want to avoid surgery at all costs but the doctor recommends an MRI.”

The result of both of those 2 statements likely leads to the same thing: Surgery and anxiety. An MRI is likely going to show something, but as stated above, how can we be sure that it is what is generating your pain?

The other complication from a psychological perspective is the label that the MRI gives. An individual that has an MRI taken in 2023 showing something such as a disc herniation will continue to live with this label the rest of their lives that they have a disc herniation. It will be 2043 and that same person will report in therapy they have had a disc herniation for 20 years despite not having a MRI since 2023. Fun fact: 85% of patients with symptoms associated with an acute herniated disc will resolve within 8 to 12 weeks without any specific treatments. Each time it makes me feel so compassionate for the patient as I can’t image how scary and anxiety-provoking it must be to have this fear that you are living with a disc herniation the rest of your life because it is what the MRI showed 20 years ago.

Conclusion

While MRI imaging is undoubtedly a valuable tool in medicine and physical therapy, it's crucial to remember that it is not always the most helpful or necessary solution. Over-reliance on MRI scans can lead to misdiagnoses, over-diagnosis, increased healthcare costs, and unnecessary patient anxiety. A balanced approach that combines clinical evaluation, patient history, and functional assessments with diagnostic imaging is essential to provide the most effective care to patients.

I use a very simple flow chart for myself, my family, and my patients when deciding if one should get an MRI. If you are questioning if you would be a candidate for an MRI I would encourage you to check out the flowchart I created below. If you are still uncertain, let’s chat. On a free and quick phone call, we would be able to quickly establish if you would benefit from an MRI and/or a thorough evaluation by a skilled PT. Perhaps you have had an MRI and are uncertain what your next steps would be. Again, let’s find time to chat and I am sure we can ease your mind and collaboratively create a plan moving forward!

Thanks for reading,

Dr. Ryan

References

Flynn TW, 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):838–46. pmid:21642763

Englund M, Guermazi A, Gale D. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008; 359: 1108-1115