Patient: "What's wrong with me? Do I need a scan? Am I normal?" Physio: "What is normal?"

I often find my patients asking me this question before I have even assessed them:

“Do you think that I should get a scan?”

My typical response is "no or certainly not yet."

They say "but won’t it show exactly what is wrong with me?”

The problem is that the scan will show all the issues that you have, but what is relevant or just incidental?

You see what is normal?

Patients presume that we are all perfect with no abnormalities so a scan will show the single abnormality causing our pain. This simple isn't true.

Here are some great examples of this point:

In the knee, Cyteval (2008) actually found meniscal (cartilage) tears on MRI scans in 1 in 3 middle aged and elderly people and these individuals had no symptoms or pain at all and would consider themselves normal. A similar finding was also found by Beattie et al (2005), they found that 60% of pain free 20-68 year olds showed abnormalities in at least three of the four regions of the knee.

In the shoulder, Connor et al (2003) performed MRI scans on the shoulders of elite athletes that perform overhead throwing as part of their sport.  Now bear in mind that these athletes were fully fit with no pain or symptoms and it was found that 40% of them had rotator cuff tears on the MRI’s!

In the general public it was found that 13% of asymptomatic (no symptoms) people aged 50 to 59 had rotator cuff tears on ultrasound scans. They found tears in 20% of people aged 60 to 69 and 51% in the over 80’s age group (Tempelhof et al 1999).

Sher et al (1995) found similar results with 50% of asymptomatic patients over 60 having Rotator cuff tears on imaging.

In the hips it was found that 54% of pain free hockey players had labral tears in their hips on MRI scans and 70% were found to have an abnormal pelvis (AOSSM 2010).

In the neck it was found that there is a lack of association between cervical spine curvature & neck pain (Grob et al 2007) and in the lower back Boden et al (1990) found the following:

Asymptomatic 60 year olds had abnormal findings on 57% of MRI's. 36% of which were herniated discs & 21% was spinal stenosis. They even found in the younger age groups that degeneration or bulging of a disc was found in at least 1 lumbar level in 35% of 30-39 year olds.

Not only can people with no pain have structural damage that is irrelevant but the people in pain aren't getting their pain from actual damage. You see pain is not always a sign of damage or harm, which is shown by this piece of evidence:

The brain is where pain is felt, it is not simply a signal that is received simplistically from the problem area, it has to be interpreted and processed by the brain. This means that the brain can actually regulate the pain that is felt, regardless of the severity of structural injuries or damage. In some people the central nervous system is in a more active and excited state when it comes to pain. It is these people that will likely feel more pain with activity, even though the activity is actually harmless and causing them no damage (Wand et al 2011).

So overall it is pretty clear that if you have pain, a scan will find lots of things that are wrong with you but it won’t tell you which of these ‘things’ is the cause of your symptoms and it certainly won’t get rid of your problem. Plus just because you are in pain doesn't always mean that you are causing damage or harm to yourself. In these cases people need to change the way they think about the relationship of pain and injury. The aim is to get back to some normal function and activity without the fear of causing more harm or damage. So my advice is to not worry or fixate on a structural abnormality, as this in itself will make you worse. Naturally you will overprotect yourself and this could be detrimental and make you feel worse. As a physio I would always want to do my own assessment first before I would consider a scan and even then you need to take the result with a pinch of salt!

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

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