Do I Need An X-Ray?

Image: B. Rushing

When you hurt your back (or ankle, or wrist) and head to the doctor, should you expect an x-ray? In my last post, I mentioned that the only way to be certain whether or not a bone is broken is with imaging, and that is true. However, not every painful joint NEEDS to be x-rayed. I find that many patients are surprised or disappointed if I do not insist on an x-ray for an acute injury, but they are simply not always necessary, and radiation is not without harm.

XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue.  (As a quick aside,  a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking x-rays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries. Stay tuned for more on those rules in my next post.)

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

An Xray for Your Aching Back?

Last week, the “Choosing Wisely” campaign was unveiled to physicians and patients alike. The concept was for each major specialty to identify five interventions that traditionally, physicians have ordered (and patients have expected) yet now evidenced-based medicine is telling us that these are simply unnecessary, not truly beneficial, and/or costly in dollars or health. For the next week, I would like to add my two cents worth for each of the five interventions highlighted by my academy- the American Academy of Family Physicians.

The first recommendation is to AVOID IMAGING (x-rays, CT or MRI scans) for LOW BACK PAIN that has been present less than six weeks
Did you know that low back pain is the 5th most common reason that people head to their doctor? We “throw out” our backs at an amazing rate, and it’s usually just from bending over or vacuuming more than moving baby grand pianos. The vast majority of low back pain is muscular, and a combination of anti-inflammatory medications (like ibuprofen), topical modalities (heat & massage) and judicious use of muscle relaxants-plus TIME measured in days, not hours- will take care of the problem. Ergonomic evaluations and physical therapy can also do wonders for low back pain, especially if it is recurrent. Insisting on an x-ray or fancy scan will certainly reduce the thickness of your wallet, but is unlikely to reduce your pain.

BOTTOM LINE: Hold off on x-rays or other scans for low back pain unless your pain has persisted more than six weeks, or your doctor sees “red flags” that suggest less common, more serious underlying issues.

XRAY X-pectations

When you hurt your back (or ankle, or wrist) and head to the doctor, do you expect an x-ray? I find that many patients are surprised if I do not insist on an x-ray for an acute injury. Mind you, I certainly order plenty of x-rays when I believe that the results will change our management (is it a broken bone or a sprained ligament), or even if the results simply tell us what to expect about the time-frame for healing, such as a minor fracture in the foot or toe.

By the way, while we're on the subject, a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

So back to XRAYs. XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue. As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking xrays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries.

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

Stress Fractures- the Runner's Bane

How do you end up with a fractured bone without knowing you "broke" it? STRESS FRACTURES are common injuries, especially in athletes (not necessarily professional athletes, mind you, but anyone jumping into serious exercise programs...often as part of New Year's resolutions!) The stress fractures show up as a persistent tender spot or swelling, most commonly in the shin (tibia), foot bones, and upper leg; rarely they also occur in the arms, spine and pelvis.

The typical story is someone who recently had a marked increase in their activity level, or very repetitive activity (running every day) without significant rest. This is why I am a huge fan of CROSS TRAINING! If you are going to start jogging, for example, run on Mondays, Wednesdays and Saturday, and try biking or swimming on the other days.

Stress fractures are OFTEN NOT found on initial xrays (up to 90% of the time). If your symptoms persist, however, a follow up xray a few weeks later has a much higher likelihood of detecting a fracture. Sometimes additional imaging, such as an MRI, may be needed to identify the fracture.

Risk factors include having > 10 alcoholic drinks per week, being female (can't change that!), smoking, low Vitamin D levels, and excessive or repetitive physical activity.

Treatment? REST- stop the activity that causes pain. This sounds simple, but is the most difficult part to enforce, especially in committed runners. Pain medicine is usually just acetaminophen (Tylenol) or possibly ibuprofen, though there is debate whether the ibuprofen may delay healing.

BOTTOM LINE: CROSS TRAIN to PREVENT stress fractures, and see your doctor if you have a persistent tender spot (especially your shins or feet) after starting a new exercise program.</span>