Why imaging is usually not necessary prior to starting PT

Do I need a MRI before starting Physical Therapy?

Feb 01, 2022

A very common question in the life of a PT is “Do I need a MRI or X-ray prior to starting physical therapy for my injury?” While this is an easy question to ask, the answer is not so obvious.



Do I need a MRI before starting Physical Therapy?

As Doctors of Physical Therapy we are trained to differentially diagnose an injury and know when something needs to be referred out for a x-ray/MRI or to a physician. At least 95% of the time a x-ray or MRI is not needed before starting PT. The most important reason is that the image will most likely not change the treatment plan.

Meet Phil


Let’s use a 60 year old male named Phil as an example. Phil woke up with acute low back pain after helping his son move furniture into their new house. He decides to power through it, assuming it will go away. Phil goes golfing the following day while ignoring the pain and continues his normal activities and routine. Finally after a couple weeks of no improvement and gradual worsening of pain he decides to go see his physician. Phil’s physician completes a screen with no red flags and refers Phil for a physical therapy assessment. Phil feels frustrated because he is in pain and went to his physician for treatment, but got referred to PT. Phil is unsure how PT can help if they don’t have a x-ray or MRI to show what’s going on with his back.

The Answer: Phil’s physician is using a set of clinically proven rules to decide the best course of action and next steps. Phil does not have any red flags present (symptoms of something more severe going on). His physician knows the physical therapist is the expert in clinically diagnosing and treating Phil’s low back pain by coming up with an effective plan of care. 

False Positives


Another thing to consider is that MRIs often show false positives. If 10 healthy people with no back pain around Phil’s age had MRIs done, the radiologist would have something to report for 8 out of 10 (80%) of them. The findings would most likely be filled with terms like degenerative disc disease, bulging discs and spondylosis. All of these can sound scary, though they also can be completely normal and may not be causing any pain or symptoms at all! Current understanding of these abnormalities and degenerative changes are that they are very common and normal as we undergo the aging process. These are kind of like a gray hair or a wrinkle, but on the inside. Do gray hairs or wrinkles cause you physical pain? No! Neither do these findings. Seeing them on an image or diagnosing them does not change how you feel, nor does it mean something is wrong with you. 

Dollars and Cents


Lastly, MRIs are very expensive for the patient and/or insurance company. Many insurance companies require physical therapy before they will even pay for a MRI because many of these patients get better and don’t require a MRI. It also has been proven that people who receive imaging (MRI/x-ray) earlier on have more expensive and invasive care than those who do not.


The Bottom Line


In many scenarios, imaging does not get you better any faster or change your treatment plan. Instead it can be a barrier to receiving timely treatment of your injury. There are absolutely cases that require ordering diagnostic imaging, but these are in the vast minority of cases. It is important to have a healthcare team you trust and are comfortable working with to establish the correct plan for you to get back to your life and goals without pain. We are always happy to help and be a resource here at Empower U PT & Performance. 

Thanks for reading!

-Dr. Dan



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