24 July 2023

Red flags for imaging in musculoskeletal conditions

General Practice Musculoskeletal Pain Rheumatology

New research suggests many referrals ‘are at odds with recommended practice’.


One in three patients with musculoskeletal complaints are referred for imaging by GPs, new Australian research reveals. 

In most instances, diagnostic imaging of non-specific musculoskeletal complaints offers little value due to the commonality of age-related degenerative changes in asymptomatic individuals.  

Consequently, many clinical care standards and practice guidelines encourage imaging only when certain conditions are met, such as when serious pathology is suspected. 

But the findings of a new Australian study, published in Arthritis Care & Research, suggest 37% of patients with an atraumatic musculoskeletal complaint had imaging requested by their GP.  

“The estimated proportion of people attending primary care with low back pain who have serious pathology ranges from 1 to 6%,” author Professor Danielle Mazza, chair of general practice at Monash University, and colleagues wrote. 

“Based [on these figures], it is likely our findings are at odds with recommended practice.”  

Professor Mazza and colleagues used data from 130,000 patients treated by 4500 GPs across about 300 practices in Victoria to examine GP-initiated imaging requests for patients with low back, neck, shoulder and/or knee complaints. 

One in three patients had at least one imaging request during the five-year study period. More than 75,000 imaging requests were made in total. Half of the patients with a shoulder complaint received an imaging request, along with 43% of those with a knee complaint, 34% with a neck complaint and 26% with a low back complaint.  

Patients living in socioeconomically disadvantaged areas were 18% more likely to receive a request for an x-ray, 17% more likely to receive a CT request and 23% more likely to receive an ultrasound request. However, these patients were 46% less likely to receive an MRI request.  

Changes in specific imaging modalities requested for specific complaints was noted over the course of the study. 

There was a 1.3% annual increase in the proportion of MRI requests for low back pain and a corresponding 1.3% annual decrease in CT requests. 

Similarly, there was a 3% annual increase in neck MRI requests and a 3% reduction in neck x-ray requests. There were no changes over time in imaging modalities requested for shoulder or knee complaints.  

Professor Chris Maher, physiotherapist and internationally renowned back pain researcher from The University of Sydney, offered an explanation for the stagnant statistics.  

“It is interesting that the RACGP Choosing Wisely recommendations do not include musculoskeletal diagnostic imaging, which may suggest that the general practice profession does not see this as an important issue to focus attention on,” Professor Maher told The Medical Republic.  

Professor Mazza offered a different explanation, saying GPs were getting the message that x-rays for back- and neck-related issues were not useful. 

“GPs are often stuck between a rock and a hard place [when a patient presents with a musculoskeletal complaint].” she said. 

“On the one hand, some patients push for imaging because they think that will lead to faster recovery, or they want reassurance with a diagnosis [because they] find it hard to accept they’re in pain. 

“On the other hand, the modalities we know that can help, such as physiotherapy, are not easy to come by in the public system and expensive in the private system. It’s one of the most difficult areas to manage.” 

The median timing of most imaging requests was on the same day as the GP made their diagnosis, with only one in three requests made in the two weeks before a diagnosis was delivered.  

This was a particularly interesting finding, according to Dr Adrian Traeger, a Sydney-based physiotherapist and lead of an NHMRC-funded trial on behavioural nudging interventions to reduce unnecessary imaging for low back pain in emergency departments. 

“It’s almost like there’s confirmation happening with the imaging test, where many [people] might argue that a clinical diagnosis would be sufficient for a lot of these conditions. That indicates a lot of these tests could be unnecessary,” Dr Traeger told TMR.  

However, Dr Traeger noted database studies such as these often don’t have the necessary clinical information to determine whether individual tests were appropriate or not.  

Arthritis Care & Research 2023, online 4 July 

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5 Comments on "Red flags for imaging in musculoskeletal conditions"

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Tom
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Tom
3 months 27 days ago

Youngish graduates are simply not confident in their physical examination Abilities. Also driven by medicolegal factors, and of course, there’s the patient expectations. The prof. Services review used to take a keen interest in this area, so it was pass the parcel as to who was going to order the X-ray .

Justin Coleman
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Justin Coleman
4 months 1 hour ago
Thanks for reporting this interesting study; it provides good evidence we tend to order too much imaging in this area. Just to respond to Chris Maher’s comment, he is wrong in his guess that the lack of a GP Choosing Wisely recommendation “may suggest that the general practice profession does not see this as an important issue to focus attention on.” I chaired the RACGP Choosing Wisely working group which produced all ten GP recommendations. Imaging for low back pain did rank highly when we polled GPs, and we ourselves ranked it as very important. However, I was also privy… Read more »
Dr Philip Dawson
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Dr Philip Dawson
4 months 6 days ago
That last line says it all. drawing conclusions from incomplete data leads to incorrect conclusions! Yes most of them may be just Osteoarthritis, but if its a new onset or sudden exacerbation in an older person thats a red flag, if there is radicular pain that requires appropriate imaging before considering physiotherapy. Osteoporotic crush fractures, Bony Metastases, Nerve root compressions- all these require exclusion in an elderly population. some pains may be best treated with injections eg facet joint arthropathy, nerve root irritation not requiring surgery, or on the ever lengthening neurosurgical waiting lists. Patients with strong family histories eg… Read more »
Maureen Fitzsimon
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Maureen Fitzsimon
4 months 6 days ago

It was once commonplace for GPs to do joint injections, using their knowledge of surface anatomy. Then Medicare abolished the item number, expecting us to “absorb” this cost, when dealing with the usual list of patient problems. These patients, previously simply, and economically treated, now go for an initial US/CT, and then an US/CT for a joint injection.

Tom
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Tom
4 months 6 days ago
Completely agree with the contents of the article as many investigations are ordered by GPs from a medicolegal perspective ie defensive medicine- buggered if you do, dammed if you don’t . The patient expects it and it appears you’re doing something . As.noted the return rate on such investigations may be as low as 1% but no better than 6%. Probably one clear indicator for investigation is a presentation of radiculopathy for low back pain but that involves a careful and timely neurological assessment as most are nonverifiable with a myofascial or trigger point nature. Tell that to the medical… Read more »
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