Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review

Abstract

Background: Musculoskeletal (MSK) pain is one of the most common reasons for primary care consultation, particularly pain in the lower back (LBP), knee and shoulder. The use of diagnostic imaging for MSK pain is increasing, but it is unclear whether this increase is justified on the basis of clinical practice guideline (CPG) recommendations. Aim: To identify and map the content of CPGs that informs the use of diagnostic imaging in those with nontraumatic LBP, knee and shoulder pain in primary and intermediate care in the UK. Design and Setting: A scoping review of CPGs. Methods: This scoping review was conducted and is reported in accordance with PRISMA guidance. A broad search strategy included electronic searches of MEDLINE, CINAHL, PsychINFO and SPORTDiscus from 2009 to 17 April 2019. This was conducted alongside a search of guideline repositories and was combined with a snowball search of Google, relevant professional bodies and use of social media. Results: 31 relevant CPGs were included. Routine use of diagnostic imaging for those with nontraumatic LBP, knee or shoulder pain is generally discouraged in primary care or intermediate care. Diagnostic imaging should be reserved for when specific or serious pathology is suspected or where the person is not responding to initial nonsurgical management and the imaging result is expected to change clinical management decisions. Conclusion: Diagnostic imaging should not be routinely requested in primary or intermediate care for nontraumatic LBP, knee or shoulder pain. CPGs do not justify the increasing imaging rates in the UK for MSK pain.

Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study

“…This finding merits further investigation in future study of healthcare practices around the management of PFP. The use of early radiographs was common practice for patients in this cohort, influenced by the use and/or timing of physical therapy, and in conflict with current recommendations [29][30][31].…”

“…A higher percentage of individuals receiving delayed physical therapy were ordered knee radiographs, compared to those with earlier physical therapy, suggesting that the ordering of a radiograph may have delayed decisions regarding physical therapy referrals. Radiographs are discouraged for non-traumatic knee pain, as current research demonstrates they often do not correlate with symptoms, are a potential waste of resources and can increase healthcare costs, and knowledge of results often lead to a poorer prognosis [28][29][30]. Delayed physical therapy is typical in a traditional healthcare system whereby individuals do not see a physical therapist or other healthcare provider until later in their care pathway [6], so the use of additional testing prior to receiving physical therapy, including radiographs, may not be surprising yet does not match current recommendations discouraging the use of radiographs.…”

The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain

“…Although routine knee radiographs are not recommended as an early management strategy in patients with nontraumatic knee pain, 10,23 42.1% (n = 9831) of the cohort underwent imaging within 30 days of their initial diagnosis. This implies that knee radiographs were commonly obtained, even though evidence suggests that imaging rarely provides meaningful information to guide clinical decision‐making, 7,13 They also have less clinical benefit in the younger population (mean age ± SD of our sample was 32.02 ± 7.47), and are not recommended for routine screening 7 .…”

“…The clinical presentation most often does not correlate with radiographic findings. Incidental findings are common, 5 can lead to additional unnecessary tests, 6 and the results rarely change management strategies, 7‐9 which is why routine radiographs are discouraged for initial management of nontraumatic knee pain 7,8,10,11 . Still, radiographs are often ordered for PFP, despite limited evidence of their value in guiding treatment choices 7,12 …”

“…Incidental findings are common, 5 can lead to additional unnecessary tests, 6 and the results rarely change management strategies, [7][8][9] which is why routine radiographs are discouraged for initial management of nontraumatic knee pain. 7,8,10,11 Still, radiographs are often ordered for PFP, despite limited evidence of their value in guiding treatment choices. 7,12 There is evidence suggesting that unnecessary utilization of diagnostic imaging for musculoskeletal disorders is common.…”