If My Doctor Thinks I Really Need an MRI, Why are X-rays Taken First?

Boyd W. Haynes III, MD
As an Orthopaedic Specialist, I want to address this frequently asked question.  Indulge me while I walk you through a typical scenario of my day seeing patients. Most patients will Google the symptoms that they are having long before they actually make an appointment to see me for a consultation.  Let’s say they have shoulder pain, which upon a Google search, may indicate a torn rotator cuff as a possible diagnosis.  Depending upon the article they read, an MRI is usually suggested to provide definitive proof of a rotator cuff tear and to ascertain its severity.  When the patient arrives in my office and I suggest that a torn rotator cuff may be the culprit, the patient immediately asks when they will have an MRI.  I may agree that an MRI scan may be necessary, but I usually don’t order it until later in the course of treatment.  Let me explain why.
Before a consultation in my office, x-rays are almost always taken of the area of the body where the patient indicates they are having pain. While x-ray doesn’t image soft tissue, like a rotator cuff, it does provide me with a clear picture of the patient’s bone and whether or not there are fractures, abnormalities, tumors or bone spurs, all of which can lead to pain and dysfunction.  X-rays are an important foundation on which to build an accurate orthopaedic diagnosis.
I may also request images of areas of the body that could be causing referred pain.  Examples of this are a person who reports back pain but who actually has a hip problem causing the discomfort or a person with shoulder pain who has a problem stemming from their cervical spine (neck).  As a physician, I try to get all of the information available before diagnosing the patient, and radiographic studies are a tool that I use to help me do so.
Another important consideration is how insurance companies have structured payment for medical care.  There is a standard protocol for providing Orthopaedic medical services which most physicians, who take health insurance, follow.  Unless absolutely warranted by acute injury which causes severe pain and/or dysfunction, we follow a conservative diagnostic/treatment plan at first.  This includes moderately priced diagnostic testing, such as x-ray, medications, Physical Therapy, bracing/taping/splinting, exercise, and injections. We usually wait a few weeks to see if the patient feels better after this treatment.
Some patients feel frustrated by this protocol, having to wait for what they deem as necessary treatment and the delay of getting an MRI. What may surprise you is that conservative treatment often works well and the majority of patients get better, without having expensive tests or surgery. As physicians, we see this proven over and over with our patients, even though the patient may not believe me when I say that they will most probably improve with this conservative regimen.  The insurance companies know this too…that is why I must document that I tried conservative treatments for your condition BEFORE moving forward with more expensive diagnostic options. The insurance company requires that I do this for payment approval.
For those patients who do not get better with a course of conservative treatment over several weeks or months, an MRI is warranted to further uncover probable issues within soft tissues.  An MRI is a much more expensive test and here’s why: 1) MRI technology is very advanced and scanners are very expensive to purchase (in the millions); 2) Only five companies make MRI scanners and once purchased, it takes about a year for delivery of the scanner from the manufacturer; 3) Buildings that house MRIs must be specially built or modified to house and cool the equipment; 4) Radiology Techs must be specially trained to operate MRI scanners; 5) Time is money and MRIs take at least 35-40 minutes each; 5) if your MRI scan requires contrast, meaning injected dye to highlight a particular body part, a physician must be nearby in case of an allergic reaction.
I hope that this information helps you understand why your treatment may vary from what you might read on the internet and expect to have happen when you come in for a consultation.  Rest assured, I am going to do everything possible to help you feel better and if an MRI is needed, it will be ordered when appropriate and approved by your insurer.