In Defence of Imaging: When Less Isn't More

Introduction: Don't Blame the Scan
​In recent years, a growing number of academic papers and social media narratives have raised concerns about rising imaging rates in musculoskeletal (MSK) care. The argument is familiar: imaging doesn’t help, causes harm, and fuels overmedicalisation by assigning labels that instill fear or lead to unnecessary interventions. (1, 2) 

Adding to the argument are studies showing that “abnormal” imaging findings such as disc degeneration or rotator cuff tears, are frequently present in people without symptoms. These findings are often used to recommend avoiding imaging in symptomatic individuals and to argue that similar findings in those with pain are often incidental or irrelevant.  (3-7) Some also claim that routine imaging fails to improve outcomes like pain, function, or satisfaction.(8) Taken together, these messages have driven a narrative that imaging is overused, harmful, and clinically invalid and should therefore be broadly avoided.(4)

Overdiagnosis and overmedicalisation are legitimate concerns. But these problems reflect how imaging is used and interpreted, not flaws in the tool itself. The greater danger is a drift toward clinical nihilism, one where we underuse valuable diagnostic tools in the name of minimalism, and lose sight of the very thing that should guide our decisions: clinical reasoning. 

While many researchers and guideline authors do call for judicious imaging based on clinical reasoning, that nuance is often lost in translation. (4, 9) The result is a reductionist message that calls for blanket imaging reduction and inappropriately applies group data from asymptomatic populations to clinical decisions in individual, symptomatic patients.

In this blog, I argue that the issue is not too much imaging, but misuse of imaging. I challenge the emerging dogma and make the case that imaging, when applied with skill and judgement, remains a powerful clinical tool in MSK care.

The Problem Isn’t Too Much Imaging - It’s How Imaging Is Used
Current criticisms of imaging often misplace blame, targeting the tool rather than the clinician’s decision-making. It’s like faulting a stethoscope for missing pneumonia. The tool is not the problem, misapplication is.

Real clinical skill lies in using imaging judiciously, as part of a diagnostic reasoning process that begins with a well-formed clinical hypothesis. Imaging should be used to help confirm, exclude, or differentiate specific conditions that require specific management when clinical tests alone are not accurate enough to do so. But without robust clinical reasoning as the foundation, even a “correct” image can mislead.

This approach reflects established cognitive models of diagnosis, such as the diagnostic reasoning cycle (10), which emphasizes hypothesis generation, pattern recognition, and iterative probability revision. As Elstein (2002) explained, diagnostic errors often arise from cognitive bias, shortcuts and failure to apply probabilistic reasoning, particularly when clinicians neglect to revise prior probabilities as new information emerges. (11) Diagnostic error remains a major contributor to patient harm. Given the often-limited accuracy of clinical tests in differentiating specific MSK pathologies, rather than abandoning useful tools like imaging, we should focus on improving how they are used in clinical reasoning. (12)

Physiotherapists "Use Less Imaging"
As physiotherapists take on more responsibility in first-contact, orthopaedic triage and other advanced practice roles, it has become common to hear that “physios use less imaging” compared to GPs or medical specialists. While often used as a political or professional selling point, this narrative is not inherently a badge of honour. If uncritically adopted, it reinforces under-investigation, not clinical excellence. We must be cautious not to equate “less imaging” with better care unless it stems from better diagnostic reasoning, not avoidance. 

Avoiding imaging altogether because it can be misused is a false dichotomy. The question is not whether to image more or less, but how to image smarter, knowing when, why, and how to use it within the context of sound clinical judgement for individual patients.

Clinical Reasoning Requires Nuance, Not Dogma
What’s often missing from the imaging debate is an honest conversation about clinician competence.

Appropriate ordering and interpretation of imaging in MSK practice requires the ability to reach a clinical differential diagnosis based on consideration of population-specific prevalence, and history and physical examination findings. In addition to clinical reasoning, imaging requires competence across multiple domains including professional and ethical practice, and communication. When imaging is applied inappropriately, it reflects not a flaw in the modality, but a gap in the clinician’s knowledge, skill and/or clinical reasoning.

Used properly, imaging can support:

• Diagnosis and differential diagnosis
• Red flag identification (e.g., trauma, tumour)
• Surgical planning
• Prognostic guidance
• Monitoring and progression of healing (e.g fractures) or pathology (e.g osteoarthritis)

Its value emerges not in isolation, but when embedded within a robust clinical reasoning process grounded in a working clinical hypothesis. Best-practice diagnostic reasoning frameworks support this approach, where information from the history and examination leads to hypothesis generation, followed by iterative testing (including imaging where appropriate).(10, 11)

When is Imaging Appropriate?
As Lin et al. (2020) and others have outlined, imaging in MSK care is appropriate when:(9)

• Serious pathology is suspected (trauma, tumour, structural injury)
• Symptoms are worsening or unresponsive to conservative care
• Imaging is likely to change clinical management

Requesting appropriate imaging is one issue; interpreting and correlating imaging findings clinically is equally critical. A growing body of research reports the prevalence of imaging abnormalities in asymptomatic populations. This information is used to suggest that the same findings in symptomatic individuals are often clinically irrelevant. However, this misapplies asymptomatic population-level data to symptomatic individuals, overlooking the key principle of population-specific pre-test probability, a cornerstone of evidence-based diagnosis.

Believing that “less imaging is always better” represents its own form of cognitive bias, one that risks harm from delayed or missed diagnoses, particularly in patients with serious or complex presentations.  If clinicians are unsure when to refer or how to interpret findings, the solution is not to abandon imaging, but to improve their clinical reasoning and interpretation skills.  

Imaging without context is noise. But in skilled hands, it helps provide diagnostic clarity and reduces error.

Conclusion: A Tradesman Never Blames His Tools
In an age rightly concerned with overdiagnosis and overtreatment, imaging has become an easy scapegoat. But scans themselves do not cause harm, poor reasoning, poor interpretation and poor communication do. Let’s shift the conversation away from polarisation and blanket calls for the reduction or avoidance of imaging, and dismissal of pathologic findings simply because they have been found in asymptomatic individuals, and back towards smarter use and interpretation of imaging. Let's not throw the proverbial imaging baby out with the bathwater. 

Like any diagnostic tool, imaging is only as effective as the hands and minds that use it. Reducing its use without improving the reasoning behind its application solves nothing. Instead, we should focus on elevating clinical competence, refining our use of imaging, and resisting the pull of oversimplified narratives. Let’s stop blaming the tool and start improving the craft.

The Defence Rests. 

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COMING SOON....
Imaging Prevalence in Asymptomatic Populations: Are We Misreading the Data?

• I'll discuss why context matters, and why prevalence ≠ irrelevance.

Scans Don't Cause Fear - Poor Communication Does. 

• I'll take a look at how effective explanation, not avoidance, is the key to better patient outcomes.

Also in the Imaging Blog Series:

• "Is X-ray Needed in the Diagnosis of Frozen Shoulder? READ NOW

MORE LEARNING...

•  Shoulder Imaging (online course) VIEW COURSE

​          A 3-hour, self-paced, online course covering shoulder imaging modalities, how to read shoulder x-rays and                        interpreting findings to assess symptomatic relevance. Ideal for anyone in an advanced practice role. 

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🔖 References
1. Zadro JR, O'Keeffe M, Ferreira GE. Is It Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions? Phys Ther. 2024;104(4).
2. Zadro JR, O'Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, et al. Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial. J Orthop Sports Phys Ther. 2021;51(8):401-11.
3. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. 2015;36(4):811-6.
4. Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. BMJ. 2021;372:n291.
5. Ibounig T, Rämö L, Haas R, Jones M, Järvinen TLN, Taimela S, et al. Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders: a systematic review. Journal of Orthopaedic Surgery and Research. 2025;20(1):7.
6. Ibounig T, Sanders S, Haas R, Jones M, Järvinen TL, Taimela S, et al. Systematic Review of Shoulder Imaging Abnormalities in Asymptomatic Adult Shoulders (SCRUTINY): Abnormalities of the glenohumeral joint. Osteoarthritis Cartilage. 2024;32(10):1184-96.
7. Shubin Stein BE, Wiater JM, Pfaff HC, Bigliani LU, Levine WN. Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. Journal of Shoulder and Elbow Surgery. 2001;10(3):204-8.
8. Karel YHJM, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. European Journal of Internal Medicine. 2015;26(8):585-95.
9. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86.
10. Higgs j, Sheehan D, Currens J, Letts W, G J. Realising Exemplary Practice-Based Education. 1 ed. Higgs j, Sheehan D, Currens J, Letts W, G J, editors. Rotterdam: Sense Publishers; 2013 11 Feb 2013. 304 p.
11. Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ (Clinical research ed). 2002;324(7339):729-32.
12. Hoffer EP. Diagnostic Error: Have We Made Any Progress? The American Journal of Medicine. 2025;138(9):1177-8.

Author

Dr Angela Cadogan is a registered Specialist Physiotherapist (MSK) based in Christchurch, New Zealand. She has a PhD and clinical sub-specialty in diagnosis and management of shoulder conditions and works in clinical consultancy, education and clinical governance roles. 

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