Live LOUD Life Podcast, Lafayette Colorado

Episode 50

Do I Need an XRAY or MRI?

With Dr. Antonio Gurule DC

In pain and wondering if you should get an Xray or MRI? Both are great tools but oftentimes they are overdone and overused. In Episode 50 of the Live Loud Life podcast, Dr. Antonio breaks down when and why you might need special imaging and when you would not need it.


Episode Highlights

  • Why imaging is overused
  • How proper evaluation trumps imaging
  • Xrays and MRIs as a first step in care
  • Pain does not equal tissue damage
  • What happens when there are other red flags?
  • Sometimes imaging will not change the course of care

About Dr. Antonio Gurule DC



  • Father
  • Doctor of Chiropractic
  • Owner of Live LOUD
  • Personal Trainer & Health Coach

What’s New on the Podcast

Welcome back to another Live Loud Life podcast episode. I’m Dr. Antonio Gurule, your host of the Live Loud Life podcast brought to you by Live Loud Chiropractic and Coaching. My wife and I own Live Loud Chiropractic and Coaching, we’re based out of Lafayette, Colorado, which is in Boulder County. We went to Boulder for our undergrad, we were out to California for grad school and we knew we were coming back home because we love the mountains, we love the sunshine and it’s an amazing place to be. But that’s not what we’re talking about, that was just a little bit of brief history.


Not a lot of housekeeping stuff today. We hope you guys are enjoying the episodes, we have some other guests that will be joining us on the episodes soon, I promise. The start of the year is always a little crazy, we’re all in from the holidays, we had a wedding and all that stuff and just the scheduling–it’s just been harder to connect with people, to be honest. But we hope that you’re finding the content still valuable and beneficial for your health and your wellness and your longevity, to help you live a loud life.


When Do You Need Imaging?

Today, we’re going to be talking about something that we get as a question quite commonly. It was sparked by a recent patient we had who is 10, who ended up having an injury playing soccer. The parents just basically wanted to know, do we need to go get Xrays or an MRI? Pretty simple as that, they wanted an evaluation done. What’s interesting is, depending on who you see, imaging is pretty much the first and only thing that they do. And so I was thrilled that they trusted us with the care for their son and glad they came to a place like ours who values an evaluation and history to understand when imaging is not necessary and when it’s, quite honestly, overdone. That’s what we’re talking about today.


Special imaging, Xrays, MRI, CT scans–amazing technology. Like it blows my mind that we can do these things and get insight into the world within our body. It is absolutely amazing and it is necessary for healthcare and for certain things. In the case of musculoskeletal care and injuries, very beneficial but again oftentimes overused and overdone, so that’s what we’re talking about today.


Changes in Body Tissue

The insight into your body is a great tool that could give indication as to why there might be certain pain in certain areas or certain issues. But that’s not always the case because they have done a number of studies on asymptomatic individuals where we see changes from the “normal” body tissue and the way things should look in asymptomatic individuals. For instance, if you’re over the age of 50 and you’re asymptomatic and you go get an MRI, you’re going to find old injuries, old disc bulges, just different things that have happened over the years that don’t correlate to any pain. When someone is in pain and we do see those changes in imaging, yes, there could be an indication that those would be consistent with the pain pattern and maybe causing it. But the question always comes down to “will it change the course of care?” We’re going to get into a little bit of that because that’s always something that we want to understand and realize.


Simple Pain Remedies

In the case of this 10-year-old, we did a knee exam, we talked about what happened, a little bit of swelling, he was limping. But a lot of the why he was having the symptoms he was having is because he had been doing the old school method of RICE (Rest, Ice, Compress and Elevate) and he hasn’t moved his knee in over a week, like hardly moved it at all. The knee is stiff as can be and so I’m asking him to move and do things, it’s going to hurt because he hasn’t been moving it. And so all we did was kind of trick him in doing some gentle plyometric walking, skipping, different things like that, and miraculously the knee was fine. There was still some end range pain in certain directions but still… It doesn’t take it all away but it was pretty cool to see this immediate change. After all the evaluation, I was just like, no, you don’t need imaging. It’s slightly hyperextended because he missed a ball and that created some tissue irritation, added some swelling. What they did was not wrong but we encouraged them to just start moving him more and more and then we’re going to get a little bit of a return to play program going in.


Examples of Overuse

But in the case of musculoskeletal injuries, we oftentimes overuse this. They would have gone to a PCP. Many PCPs are skilled in orthopedic evaluation and they hopefully would have come to the same conclusion, but many would be like, yeah, it’s always good to just get an Xray to see if anything’s going on. Why? Just do the evaluation to figure out if something’s going on!


This is definitely the case, depending on the cascade of events of how you get to whoever’s helping you. And again, nothing against orthopedists but they are skilled at their role and almost everything they do revolves around having some sort of image around something. Many of the orthopedists that we work with, people will go see them and they’ll basically say nothing’s wrong with you–you need to go see a physio, a chiro or a personal trainer and you need to rehab this out. Which is amazing, but even chiropractors depend on Xrays to set up their treatment course and plan. There’s absolutely no reason you need to get Xrays before starting chiropractic care. Nothing indicates that that would be the case.


This is not a pain science episode, we just wanted to talk about some of the reasons as to maybe why you might get imaging. This is not a pain science episode talking about the complexity of pain, but we do know that tissue damage does not equal pain and pain does not equal tissue damage, and that’s the whole premise of this. You could have an injury or pain in an area and everything would check out, which would mean you would not need imaging. There are functional MRIs and stress Xrays but most of them are a stilled image of what the tissue looks like beneath the surface. Beneficial, but more times than not we’re going to try to do an appropriate evaluation and assessment to determine if something actually does need an image, and more times than not it doesn’t.


Here are some reasons as to why imaging might be good, and I’ll try to give some examples as they come up.


Significant Trauma

Let’s say for instance, someone was in a rollover car accident. If they were in a rollover, they probably were checked out by EMTs at the scene–and if they cleared everything, then most likely you’re good. But significant trauma like from a car accident and they’re having unrelenting pain and there’s just a number of different things going on, that would be a good time to be like, hey, let’s get some imaging to make sure things are good. And if you’re checked out by the EMTs, depending on the severity of the accident, you might be in a C-spine, on a board, brought to the hospital, and they’re going to do all that imaging to check you out.


When people are in significant car accidents and they come in to us, it’s kind of this middle ground where we’re like we want to find out about the severity. More times than not, the people that are walking in the clinic after a car accident probably don’t have something broken. It’s not to say they don’t. Depending on the story and the history as we go through it, that would lead us to believe if there’s something correlated to the traumatic trauma.


Another example would be a patient that I’ve seen on and off, does CrossFit, a lot of intense stuff, oftentimes will come in with like, oh my gosh, my back hurts so bad. I did this, this or this, whatever it might be. Chatting more with this individual, she’s like, oh, yeah, I got bucked off my horse last week and I’m having this SI joint, lower back pain–and she points kind of to the back of her pelvis and her lower back. We’re chatting a lot more and it’s like, yeah, getting bucked off a horse and hitting the ground, that’s quite a bit of trauma. I want you to get an Xray first. Fractured her pelvis, right? She had a fracture in her pelvis. It didn’t really change the course of care for what we did because we can still do some soft tissue and stuff, but I’m not going to be doing a lot of adjustments around a fractured pelvis that takes time to heal. That would be an example of significant trauma.


Inability to Bear Weight

Now, with significant trauma, we’re looking at things like is the individual able to bear weight? There are certain criteria, without getting to the specifics of it. Let’s say for instance you twisted your ankle. “I don’t know if I broke my ankle.” Obviously, a lot of swelling, different things like that, and we’re looking at can you bear weight. If someone’s able to bear weight and walk and do certain things after a sprain or a twisted ankle, the likelihood of them having fractured their ankle goes down. What’s great about an Xray is that a three-view ankle Xray cache is like $45 so it can be a simple easy tool to just rule that out. We’re not saying don’t do imaging; we’re just trying to find the appropriate time and place so that you’re not doing unnecessary imaging. In the case of something like that, it’s like, yeah, we’re curious. Let’s go get a quick image and we’ll hopefully be able to see something. So inability to bear weight could be a factor as well.


Cancer and Other Red Flags

When we’re looking at more potentially sinister things, these are these red flags where it’s like, yeah, let’s dive into some of these things. In the case of even something like lower back pain, part of our questionnaire is do you have a history of cancer? Cancer can grow in other areas and the spine depending on it can be an area that it definitely can. Someone who basically has this unexplained lower back pain that’s started and they have a history of cancer, it’s like let’s go get some Xrays and let’s get some imaging and see if there’s anything going on. That’s an easy way to rule out if it has metastasized to a different part. That can be again a very useful tool so that you’re not creating more of an issue where their pain might be. And we want to know those types of things to help manage their care because it’s not just something that we’re going to be managing on our own.


Signs of Inflammation

Other things that could be in the spine but let’s say even more peripheral, and we’re talking about more like a joint here, the affected area is very hot and swollen. We can have joint infections and there’s different reasons as to why that might happen. When something is infected, it doesn’t have to be very swollen but it can be very warm to the touch. We see a lot of this like acute inflammation moving to this area, trying to fight off whatever that is. That would be an indication of looking into further imaging or evaluation assessment to determine what that might be. Also, looking at the overall temperature of the individual and other things like that would lead you down that road.


Neurological Symptoms

Other things, let’s take into consideration lower back pain or even neck pain or something like that–progressive weakness or progressive neurological symptoms. A term that gets overused way too often is sciatica. Basically, anything from your back or in your butt or down your legs a little bit is going to be sciatica, that’s how people portray it. It’s a little bit more defined than that but we’re not going to talk about that today. When someone has a lower back injury or neck injury and let’s just say it is a disc herniation or a bulge and we’re having inflammation and/or direct pressure on the nerve root, they could be having weakness or neurological symptoms such as numbness and tingling, burning pain, or even motor deficit loss. Those would be considered neurological symptoms.


If we’re seeing someone and progressively those symptoms are getting worse, we want to get an MRI and check out to see what’s going on, what’s pushing on the nerve. There are obviously different interventions such as steroid packs and other things like that which would significantly help. (We don’t prescribe that because that’s a medication but we would refer on to that.) But that would be a time where I would be like, hey, your weakness is getting worse, your motor loss is getting worse, your numbness is becoming more prominent, if you will, and/or the area in which it is numb is growing. The tingling would be kind of correlated with that as well and then even if someone is having like burning pain, if it’s getting more intense, it’s progressing and/or the area is getting larger, you’re not going in the right direction–we want some imaging, we want to go check it out, we want to make sure what’s going on. That would be another indication of doing it.


Lack of Progress

And then last, one of the criteria is a potential just lack of progress. While what we do is super beneficial and it helps a lot of people in a lot of different areas, there are times when we’re just not getting the progress that we want to see. So if for whatever reason we’re working on an ankle injury, something like that, a knee or something like that. We’re working on it, we’re rehabbing it, we’re strengthening it and it’s just like, oh, I’m not getting better, there’s still this one thing or this one position or this is happening. I get a sharp pain or something like that in these certain angles, positions, so on and so forth, there might be something in there that’s just not right.


One case that comes to mind is I had a CrossFitter, this was years ago, who had a sticky elbow. Sticky elbow, the elbow did not like end range flexion and end range extension. There’s not many times when you go into like deep, deep flexion. Front rack would be definitely one of those. You have the barbell on your shoulders, rested on your fingertips and your elbows up–that’s deep weighted flexion. And then terminal extension, I actually do quite a bit because you’re locking everything out, whether that’s a press overhead, whether it’s a push up or dips. And we’re mobilizing, we’re working on it, we’re adjusting it, we’re doing all these things, and it’s just not getting anywhere. I was like, dude, I don’t know what’s going on. Can I just refer you for a quick Xray? He had a loose body in there. Basically, like a little fragment of connected tissue bone, whatever it was, that was basically just blocking the joint. You know a hinge? Imagine you have a door hinge with like a big granule of sand in there, it’s not going to be able to function as good as it could. A simple thing such as that, we found it. For him, it was enough where it was restricting the things that he wanted to do. They went in, they took that out, and it was like he had a brand-new elbow, nothing was wrong. So a lack of progress can be an indication of when to do it.


Pain Does Not Equal Tissue Damage

But, overall, when we’re looking at these, most of these are fairly intense things and the likelihood of these being the cause of your pain issue and under function are low. They are a possibility, we are not saying that this is not the case, but we do have to take into consideration (and just coming back into this) tissue damage does not equal pain and pain does not equal tissue damage. You can be in intense pain with literally nothing physically wrong or broken. The pain cycle is complex, that’s not to say that your pain is not real. Making sure that we make that a point. That does not mean that what you’re feeling is not real. It’s just saying that when you’re looking for imaging to try to find the cause and when you’re going through all these diagnostic things, sometimes providers make up things to correlate and associate with it because we need an answer, we need to know why. That’s getting down into again the pain science discussion, that pain is complex or our bodies are complex and when we want answers and we’re searching for answers, you’ll find something. You’ll find something but that doesn’t mean it’s the cause.


If you have an injury, obviously get it evaluated, get it checked out, but hopefully this brings a little bit of awareness and comfort in knowing that the majority of these things that would require special imaging, Xrays, MRIs and CT scans, if the individual who’s evaluating you does a really good assessment and evaluation, they’re going to rule those things out. So then if we’re working with something, we know we’re not dealing with a structural issue.


Would Imaging Change the Course of Care?

I just finished up with a gal who had a pinchy shoulder. She has been told, oh, it’s probably a rotator cuff tear and all these other things. It was just like, hey, your strength and everything is checking out, you have poor scapular mechanics and weakness in the shoulder. (Weakness meaning like a complete deficit from right to left as to what she’s able to accomplish.) Especially talking about an overhead athlete, it’s like let’s just try to make it super strong, work on your range of motion mechanics, so on and so forth, and see where we get. We checked it out, there doesn’t appear to be any sort of structural damage based on an evaluation. I don’t know that for sure, obviously, because I didn’t have an MRI. But even then, if her pain gets better but yet she did have a rotator cuff tear, does that mean the rotator cuff tear needs to be addressed or fixed? And that’s the conversation that we have constantly–will it change the outcome of care?


Do you want to know if you have a rotator cuff tear? Yes. Okay, fine, we can get imaging. We have insurance and free market healthcare allows us to get those things fairly quickly. You could pay cash for it too. Fine, ease of mind, great, and then we can set it up from there. But for a lot of people, you’re just like I’m not going to do surgery so it doesn’t really matter. It’s just like, cool, then let’s just dive into what we know and help make it better.



Special imaging–we love it, we need it, it’s great. But knowing when and what we are to do. And for your injuries, being evaluated by a good provider will help you strongly determine what needs to be done and so that way you’re not also just getting unnecessary imaging. Also, just knowing. It’s just like we said, the more things you go through–the more imaging, the more diagnostics, the more things you’re looking for–you’re getting further down that road that pushes towards more interventions such as injections and medications and surgeries and things like that. So, understanding that if you don’t need those things right off the bat and you can start a course of conservative care and improve, then you don’t even have to go down that slippery slope.


Live LOUD Chiropractic and Coaching Serving the Communities of Lafayette, Louisville, Erie, Broomfield, Longmont, and Boulder Colorado.