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

Key points

1. 0131 clinical practice guidelines consistently discourage routine imaging for non-traumatic lower back, knee and shoulder pain in primary and intermediate care.
2. 02Imaging is only advised when serious or specific pathology is suspected, when conservative care is not working, or when the result would change management.
3. 03For low back pain, X-ray is discouraged unless a fracture or axial spondyloarthritis is suspected; for knee and shoulder pain, X-ray can be a first-line test in a minority of cases.
4. 04Knee osteoarthritis is generally a clinical diagnosis (age 45 or older, activity-related joint pain, no significant morning stiffness) and does not need routine imaging.
5. 05The authors conclude guidelines do not justify the rising imaging rates in the UK, pointing instead to clinician behaviour and patient expectations.

How it was conducted

Design

Scoping review of clinical practice guidelines, conducted and reported per PRISMA and Joanna Briggs Institute guidance

Search

MEDLINE, CINAHL, PsycINFO and SPORTDiscus from 2009 to 17 April 2019, plus guideline repositories, a Google snowball search, professional bodies and Twitter

Eligibility

Guidelines developed in or intended for the UK, meeting the formal CPG definition, with imaging recommendations for adults with non-traumatic lower back, knee or shoulder pain

Appraisal

AGREE II domain 3 (Rigour of Development); a score of 50% or higher deemed high quality

Synthesis

Narrative synthesis of similarities and differences across included guidelines

What they found

• 12,775 citations were identified and 31 clinical practice guidelines met the inclusion criteria.
• 26 citations were excluded at full-document stage; 18 of these were due to not fulfilling the CPG definition (n=12) or being unable to determine if criteria were met (n=6).
• Most guidelines were developed in the UK (n=19), followed by European (n=9) and international (n=3) development.
• 16 guidelines covered a specific MSK presentation: low back (n=5), knee (n=8) and shoulder (n=3); 15 covered regional pain conditions that may present at these sites.
• 27 of 31 guidelines were deemed high quality on the AGREE II Rigour of Development domain.
• 21 of 31 guidelines made recommendations on the use of diagnostic imaging in primary and intermediate care.
• The search tweet was retweeted by 73 people and seen by 21,375 Twitter users over 14 days, yielding 8 additional hits, 2 of which were included.

Limitations

• Only documents meeting the strict formal definition of a clinical practice guideline were included, so other clinician resources labelled as guidelines may have been excluded.
• The review focused on UK practice, which limits generalisability, although findings matched an international guideline review.
• Title screening and final charting were done by a single reviewer (AC), with verification by a second reviewer.
• One NICE-accredited document underpinning the included shoulder CKS was excluded for not meeting the CPG definition, raising questions about whether some included recommendations rest on the most contemporary evidence.

Why it matters

For patients

If you have back, knee or shoulder pain without injury, a scan usually will not help and is not routinely recommended unless something serious is suspected or you are not getting better.

For clinicians

Guidelines support withholding routine imaging in primary and intermediate care, reserving it for suspected serious pathology, failed conservative care, or when results will change management.

For readers

Rising MSK imaging rates in the UK are not justified by guideline recommendations, pointing to clinician behaviour and patient expectations as drivers to address.