The short answer

Most back, heel and outer-elbow pain can be managed conservatively at first, not with an immediate scan or early surgery. The practical split is simple: back pain with nerve-warning symptoms or major trauma needs urgent assessment, while plantar fasciitis and tennis elbow usually deserve time plus sensible self-care before escalation. For low back pain, routine imaging is usually deferred unless red flags are present or symptoms are still not improving after about 6 weeks; plantar fasciitis often settles over 3 to 6 months; tennis elbow is often slow and may take many months to calm down.

• Seek urgent help now for back pain if there is loss of bladder or bowel control, numbness around the genitals or anus, severe or worsening weakness in both legs, or pain starting after major trauma.
• Book a routine review for back pain if it is not improving after a few weeks, is stopping normal activities, or is still not settling by about 6 weeks; early scans are not usually helpful in routine nonspecific cases.
• Heel pain usually does not need imaging early. Plantar fasciitis is often diagnosed clinically, but GP review is sensible if pain is severe, worsening, recurrent, or not better after 2 weeks of self-care.
• Think about later escalation if plantar heel pain is atypical or still going beyond 6 months, or if tennis elbow is still present after 2 weeks of self-care, not improving after 6 weeks of home treatment, or persists for 6 to 12 months despite good conservative care.

Back pain that should not wait

Certain back-pain features move it out of the usual “wait and settle” category straight away. NHS advice treats bladder or bowel change, loss of feeling around the genitals or anus, symptoms in both legs such as worsening weakness or numbness, and pain starting after major trauma as emergency signs because they can point to serious nerve compromise, including cauda equina syndrome. Feeling hot, cold or shivery, being generally unwell, or pain that becomes severe suddenly or worsens quickly also needs urgent same-day assessment.

Outside those red flags, the more common picture is mechanical lower back pain after lifting, prolonged sitting, driving, or an awkward twist. A narrative review of low-back imaging found that most acute, nonspecific cases improve substantially within the first 4 weeks, so an early MRI or X-ray is usually not the best first step. In routine cases, scans often show age-related changes in discs or joints that may not explain the pain and can lead to extra tests or referrals without improving outcomes.

The threshold changes when the problem is not settling. If lower back pain is still not improving after about 6 weeks of medical management or physiotherapy, or if leg pain, numbness, reduced walking tolerance, or repeated flare-ups are becoming more limiting, further clinical assessment and, where appropriate, targeted imaging become more reasonable.

Heel pain that deserves a second look

For heel pain, the key decision is whether it still looks like straightforward plantar fasciitis or whether it has stopped following the usual script. In a typical case, the diagnosis is made clinically from the history and examination rather than from an early scan, often with the familiar “first-step” pain when getting out of bed in the morning. Initial care is usually simple: activity modification, stretching, anti-inflammatory measures where appropriate, and a cushioned heel insert. Published evidence suggests about 90% of cases settle without surgery, but it commonly takes 3 to 6 months, so a scan is not usually the first move when the pattern is typical.

A second look becomes more important when the story is less tidy. NHS advice supports earlier review if heel pain is severe enough to limit normal activity, is getting worse, keeps returning, has not improved after 2 weeks of self-care, is linked with tingling or numbness, or occurs in someone with diabetes. At that point, or when the diagnosis is uncertain, clinicians start to think beyond plantar fasciitis alone: persistent heel pain may sometimes reflect a stress injury, nerve irritation, an inflammatory problem, or another soft-tissue condition.

The clearest escalation point from the evidence is persistence beyond about 6 months despite good nonoperative treatment. That is the stage where specialist review, and sometimes imaging, becomes more relevant.

Tennis elbow and the long game

Tennis elbow is often a long-game problem: the AAFP notes that, if untreated, symptoms can last 6 to 24 months, so a slow recovery on its own does not usually mean something serious has been missed. That is one reason watchful waiting is considered reasonable in many cases, as long as the pattern still fits outer-elbow overload and day-to-day function remains manageable.

The early checkpoints are practical rather than dramatic. NHS guidance suggests a GP review if the pain is still present after at least 2 weeks of rest and self-care, and physiotherapy becomes a common next step if home treatment has not helped after about 6 weeks. At that stage, the goal is usually to confirm the diagnosis, look at grip-heavy work or sport, and tighten up load management and exercise technique rather than to rush towards an operation.

Surgery sits much later in the pathway. Public guidance from AAOS and AAFP commonly places it only after roughly 6 to 12 months of unsuccessful conservative treatment, particularly when work tasks, grip strength, or ordinary activities are still significantly affected. Even then, specialist review is not automatically about surgery; it is mainly about checking that it really is tennis elbow, reviewing what has and has not been tried, and deciding whether the next treatment stage is actually needed.

When scans actually help

The practical question is not whether a scan is available, but what it would change. In low back pain, the NHS red flags have already been covered; outside that setting, a 2018 narrative review found that routine early imaging for nonspecific pain is usually unhelpful, and is generally held back unless serious pathology is suspected or symptoms are still not improving after about 6 weeks of treatment. That matters because an early MRI can uncover incidental changes, prompt more tests or referrals, and still leave the first-line plan unchanged.

Heel pain follows the same logic for a different reason. A review of chronic plantar fasciitis reports that diagnosis is usually made clinically, with imaging mainly reserved for an atypical pattern or pain that has not responded to initial treatment. Since about 90% of cases improve with nonoperative care over 3 to 6 months, an early scan often does not alter the usual starting point of load adjustment, stretching and heel cushioning.

For tennis elbow, the NHS pathway also moves first through self-care, then GP review after around 2 weeks, and physiotherapy if things are not improving after about 6 weeks. In practice, scans become more useful when the picture is unclear or recovery has stalled. Across all three problems, the image is only one piece of evidence: symptoms, examination and timing usually decide whether a scan helps or merely adds noise.

What to do next if you are not improving

A more useful ending point is a simple map, not another recap. If the pattern still fits and symptoms are gradually easing within the NHS or review-based time windows already outlined, the next step is usually to stay with conservative care rather than jump to an MRI, injection or operation. If progress has clearly stalled at one of those checkpoints — 2 weeks, 6 weeks or, for persistent plantar fasciitis, around 6 months — the question changes from “what treatment next?” to “have we got the diagnosis right?”

In practice, “specialist review” can mean a GP with musculoskeletal expertise, a physiotherapist, a sports-medicine clinician, a spinal specialist, an orthopaedic consultant, or a consultant-led MSK clinic. A good assessment should cover the symptom pattern, examination findings, function, what has actually been tried, and whether imaging would genuinely change management rather than simply add another label.

That is the final pathway: keep self-managing while recovery is typical and moving forward; book review when symptoms are persistent, atypical or no longer improving; and use same-day or emergency care for the back-pain warning features already covered. Where a consultant-led opinion would help sharpen that plan, MSK Doctors accepts online self-referral at mskdoctors.com.