When we're in pain or have suffered an injury, we want to know what's going on. Understanding our pain is the first step to overcoming it. But HOW we understand our pain is not as straightforward as it seems.
In the traditional medical model, the typical patient journey starts at their doctor or an orthopedist. Then they order an X-ray. The rationale is simple: when you have pain, we need to visualize what's going on inside your body.
Sometimes the imaging stops there. The radiologist sees "arthritis" and you learn your knee is "bone on bone." They tell you to stop running unless you want a knee replacement in a few years.
For some people, the X-ray comes back totally normal, so the next logical step is an MRI. X-rays can really only show what's happening with bones and joints (helpful for diagnosing a suspected fracture), so when the X-ray is "negative," the docs need to see your soft tissue. That's when they bring in the big guns and order an MRI.
Maybe you have back pain and they want to look at your discs. Or you have shoulder pain and they want to check your rotator cuff. It makes sense that if something comes back abnormal on an MRI, boom—you've found it! That protruding disc at L5/S1? Clearly the cause of your back pain. Or the "inflammation" in your rotator cuff? Obviously the source of your shoulder pain.
These abnormal findings are, in a way, oddly comforting to patients because now there's validation that something is "wrong" that can be "fixed."
I hope you're starting to sense some sarcasm in my tone with the widespread use of "quotation marks."
We've been led to believe that imaging the structures of our body is what we need to understand what's causing our pain. The typical patient journey has become the standard of care for orthopedic injuries and chronic pain.
But I want to push back against that.
Your MRI reveals far less than you think it does—and often results in mismanaged treatment protocols, and more confusion instead of clarity.
The Story of the Woman Who Got 10 MRIs
In 2017, a study was published in The Spine Journal that tracked a 63-year-old woman's efforts to understand her back pain with an MRI (Herzog 2017).
This patient was suffering from lumbar radiculopathy (back pain with radiating pain down her right leg). She visited 10 different MRI centers around New York City over the course of 3 weeks, seeking answers.
Instead of clarity, she received conflicting interpretations resulting in 49 distinct findings between the different radiologists who read her MRI reports.
49 distinct findings. That means 49 unique interpretations of what was being shown on the same MRI.
If you don't like what you see, just go get another one at another location, right?
The Outdated Belief Driving This Madness
The reliance on X-ray and MRI to "diagnose" musculoskeletal pain stems from the deeply rooted belief that pain must equal tissue damage and that something must be "fixed" to solve your pain problem.
With our current understanding of pain science, we know that pain is far more complicated than that. Pain can exist in the absence of tissue damage.
In fact, there are hundreds of thousands, if not millions, of asymptomatic individuals walking around in the world who show abnormal findings on an MRI.
Pain-Free People with "Abnormal" MRIs
There is a growing body of evidence documenting the vast numbers of totally pain free people who show abnormal MRI findings. This occurs in all areas of the body and across all age ranges. Below are just a few examples.
Low Back (Lumbar Spine) (Brinjikji 2015):
- 37% of pain-free 20-year-olds show "disc degeneration" on MRI
- 96% of pain-free 80-year-olds show "disc degeneration" on MRI
Think about that. Over a third of 20-year-olds walking around totally pain-free will show an "abnormality" like disc degeneration on their MRI. They have the back of a 50-year-old. But they are totally pain-free!
Neck (Cervical Spine) (Nakashima 2015):
- 88% of asymptomatic individuals aged 20-80 had a cervical disc bulge at one or more levels
Hip (Kim 2015) :
- In a study of 946 patients, only 15.6% had symptoms of hip pain that correlated with "osteoarthritis" as confirmed by X-ray
- In most hips, despite X-ray evidence of osteoarthritis, the vast majority of patients have no hip pain
Knee (Guermazi 2012):
- 710 subjects over age 50 were put in an MRI machine
- 89% had abnormalities on MRI
- 74% showed osteophytes (bone spurs)
- 69% showed cartilage damage
- Only 29% actually had knee pain
- 88% of subjects WITHOUT knee pain exhibited abnormalities on their MRI
What This Actually Means
Big picture: These studies show that the majority of people walking around totally pain-free have evidence of something "wrong" with them on imaging.
But think about it—as you age, your body naturally starts to break down. It's NORMAL for this to happen.
We all inevitably get gray hairs and wrinkles on our faces. Our hair loses pigment and our skin loses collagen and becomes less elastic. We don't think anything of it because we see it every day and it happens slowly over time.
Our bodies age the same way on the inside—we just don't see it every day.
The Disease of Aging
I die inside a little every time a patient, friend or family member talks about and MRI that shows "Degenerative Disc Disease."
There is no disease process occurring in these patients other than the natural aging process. The use of imaging and labeling the findings with this type of language can, at best, create an unhelpful, or at worse, harmful self-perception of health. If these beliefs persist, they can lead to fear avoidance or catastrophizing behaviors and the development of chronic pain.
Langauge matters. We don't call wrinkles "Degenerative Skin Disease." That just sounds laughable!
In the same way our skin ages, our discs naturally lose hydration and pliability. Think of them as wrinkles in your spine. The difference is that we don't see our spine every day, so when we do have it imaged, we're SHOCKED to see the natural aging process at work.
The Problem with Image-Driven Treatment
When we rely solely on MRI findings to guide treatment, the process becomes fixated on finding the damaged tissue and repairing it.
However, if you look back to The I3 Model of Pain article, you'll remember that pain and injury are rarely caused by one incident (unless you fall and break your arm).
Instead, a host of factors interact to create a complex pain experience unique to the individual:
- Movement dysfunctions
- Social and environmental factors
- Psychological factors
- Personal beliefs and biases
Your MRI is a snapshot of your body lying still for 30 minutes. Most likely you have pain when you deadlift, run, throw a baseball, or move your body—none of which are accurately represented by lying in a metal tube.
What the Guidelines Actually Say (Spoiler: Skip the MRI)
The sad reality is that many patients still believe they need an MRI to understand their pain, despite a growing body of evidence and recommendations to avoid imaging as a primary intervention.
The Research Recommends:
Journal of Orthopedic & Sports Physical Therapy (JOSPT): Recommends physical therapy as the first-line intervention for acute low back pain while avoiding imaging. A direct quote from the authors states:
Specifically, the research shows that overuse of MRI for patients with low back pain is related to an increased rate of surgical procedures that have not consistently been shown to significantly reduce painful symptoms and improve daily function. - J Orthop Sports Phys Ther 2011
American College of Physicians (ACP): Recommends against MRI for low back pain unless there are red flag signs such as:
- Previous history of metastatic cancer
- Suspected abdominal aneurysm
- Progressively worsening neurological signs
The ACP reasons that imaging early in the treatment process may result in incidental findings that divert attention and lead to an increased risk of unnecessary surgeries.
And if you think I'm biased because I'm a PT, consider that these are recommendations from independent groups looking at the research objectively.
So What SHOULD You Do Instead?
At Pack Performance PT in Rocky Hill, CT, we start with a different approach—one that focuses on you as a whole person, not just a picture of your insides.
Our 3-Step Process: From Understanding to Performance
STEP 1: UNDERSTAND We provide full clarity through comprehensive assessment—not imaging. We want to know:
- What movements cause your pain?
- What are your training and injury history?
- What lifestyle factors might be contributing?
- What are your goals and what's holding you back?
This isn't about finding a "thing" to fix on an image. It's about understanding the complete picture of why you're in pain and what YOUR body needs.
STEP 2: RESTORE We create a personalized plan to eliminate pain and restore optimal movement based on YOUR unique presentation—not what a radiologist saw in a snapshot.
STEP 3: REBUILD We build long-term strength, capacity, and resilience so you can handle life's demands without fear. We don't stop when pain is gone—we continue until you're stronger and more capable than before.
The Bottom Line: Your Body Is Smarter Than a Picture
Here's what I want you to take away from this:
An MRI doesn't tell your story—it provides a snapshot.
That snapshot might show "abnormalities" that:
- Are completely normal for your age
- Have nothing to do with your pain
- Create unnecessary fear avoidance and harmful self-perception
- Lead to interventions (like surgery) you don't need
Your pain is complex. It's influenced by how you move, how you train, how you sleep, how you manage stress, and dozens of other factors that won't show up on an MRI.
At Pack PT, we don't need a picture to understand your pain. We need to watch you move, hear your story, assess your capacity, and understand your goals.
That's how we create real, lasting solutions—not by chasing images, but by addressing the root causes that imaging can't capture.
When DO You Need an MRI?
To be clear: MRIs aren't useless. They're just overused.
You SHOULD get imaging if:
- You've experienced significant trauma (car accident, bad fall)
- You have red flag symptoms (loss of bowel/bladder control, progressive neurological changes)
- Your PT suspects a serious medical condition
But for the vast majority of musculoskeletal pain? You don't need it.
Start with movement assessment, proper diagnosis through functional testing, and a comprehensive treatment plan. Save your money and the MRI for when it's actually necessary.
Ready to Understand Your Pain Without the Pictures?
At Pack Performance PT, we help active adults and athletes in Rocky Hill and Central Connecticut understand and overcome their pain—no MRI required.
Our comprehensive evaluation gives you the clarity you need without the confusion, cost, and potential misdiagnosis of imaging.
SCHEDULE YOUR FREE CONSULTATION
During your 60-minute assessment, we'll:
- Identify the TRUE root cause of your pain
- Rule out any red flag concerns
- Create a personalized plan based on YOUR body
- Give you confidence in the path forward
Questions? Text us at 860-266-6287 or email dr.matt@packperformancept.com.
Citations:
Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017 Apr;17(4):554-561. doi: 10.1016/j.spinee.2016.11.009. Epub 2016 Nov 17. PMID: 27867079.
Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015 Dec;36(12):2394-9. doi: 10.3174/ajnr.A4498. Epub 2015 Sep 10. PMID: 26359154; PMCID: PMC7964277.
Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8. doi: 10.1097/BRS.0000000000000775. PMID: 25584950.
Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, Aliabadi P, McLennan CE, Felson DT. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339. doi: 10.1136/bmj.e5339. PMID: 22932918; PMCID: PMC3430365.
Kim C, Nevitt MC, Niu J, Clancy MM, Lane NE, Link TM, Vlad S, Tolstykh I, Jungmann PM, Felson DT, Guermazi A. Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study. BMJ. 2015 Dec 2;351:h5983. doi: 10.1136/bmj.h5983. PMID: 26631296; PMCID: PMC4667842.
Tonosu J, Oka H, Higashikawa A, Okazaki H, Tanaka S, Matsudaira K. The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS One. 2017 Nov 15;12(11):e0188057. doi: 10.1371/journal.pone.0188057. PMID: 29141001; PMCID: PMC5687715.
JOSPT perspectives for patients. Low back pain: MRIs should be used sparingly in patients with low back pain. J Orthop Sports Phys Ther. 2011 Nov;41(11):847. doi: 10.2519/jospt.2011.0507. Epub 2011 Oct 31. PMID: 22047999.
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–91.
Matthew Szymanski
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