Why Your MRI Doesn’t Always Tell the Whole Story

Tell me if this sounds familiar. You wake up one day and notice your back is hurting. You wait for it to go away in a few days like it usually does, but this time, the pain unpacked its bags and is settling in. You eventually go to the doctor. (Or maybe you’re still toughing it out – if that’s you, this is your sign to make that appointment.) Your doctor orders an MRI to see what’s going on. You squeeze yourself into the impossibly tiny tube of the MRI machine and endure what feels like an eternity of the loudest, most expensive, most scientifically advanced jackhammer ever invented. A few days later you get your results and go over them with the doctor. He tells you the MRI showed herniated discs, bulging discs, arthritis, you name it. You may not be a degenerate, but you are degenerating. Given this news, anyone would be concerned. It sounds as if you are one wrong move away from disintegrating. This scenario is remarkably common. I see it every day. What is crucial to understand is that imaging does not tell the whole story. “Abnormalities” on an image, whether they’re an X-ray, MRI, CT scan, are often more the norm than the exception.

The irony of medical progress

Wilhelm Röntgen accidentally discovered X-rays in 1895 while experimenting in his lab. The technology spread like wildfire. Within a year, X-rays were being used in hospitals around the world and 6 years later Röntgen won the first Nobel Prize in Physics. In Germany, X-rays are still called Röntgenfoto in his honor. Decades later, in the 1970s, Raymond Damadian, Paul Lauterbur, and Peter Mansfield developed magnetic resonance imaging (MRI), giving us the ability to see soft tissues in stunning detail. These monumental achievements were gifts to humanity that have saved countless lives and revolutionized medicine. What these visionaries couldn’t have known was that these same technologies would become a double-edged sword. They would reveal all sorts of things – bulging discs, tears, degeneration – that look ominous on a report but often have little to do with why someone is actually in pain. Imaging needs to be understood within the larger clinical picture. And for millions of people with back pain, knee pain, shoulder pain, this lack of context has led to unnecessary fear, unnecessary procedures, and sometimes unnecessary suffering. They opened a window to the body, but once opened, it can never be fully closed. We cannot unsee what the scans show, even when they don’t show the whole story.

What is “Normal”?

To understand what is abnormal, we must first understand what normal looks like. In the case of a broken bone, for example, we know precisely what a normal X-ray looks like. So when a doctor sees a fracture, a break in the bone, it’s clear that it shouldn’t be there and should be treated appropriately. What about a bulging disc? Degeneration of the spine? These sound just as bad. But as it turns out, once you get out of your teens, these are very common. By the time you reach your 40s and 50s and beyond, they are present in the majority of people. In one study looking at over 3,000 people with no pain, researchers found that “abnormal” MRI findings were very common.1 They divided groups by decade from ages 20-80, and each finding became more and more common the older people got. This pattern shows up again and again in every joint that’s been studied: hips, knees, shoulders and more.2,3 We have a saying in PT. These findings are like “gray hair on the inside”. Gray hair doesn’t mean your head is broken and disc degeneration doesn’t mean your back is broken. One shows up in the mirror and the other on an MRI.

When imaging matters, and when it doesn’t

Now, this is not to say these scans are worthless: far from it. A skull fracture, a collapsed lung, a ruptured aneurysm, spinal cord compression – these are emergencies where imaging provides answers that guide immediate, life-saving treatment. These technologies have fundamentally changed the landscape of modern medicine for the better. But in the context of non-traumatic, gradual-onset pain, imaging becomes much less useful. The scan may show multiple “abnormalities”. Which one is causing your pain? All of them? None of them? It is often impossible to say. To be perfectly clear, there are certainly times when the results of a scan are relevant and should strongly guide treatment. The core issue is how to know which findings are truly abnormal and related to your pain and which ones are not? There is usually no great way to tell. This is where understanding the whole person and the details of the clinical picture becomes critically important.

What this means for you

Here’s the bottom line: unless the imaging shows something truly extraordinary, the treatment pathway is going to be similar regardless. You may get anti-inflammatory or pain medication, an injection, and/or be prescribed physical therapy. This is where physical therapy stands out. We don’t treat the scan. We treat the person. Physical therapy isn’t here to fix the anatomy on the MRI, because it’s very possible that “abnormality” was there before you ever felt pain. The herniated disc might have been there for years. The meniscus tear could’ve happened gradually and painlessly, until something else changed. We don’t need to change what shows up on imaging to change how you feel. Instead, the goal of PT is to address the individual. What are you having difficulty doing? Build strength where you’re weak. Add flexibility where there is stiffness. Adjust movement patterns that aren’t serving you. Reduce the fear that’s keeping you from living your life. There’s mounting evidence that physiology plays a bigger role than anatomy in these situations. Inflammation, metabolic health, stress levels, sleep quality – all of these can influence what feels painful.4 Physical therapy can help address these factors as well. But that’s a topic for another article. And with PT this is what we often see. The pain improves. Function gets better. People are able to get back to more of the things they want to do. It doesn’t always work perfectly, and it’s rarely a quick fix, but it’s a legitimate path forward that doesn’t require you to be defined by what showed up on a scan. So the next time you get an imaging report that looks scary, remember: those findings might just be wrinkles on the inside. They’re not your destiny. They’re just one piece of a much bigger puzzle — and often not even the most important piece.

Resources

Brinjikji W, Luetmer PH, Comstock B, et al.

Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173

Gill TK, Shanahan EM, Allison D, Alcorn D, Hill CL.

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int J Rheum Dis. 2014;17(8):863-871. doi:10.1111/1756-185X.12476

Culvenor AG, Øiestad BE, Hart HF, et al.

Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med. 2019;53(20):1268-1278. doi:10.1136/bjsports-2018-099257

Aboushaar N, Serrano N.

The mutually reinforcing dynamics between pain and stress: mechanisms, impacts and management strategies. Front Pain Res. 2024;5:1445280. doi:10.3389/fpain.2024.1445280