Mythbusting: Imaging and Pain

Key Points:

• Medical imaging can tell us a lot, but it never tells us the whole story about pain
• Many “findings” on imaging are simply age-related changes and aren’t related to pain

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The Myth

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Let’s say you’ve got some back pain. It’s a new problem, it’s been bothering you for a few days, and it’s gotten pretty bad. You’re worried about it. You go to your doctor, and they recommend taking some images to see what’s going on.

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You get the results back and are staring at a page full of big, scary words: “degenerative”, “arthritis”, “disc bulge”, “spondylolysis”, etc. What do you do?

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First step: Don’t panic. 

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These are all just words that medical providers use to precisely describe what they see. They’re not good or bad - just descriptors. 

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The good news is that a lot of these words are just things that show up in our bodies as we get older. Some of them are more concerning, but none of them matter if they don’t match up with your symptoms.

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So here’s the myth: Your pain experience and appropriate treatment are defined by your imaging findings.

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And the reality: Imaging findings are just one (rather small) piece of the pain puzzle, and they may not matter at all.

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The Imaging Conundrum

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Medical imaging is largely a tool for ruling things out, or confirming that something is not present. Before we had x-ray and MRI machines, we would often have to cut people open to figure out what was going on inside their bodies. Not great!

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Now, we can use these fancy scans to make sure that there’s nothing big and scary hiding behind your back pain without having to poke holes in you.

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Unfortunately, this has led to lots of people getting lots of images done without having a good reference for what a “normal”, asymptomatic spine looks like under the same lens. It might be great news that your back isn’t broken, but then what’s all this other stuff?

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One of the biggest problems with imaging is that you can’t see pain on an x-ray. All you can see are structures, and structures vary a lot between people and across our lifespan.

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In fact, some of the most frequent findings on low back imaging are found consistently in people who don’t have any pain, and these findings get more common as we get older.

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For example, Brinjikji et al. (2015) did a review of 33 studies involving a total of 3110 people who had no back pain and found that:

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• Disc degeneration was present in 37% of 20-year-olds and 96% of 80-year-olds
• Disc bulges were found in 30% of 20-year-olds and 84% of 80-year-olds

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The same pattern holds true for basically every finding they investigated: They were more common as people got older, but were not associated with any symptoms.

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You know what else affects everyone to some extent as we get older and is not associated with pain or other symptoms?

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Balding.

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Put simply, it can be argued that disc degeneration and other similar findings are basically balding for your spine.

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So all these findings are normal in people that don't have pain, and having them doesn't mean you're destined to hurt forever.

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Several similar studies have been done on other parts of the body, with similar results: 

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1. The Framingham Osteoarthritis Study found that 86-88% of people with no pain in their knees had some kind of abnormality on their MRI (more common in older folks)
2. Minagawa et al. (2013) found that ⅔ of people over 60 have a painless rotator cuff tear
3. Farrell et al. (2019) and Nakashima et al. (2015) found similar findings to Brinjijki et al., but in the neck - lots of disc bulges, no pain

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The list goes on. There’s a lot more to pain than what we see on an image!

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But It Still Hurts!

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Knowing that these findings are “normal” may not be very comforting to someone currently experiencing pain. But this does mean that we don't have to find a specific "fix" for pain many times, since there's nothing "wrong" with the involved structures. They just happen to hurt.

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This lets us be a lot more flexible with our treatments, since we can follow someone’s symptoms rather than having to come up with a specific "fix" based on your diagnosis. Treating the symptoms rather than the image means we can personalize the rehab process.

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So if you get an image taken and it has some stuff on it, don't panic. They might just be normal findings that you've had for years, and if there's nothing medically concerning on the image, it means you're not broken!

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Medical imaging can be scary, but it doesn’t have to be. If you’ve had imaging and are curious about what it means, or you’re thinking about getting imaging and would like some professional input, we can help.

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Physical therapists are actually qualified to prescribe images in many states, and although reading images reliably is a job best left to radiologists, we can certainly help explain and interpret the results of your imaging.

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So drop us a line and let us know how we can help!

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