Pain doesn't equal damage: what scans actually tell us
Getting a scan can feel like finally getting answers. But for most musculoskeletal pain, scans raise more questions than they resolve. Here's what the research actually says about what those images mean — and what they don't.
“Most scan findings are normal age-related changes — knowing this protects you from unnecessary fear and unnecessary treatment.”
The landmark study everyone with back pain should know
In 2015, Brinjikji and colleagues published a systematic review in the American Journal of Neuroradiology looking at MRI findings in people with absolutely no back pain — no complaints, no treatment history, no symptoms whatsoever.
The results were striking. Disc degeneration was found in 37% of asymptomatic 20-year-olds, rising to 96% of asymptomatic 80-year-olds. Disc bulges showed up in 30% of 20-year-olds and 84% of 80-year-olds. Disc protrusions were found in 29% of people aged 20.
None of these people had pain. All of them had findings that, in a clinical context, are routinely used to explain pain.
These findings are normal ageing, not disease
Brinjikji's study built on earlier work by Jensen and colleagues in the New England Journal of Medicine, who found disc abnormalities in 64% of asymptomatic people back in 1994. The picture that's emerged over 30 years of imaging research is consistent: the spine changes with age, just like skin and hair do. Most of those changes are visible on MRI — and most cause no pain.
The clinical term is "incidental findings" — things the scan picks up that aren't the cause of the problem. The challenge is that when a radiologist reports "disc degeneration at L4–L5," it sounds alarming even when it's completely normal for the patient's age.
The nocebo effect: when scans cause harm
Telling someone their spine looks like "that of a 70-year-old" when they're 40, or that they have "significant degeneration," can cause measurable harm. The nocebo effect — the opposite of placebo — describes how negative information and expectations can worsen symptoms.
Patients who receive alarming imaging reports consistently show higher pain levels, greater disability, and are more likely to need ongoing care than those who receive reassurance or proper context. The scan hasn't changed their tissue — it's changed their perceived threat level.
In my practice, I'm careful about ordering imaging for non-specific pain. And when imaging is necessary, we go through the results together — with full context of what those findings mean for that person's age.
When scans are actually useful
Scans are essential in the right circumstances. Red flags — significant trauma, unexplained weight loss, fever, neurological deficit, saddle anaesthesia — warrant urgent imaging. Progressive neurological symptoms, suspected fracture, and a history of cancer are also clear indications.
For run-of-the-mill back pain, neck pain, or shoulder pain without any red flags? The evidence suggests imaging adds very little to clinical decision-making and often makes outcomes worse by creating unnecessary fear. The best scan is often no scan.
References
- 1.Brinjikji W, Luetmer PH, Comstock B, et al. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811–816. PMID: 25430861.
- 2.Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69–73. PMID: 8208267.
- 3.Moseley GL & Butler DS. (2015). Fifteen years of explaining pain: the past, present, and future. The Journal of Pain, 16(9), 807–813. PMID: 26051220.