I’m in pain. Do I need an MRI?
When pain won’t go away, it is natural to want to understand why we hurt. This leads most people with chronic pain to see many specialists and to get multiple X-rays and MRIs.
Unfortunately, you can’t see pain on an MRI or an X-ray, and this is the heart of why conventional medicine often fails people living with chronic pain. Conventional medicine relies on imaging and blood work to diagnose a condition. This system is based on the faulty logic that pain is the result of an injury, and you should be able to see tissue damage on diagnostic imaging.
Pain is not due to injury; Pain is a nervous system response to perceived danger.
This means you can have pain without having any tissue damage, and you can have tissue damage without having any pain.
In this blog, I’ll unpack the poor correlation between findings on an X-Ray or MRI and painful symptoms, and help you understand why your MRI results can’t tell the whole story when it comes to pain.
Tissues Heal
The body is exquisitely designed to heal. Many injuries, including broken bones, bulging discs, and ligament strains, repair themselves within 6 - 12 weeks. Some injuries, like certain types of fractures, muscle tears, or deep lacerations, require surgery to reinforce the body’s natural healing process, but after surgery, the tissues will typically heal within 3 - 6 months.
You may be thinking, “But, I have a bulging disc and I’ve had pain for years.”
Bulging discs can be quite painful. That pain is a protective response to limit movement so the discs can heal, which they typically do.
MRI studies have shown that most bulging discs are 50% smaller when rescanned after two months, and 100% resolved within 9 months.
Pain that persists after the tissue heals is due to hypersensitivity of the nervous system.
Injury Without Pain
Studies on multiple areas of the body have repeatedly shown that you can have “tissue damage” without having any symptoms.
Below I will share a sampling of research studies that documented positive findings on an MRI in individuals that do not have pain or limited function. These studies show that findings on an MRI do not mean that you will have pain.
This type of research is important because it can destigmatize positive MRI findings, reduce fear, and restore hope for a full recovery.
Low Back Injuries Without Pain
Asymptomatic Bulging Discs
As I described above, most disc bulges heal. Even if you have a disc bulge that doesn’t full resolve, it is possible to not have any pain or symptoms.
If the bulging disc was the source of pain, you would expect 100% of people with bulging discs seen on an MRI would have pain, but that isn’t the care.
40% of people whose MRIs show bulging discs do not have any pain.
Even people with disc herniations severe enough to require surgery can make a full recovery.
80% of NFL players and 85% of NBA players who have lumbar discectomy back surgery return to the NFL and NBA, respectively.
Asymptomatic Lumbar Spine Arthritis
Arthritis develops gradually over the course of the human lifespan. The highest incidence of arthritis in the low back occurs in people aged 70+.
If arthritis was the cause of low back pain, you would think that the people with the highest incidence of arthritis (those over 70 years old) would have the highest levels of back pain, but that isn’t the case.
The people with the highest levels of back pain are not the people with the highest levels of arthritis. People in their 40s, who have less arthritis than people over 70-years old, have the highest incidence of low back pain, and many people in their 70s and 80s have arthritis in their low backs, but don’t have pain.
Shoulder Injury Without Pain
It is quite common for people to have rotator cuff damage and not be aware that there is an injury.
1 in 3 asymptomatic people over 30 years old and 1 in 2 asymptomatic people over 70 years old have abnormal MRI findings of their rotator cuff.
After successful surgery (i.e. recovery of range of motion and resolution of painful symptoms), more than 2 out of 3 people still have abnormal rotator cuff findings on their follow-up MRIs.
Knee Injury Without Pain
The same is true for knee pain. While some people have trouble coping with arthritis, meniscus tears, or ACL tears, others do not have any limitations in pain or function.
50% of people with osteoarthritis of their knee don’t have any pain.
1 in 3 pain-free college basketball players have abnormal findings on knee MRIs.
Car Accidents Without Pain
If you’ve ever been in a car accident, you know that you can feel pretty sore after even a minor fender bender. The amount of pain you feel after a car accident depends upon the context and the level of stress and fear the accident causes.
Demolition derby drivers who intentionally crash their cars for sport can crash over 50 times per performance at an average speed of 24 mph. That’s a lot of car crashes!
Remarkably, only 2 - 3% of demolition derby drivers experience chronic pain, despite repeated car crashes, indicating that the context plays a large role in the experience of pain.
Pain Without Injury
Just as you can have tissue damage without having pain, you can also have significant pain and functional limitations without having any tissue damage.
Pain is a nervous system response, and if the nervous system feels threatened, it can lead to pain, even without any injury.
In fact, 1 in 4 people have significant pain and functional limitations without an injury, accident, or surgery.
You Can’t See Pain on an MRI
An MRI shows changes in the tissues, but it doesn’t show how the nervous system interprets those changes.
The context, and the way we perceive a situation, influence how we will experience that situation.
You can’t see pain on an MRI; you can only see tissue changes. As the research presented above shows, tissue damage does not equal pain.
To understand pain, you have to understand the nervous system’s role in generating a pain response.
To learn more about central sensitization, which is pain that is generated not because of tissue damage, but because of a hypersensitive nervous system, please read this article:
Is My Pain Caused By Nervous System Sensitivity?
The Disadvantages of MRIs
Have you ever noticed that young children who fall down look to the adults to see how they should react? If the adults are not concerned, the child can usually hop back up without any tears or pain, but if the adults are freaking out, the child will often burst into tears.
Since MRI results are often not correlated with pain symptoms, positive findings will not necessarily explain your pain.
The danger in getting an MRI is that positive results could increase the fear and the protective response your nervous system has, and inadvertently increase your pain.
The more tests, opinions, and failed treatments you get, the higher your stress and fear, and the worse your pain will become.
While the instinct to understand why you hurt is completely normal and logical, pain is not simply a structural problem, and so looking for structural evidence does not tell the whole story.
Learning about pain neuroscience is the best way to really understand why you hurt because it will help you to decrease your fear of pain, and ultimately to decrease the sensitivity of your nervous system.
Understand Why You Hurt
To learn more about the neuroscience of pain, decrease the sensitivity of your nervous system, and get back to living your life without fear of pain, enroll in my 8-week online Break the Pain Cycle Course and Group Coaching Program.
Frequently Asked Questions (FAQs)
Can you have pain even if your MRI is normal?
Yes, it’s very common to have pain despite a normal MRI. Pain is often caused by a hypersensitive nervous system rather than visible tissue damage. MRIs show structure, not how your body feels.
Why does my MRI show damage if I’m not in pain?
MRI scans frequently detect tissue changes that don’t cause pain. Many people have disc bulges, arthritis, or tears without any symptoms. These findings are often a normal part of aging, not a sign of ongoing injury.
Do MRI results always explain the cause of chronic pain?
No. Chronic pain is often the result of nervous system sensitization, not structural injury. MRI results may not correlate with your pain levels and can sometimes increase fear unnecessarily, generating increased pain.
Should I get an MRI if I have chronic pain?
That really is a decision for you to make with your doctor. Without knowing the specifics of your history, the research shows that in the absence of red flags (like severe weakness, loss of bladder control, or unexplained weight loss), MRIs are often unnecessary and may lead to unhelpful or misleading diagnoses.
Treating chronic pain as if it is a structural problem can result in prolonged pain and suffering. To address chronic pain, it is important to help the nervous system feel safe and to reduce the sensitivity of the nervous system so the pain alarm is not so easily activated.
Can pain exist without any physical injury?
Yes. Pain is a protective response generated by the nervous system when it perceives danger. It’s possible to experience significant pain even when there’s no tissue damage or injury present.
What is central sensitization and how does it relate to pain?
Central sensitization is a condition where the nervous system becomes overly sensitive, amplifying pain signals. It’s a common cause of chronic pain and can develop without any injury or tissue damage. Central sensitization can also be causes by pain that persists even after an original injury has healed.
References
Low Back Pain Research
Videman T, Battie MC, Gibbons LE, Maravilla K, Manninen H, Kaprio J. Associations between back pain history and lumbar MRI findings. Spine. Mar 15 2003; 20(6):582-588.
Kjaer P, Leboeuf-Yde C, Korsholm L, Sorensen JS, Bendix T. Magnetic resonance imaging and low back pain in adults: A diagnostic imaging study of 40-year-old men and women. Spine. May 15 2005;30(10):1173-1180.
Hsu WK. Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine. May 20 2010;35(12):1247-1251.
Anakwenze OA, Namdari S, Auerback JD, et al. Athletic performance outcomes following lumbar discectomy in professional basketball players. Spine. Apr 1 201;35(7):825-828
Twomey LT, Taylor JR. Age changes in lumbar vertebrae and intervertebral discs. Clin Orthop Relat Res. Nov 1987(224):97-104.
Shoulder Pain Research
Spielman AL, Foster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals — initial experience. Radiology. Dec 1999;213(3):705-708.
Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJ. Dean men and radiologists don’t lie: A review of cadaveric and radiological studies of rotator cuff prevalence. Ann R Coll Surg Engl. Mar 2006;88(2):116-121.
Knee Pain Research
Munk B, Lundorf E, Jensen J. Long-term outcome of meniscal degeneration in the knee: Poor association between MRI and symptoms in 45 patients followed more than 4 years. Acta Orthop Scand. Feb 2004;75(1z0:89-92.
Major NM, Helms CA. MR imaging of the knee: Findings in asymptomatic collegiate basketball players. AJR AM J Roentgenol. Sep 2002;179(3):641-644.
Car Accident Pain Research
Simotas AC, Shen T. Neck pain in demolition derby drivers. Arch Phys Med Rehabil. Apr 2005; 86(4):693-696.
Central Sensitization Pain Research
Gifford LS. Pain, the tissues, and the nervous system. Physiotherapy. 1998;84:27-33.
Gifford LS. Tissue and input related mechanisms. In: Giffort LS, ed. Topical Issues in Pain. Falmouth: NOI Press; 1998.
Gifford LS, Butler DS. The integration of pain sciences into clinical practice. J Hand Ther. Apr-Jun 1997;10(2):86-95.
Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopedic Rehabilitation. 3rd ed. Philadelphia, PA: Elsevier; 2011.
Multiple Tests and Opinions Increase Pain Research
Kendall N, Watson P. Identifying psychosocial yellow flags and modifying management. In: Gifford LS, ed. Topical Issues in Pain 2. Falmouth: CNS Press; 2000.
Grotle M, Vollestad NK, Brox JI. Screening for yellow flags in first-time acute low back pain: Reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire. The Clinical Journal of Pain. June 2006;22(5);458-467.
Disclaimer
The information in this blog is for informational purposes only. Learning about the science of pain does not replace the individual care you receive from your medical providers. While this information may inform the questions you ask your medical providers, it is in no way meant to be taken as personal advice.
