What Éric-Olivier loves most about physical therapy is his ability to have the chance to truly learn about his patient beyond the body mechanics. Getting to know patients allows him to better tailor h...
This article aims to help people better understand how their MRI results should be used, what they should mean for them and if getting an MRI would be useful to help fix their pain. This article looks at Back, Neck, Shoulders and knees MRIs. The goal is also to bring awareness to health professionals about the potential adverse effects of requesting MRIs too early for their patients.
My MRI says that I have a herniated disc and my doctor said I should avoid doing exercises and be careful with what I do in my day, or it could worsen… My MRI says that I have osteoarthritis (OA). So that must be why my knee hurts so much… My MRI says this (XYZ)... what does it mean? Should I be worried?
Does this sound like you? If this is something you've said or thought of before, don't worry, it is perfectly normal. These are very common thoughts after receiving MRI results.
Magnetic Resonance Imaging (MRI) is a fantastic tool, and I can't say it enough. MRI is a phenomenal imagery technology. It allows us to see inside the body without having to open it. Pretty useful, am I right? MRIs allow us to see almost everything in your body, from cancer to herniated discs to fractures and torn muscles. These can all be extremely useful. (12) (13) (14)
In the medical world, they are essential to detect if there are life-threatening anomalies. As valuable as they can be, just like anything, there are pros and cons to their usage. Unfortunately, it is very rare to hear about any potential negative consequences of using MRIs (No, they will not make you radioactive or give you 5G, these are things that should be talked about less…).
Have you heard of the story of the person who had disc herniations shown on his MRI and was able to continue living without back pain? Have you heard of the person who had meniscal tears in his knees shown on his MRI and was able to go back to running without pain? More about their story later in this article.
It's important to know that while they can be very telling, MRIs often aren’t enough. This article is only about musculoskeletal conditions, meaning that it is only for things that concern your joints, muscles, tendons, ligaments, and discs. I do not have the knowledge and would not feel comfortable writing about MRI and cancer or any other condition isn't related to the musculoskeletal world.
This article is to help you better understand what is happening to you and what can potentially be done to help with your pain.
I have seen too many people being hurt more than anything by unnecessary MRIs. Unfortunately, this is a very well-known consequence of premature imagery such as MRIs and X-rays. It is so common that it has a name; iatrogenesis. It means a negative impact from any medical activity such as diagnosis, intervention error or negligence.
After receiving the results (diagnosis) of MRIs, it is very common for people to become very stressed or fearful to the point of stopping what makes them happy. For these reasons, sometimes, requesting MRIs early in the quest for finding a solution for pain or discomfort or recovery process can be more harmful than beneficial. Very few conditions in the musculoskeletal world (MSK) require MRIs or X-rays, or ultrasounds. It is essential to be mindful of the consequences of an unnecessary MRI on people.
It has been shown that people with recent acute low back pain who received early MRI (within less than 30 days since their pain started) took on average more than twice as many opioids (pain medication), were more likely to go on disability, and took 3 to 4 times longer before being pain-free than those that didn't have an MRI in the first month of their back pain. (1)
As you can see in this graph, it shows the % of people on work disability and for how long. The different lines compare the individuals who did and didn't have an early MRI. The top 2, as you can see on the legend, represent people that had MRIs, and the lower two represent those who didn't.
This shows very well how people with very similar conditions can have very different recovery times simply by adding an MRI result. Many would think that MRIs would have helped increase the success rate of rehabilitation for many people. Many would assume that having a beautiful and clear picture of the inside of the knee could help better diagnose the problem and, in consequence, know better how to treat the problem. But, unfortunately, the results in the last few years tell a different story. Scientific articles that did studies on this very specific topic show quite the contrary. (1-2)
Most people believe that having a herniated disc means that they won't play sports anymore. They won't be able to pick up their babies, will have to wear a brace to protect their back and might even think that surgery will be required to fix it. But did you know that 29% of individuals between the ages of 20 and 30 have a disc herniation and absolutely no symptom (3)? Pretty surprising.
If you are thinking that they don't have pain because they are young, this number increases with age. For instance, 38% of people between 50 and 60 have a disc herniation and no symptoms (3). Who would have thought that so many people walk around clueless that some of their discs are herniated!
But what if my pain is excruciating? It must be because of my herniated disc or maybe because of the meniscal tears shown on my MRI? In some cases, it could be. But remember, the fact is that a lot of people who are in a lot of pain don't have anything wrong shown on their MRIs, and there are a lot of people with no pain who have a lot of degenerations and abnormalities shown on their MRIs.
In the musculoskeletal world, the one you are concerned with most likely if you are reading this (pain related to muscles, intervertebral discs, joints), the use of MRIs is not unanimous among doctors, researchers, physiotherapists and other health professionals.
MRIs are extremely specific and sensitive to changes and anything that isn't within the average/normal values. If the goal is to find something that isn't within that normal range, MRIs are probably the single best thing that we have. However, they fall short in telling us the whole story; if that anomaly is the source of someone's pain, especially in MSK. As you will see in the following pages, it has been shown multiple times for various body parts that the condition of a tissue (body structure, for instance, a tendon) isn't always related to symptoms or pain.
MRIs are great at telling us what looks different from the usual, but something unusual doesn't always mean pain.
A good analogy to understand why doing an MRI might not identify the main source of your pain is to think about a bicycle that can't go forward anymore. You now need to find why your bike isn't working. An MRI is like a very powerful magnifying glass. If you put your bike under the magnifying glass, you'll notice all these rusty spots on your bike that look like they might be the reason why your bike isn't moving anymore. Under the magnifying glass, these rusty spots look huge. But once you remove your magnifying glass, you realize that you can't even see those rusty spots anymore.
Instead, what you see is that your chain has been detached. But a detached chain is not something you could see because you were too zoomed in on your bike when examining with your magnifying glass. If you were to fix the rust on your bike, your bike would still not function because you're not working on the source of the problem. Therefore, having too much info (such as with the MRI) can sometimes lead us astray.
Now let's look at a few studies on MRIs for different body parts and what they say.
Let's start by looking at the lower back. Most of us will have back pain at some point in our life, so it is only fair to start here. For most people in the medical world, there are a lot of scary words to describe and diagnose back pain. For instance, disc herniation, bulging disc, spinal stenosis, disc degeneration, osteoarthritis. But did you know that a lot of people have these and don't even know it? What do you mean they don't know it? It must be painful, right?
What if I told you that what they see and what you feel aren’t always related? Surprisingly, most of us have abnormal findings, yet don’t know and live without pain. Let’s look at how often we find abnormal things in people’s spines that have no pain at all, or the prevalence of imagery findings in the asymptomatic population.
Here’s a table that shows in percentage (%) how often we find different abnormalities in people without any pain according to different age groups. ( 3)
Let's look at the first row named "disc degeneration."
When we look at the column that says 20, we are looking at how often individuals between 20 and 30 were diagnosed with disc degeneration and had no pain. Here we can see 37%. In other words, this means that 37% of individuals between the age of 20 and 30 with no back pain had signs of degenerative discs. They had an abnormal result but no abnormal sensations! What about people in their 40's?
What does it say for them? If you are between 40 and 50 and have no back pain, you have a 68% chance of having disc degeneration and not feeling it. Individuals between 70 and 80 without back pain showed disc degeneration on imagery 93% of the time. 93% of them had abnormal findings and NO pain at all!
Considering all of this, what does it mean then to have a disk herniation (disc protrusions)? Everyone fears hearing they have a disc herniation after all.
If we look once again at the table, it says that 29% of individuals between the age of 20 and 30 have a disc herniation and no symptoms. By 40, that number creeps up to 33% and by 60 to 38%. This means that 1 out of 3 individuals around 40 have a disc herniation and don't even feel it. Isn't it crazy that so many people live with herniated discs and don't even know? How could that be? Isn't it supposed to always be very painful?
If we look at the column of people that are 80 or older that don't have back pain, it is almost sure that they will have five abnormal findings/conditions in their back. Does this mean they should stop doing what they enjoy? Should they be extra careful and stop biking or going for walks? Was it a problem yesterday? No, so why should it stop them from doing what they love today?
It is essential to realize that a lot of people have abnormal findings without any pain. This means that in these people, disc degeneration is not a source of pain. This is very useful to understand because if someone that is 43 starts having back pain for the first time in his life and ends up having an MRI, and the MRI says he has disc degeneration, it is crucial to not jump to the conclusion that this is what is causing his back pain.
Why do I say that? Well, the odds are that he already had that same disc degeneration two years ago when he had no pain since, if you remember, 68% (3) of people without any pain between the age of 40 and 50 have disc degeneration and no pain. If it was there before and it wasn't painful, that most likely means that something else is causing the pain. All the MRI says is yes, there is disc degeneration, but it doesn't tell us that that's the origin of his pain. This is why it is so important not to rely too heavily on what the MRI says sometimes.
Now, if your MRI says you have cancer, please listen to your doctor. But if you are told you have back pain because of disc degeneration, please remember that this isn’t enough to diagnose your pain. A thorough physical exam and a lot of questions about your pain, how it impacts you and what movements or positions can affect it should be asked, and then, only then maybe the MRI could be necessary and taken into consideration as a potential means to confirm a diagnosis.
I'll share a personal story. Five years ago, while I was still playing hockey full contact at an elite level and training for powerlifting on the side, lifting over 400 pounds regularly, I started having back pain. I went to a chiropractor because I couldn't get an appointment fast enough with a physical therapist. I went to my appointment, and the first thing they did was X-rays. Now X-rays aren't as precise for certain things as MRIs are, but they are excellent for bones.
The day after my first appointment, the clinic called me to move ahead with my second appointment. When I got there, the chiropractor told me that according to the X-ray, I had scoliosis and, in the past, had had micro-fractures in 5 different vertebras and that, for those reasons, he wouldn't treat me. Isn't it amazing that I had five microfractures and yet didn't even know? Or yet even better, what about that scoliosis I didn't know I had been living with for the last 18 years without ever having back pain? I ended up getting treated by a physical therapist at my gym, and with a simple exercise, my back was back on track, and I no longer had pain by the end of the week.
What I'm trying to get at here is that people go through their entire life with things that we learn of in our books as awful and that should induce tons of pain. Yet, most will never experience any pain associated with these conditions, which is why it is important to not base our diagnosis and treatments entirely according to the findings on the picture.
We should first rely on the symptoms and the behaviors of people’s pain before considering imaging. Imaging should only be used if we believe there is a significant risk of further damaging something without a complete picture of the spine, for instance when we think there might be something more serious going on (for example, after a big fall on the back). As we’ve seen previously, it can have a strong adverse effect using imaging early in the process. There is nothing unless there are red flags that provides a reason to use X-rays and MRIs before even meeting the patient. This is unfortunately a very common practice for chiropractors and doctors.
Why should we treat a diagnosis if we aren't sure, it is the origin of the problem? Wouldn't it be more logical to treat people according to their symptoms? Aren’t the symptoms what we are trying to fix, and not some findings on some images? By the way scientists have found that 67% of disc herniations resorb themselves naturally (4).
Results in the neck region are very similar to the ones in the lower back, a high frequency of findings in individuals without any symptoms. Let’s look at the different findings of studies that evaluated the frequency at which abnormal results such as disc herniations and disc degeneration were found in individuals with no abnormal sensations (pain, numbness, weakness, pinching.)
A first study looked at 1211 healthy volunteers. Their age varied from 20 to 70 years old, with approximately 100 individuals per decade, per sex. Their goal was to assess the prevalence of disc bulging (disc herniations) in different age groups. (5)
Here’s a graph that shows the percentage (%) of individuals in the study that were found to have disc bulges in their cervical spine (neck). As you can see in this graph, you’re more likely than not to have a disc bulge no matter your age group.
Let's look at the first column that says (20’s). We are looking at the frequency at which individuals in their 20's that have disc bulges and absolutely no pain or even an idea that they have this. The table shows that 73.3% of the males and 78.0% of the females had bulging discs on their MRIs. If we look at any other age group, the odds of having a disc bulge in the neck and not having pain is at least 80%. This means that if you know five people that are 30 or older and don't have pain, only one of them doesn't have a disc herniation. The one that doesn't have a disc bulge is the "abnormal one" here. Overall, in this study, 87.6% of the volunteers had disc bulging regardless of age. Almost all of them had a disc herniation and yet absolutely no pain at all.
With such numbers, it is hard to defend the idea that we can determine the origin of their pain by only looking at the MRI of someone. These results mean that if I was in my office and was only asked to decide who had neck pain and who didn't, I would have been wrong 87.6% of the time. Just by looking at the pictures, almost 90% of them should have had pain according to the MRI, yet none of them did.
A second study (6) found similar findings. In this study, they looked at the degenerative changes in the neck of 497 individuals that had no pain or symptoms in their neck to see once again how often abnormal findings were found on MRIs. Here's what they found:
Disc degeneration was determined to be present in 86% and 89% of discs of both men and women respectively over 60 years of age. So once again, just like the previous study, it shows that a very high number, the large majority of people in their 60's and older that don't have neck pain, on their scans technically should have neck pain.
This trend repeats itself with the shoulder. Some fascinating studies for the shoulder looked at the frequency of abnormal MRI results in people with and without shoulder pain, allowing us to see if people with pain have these “conditions” more often than those that don’t.
A study looked at 123 individuals who had shoulder pain only on one side (7). They took MRIs of both shoulders and compared how often conditions were found in painful and non-painful shoulders. The average age was 39 years old. Here’s what they found:
Rotator cuff tendinopathy (degeneration of the tendons in your shoulders) was found 92.7 % of the time in painful shoulders. In comparison, it was found 88.6% of the time in non-painful shoulders. This means that signs of tendinopathy on MRI aren’t very useful to help us determine if the pain is caused by the tendon or not, since almost as many people don't have pain with it as people that do. It also tells us that almost every single shoulder in that study had something abnormal on MRI, even if 50% of them were pain-free.
Partial tears of the rotator cuff muscles were found 27% of the time in painful shoulders and 20% in non-painful shoulders.
AC joint alterations such as signs of OA (osteoarthritis in the shoulder joint, degeneration of the cartilage in your joint) were found 92% of the time in painful shoulders and 89% of the time in non-painful shoulders.
Labrum anomalies were found 44% of the time in painful shoulders and 42% in non-painful shoulders.
The most surprising one is that bursitis was found more often in non-painful shoulders (56%) than in painful shoulders (55%).
The knee is no different than the other joints.
This first study looked at the prevalence of abnormal findings on MRI in knees of 71- individuals with and without pain (8). The mean age was 62 years old. Here is what they found:
Osteophytes (new bone formations, often seen in patients with osteoarthritis) were found in 77% of the knees that were painful. These were also present in 72% of the knees that weren’t painful.
As you can see with the rest of the graph, this tendency is true for almost all the findings. Abnormal findings are present almost as often in knees without pain as in knees with pain. The only exception to this is meniscal tears.
In this first study, torn menisci were found in 25% of the knees with no pain and only 20% in painful knees. More people had a torn meniscus without pain than with pain. Hard to conceive.
A second study included the results of 63 studies in total and mashed all the numbers together to give us a really good global/average of how often different findings are found in the knees of individuals without knee pain (9). In total, 5397 knees were included in the results of this study. This study found torn menisci on average 10% of the time in pain-free knees, being present 4% of the time when 40 or younger and 19% of the time in individuals older than 40.
In this first study, 72 % of painful knees were presenting with some vexing levels of cartilage damage. This is quite scary at first, but then again, they also found the exact same cartilage damage in 68% of the non-painful knees.
The same second study found the overall frequency of cartilage damage was 24%, This means that 24% of all the painless knees on MRIs showed signs of damage and a potential source of pain.
A third study recently done looked once again at abnormal findings in MRIs in 230 pain-free knees (10). Here’s what they found: MRI showed abnormalities in the majority (97%) of knees. Only 3% of all the knees evaluated in this study looked perfectly normal on MRI, yet 100% of them felt perfectly fine.
This should make you stop and think about the importance we should give to MRIs findings to determine the best treatment approach to help with your pain.
Enough with the numbers. The goal was to show you that this isn’t an isolated case. It is true for all joints. Before laying down my conclusion from all this, here are the conclusions from a few of the studies:
- It would be dangerous to only base decisions on MRI findings to determine if surgery would be the best approach. It is strongly suggested to also base our decisions according to the signs and symptoms of the person. (4-5)
- We were not able to predict who would experience pain from the MRI findings. (6)
- The high increase in usage of MRIs by up to 30% annually has not resulted in improved treatment decisions or outcomes for people with knee pain in general practice settings over the past two decades. (9)
- Despite the increasing use of high-resolution MRI, in practice, a diagnosis should be primarily based on the person’s medical history and physical examination by an experienced clinician instead of solely focusing on the MRI results. The images may assist in correlating clinical signs and symptoms but should not replace clinical evaluation (10)
If you receive MRI results, you should wait before going on Dr. Google, since it seems, according to the research, that we cannot make a clear decision of what the problem is solely from MRI results. Before considering the worst, it would be a good idea to consult a health professional such as a physical therapist or a doctor specialized in musculoskeletal care who will provide you with a complete physical examination.
The physical examination is most likely more reliable to determine the best approach to treat your problem compared to an MRI or other imagery technologies alone. The MRI may be right, but it is impossible to say so until someone looks at you and asks you questions about how you’ve been feeling and what you’ve been dealing with. Without context, MRI results are no more than pictures. As we’ve seen, flipping a coin will be as accurate to determine if your torn meniscus is or isn’t what is causing your knee pain. As good as MRIs are, it would be irresponsible to make a decision only with an MRI reading.
For us health professionals (myself included, I am as vulnerable as other clinicians making these mistakes), let’s make sure not to lose sight of the big picture by only looking at one picture (MRI). Let’s be aware of the potential impact that requesting an MRI can have on our patients.
It is most certainly pleasant to have a nice picture of what is happening inside, but at what price? Do we need them most of the time? Not really. Let’s remember that there is nothing more specific and sensitive than the person with pain themselves. Before asking for a picture, let’s take time to ask the person questions and learn about them and what they’ve been dealing with.
Let’s also remember there are pathologies that, even after being treated, will look the same as they did on the first session (11). Let’s focus on treating the disability and the pain rather than trying to emphasize anato-pathological diagnoses. I hope this helped make clear that we cannot associate pathologies and pain every time.
This also brings forth the question of why so many people are sent to get invasive surgeries to treat a pathology before being first referred to an approach that doesn’t require surgery such as physical therapy? If we know that in many cases, treating the pathology or abnormalities will not solve the problem as it was never the cause of the pain, is this truly a good idea?
If you feel like you would benefit from an evaluation to identify and treat your pain from a health professional, you are welcome to take an appointment with me. It will be my pleasure to guide you and answer your questions.
For more information, make sure to read my other articles which you can easily find on my profile. To discuss the information disclosed in this article, feel free to reach out and let me know, I am always eager to learn. To do so, you can contact me by email at firstname.lastname@example.org
Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine, 38(22), 1939–1946. https://doi.org/10.1097/BRS.0b013e3182a42eb6Brealey, S. D., & DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team (2007). Influence of magnetic resonance of the knee on GPs' decisions: a randomised trial. The British journal of general practice : the journal of the Royal College of General Practitioners, 57(541), 622–629. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173Zhong, M., Liu, J. T., Jiang, H., Mo, W., Yu, P. F., Li, X. C., & Xue, R. R. (2017). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain physician, 20(1), E45–E52. Nakashima, H. , Yukawa, Y. , Suda, K. , Yamagata, M. , Ueta, T. & Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects.Spine, 40(6), 392–398. doi: 10.1097/BRS.0000000000000775.Matsumoto, M., Fujimura, Y., Suzuki, N., Nishi, Y., Nakamura, M., Yabe, Y., & Shiga, H. (1998). MRI of cervical intervertebral discs in asymptomatic subjects. The Journal of bone and joint surgery. British volume, 80(1), 19–24. https://doi.org/10.1302/0301-620x.80b1.7929Barreto, R., Braman, J. P., Ludewig, P. M., Ribeiro, L. P., & Camargo, P. R. (2019). Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. Journal of shoulder and elbow surgery, 28(9), 1699–1706. https://doi.org/10.1016/j.jse.2019.04.001Guermazi, A., Niu, J., Hayashi, D., Roemer, F. W., Englund, M., Neogi, T., Aliabadi, P., McLennan, C. E., & Felson, D. T. (2012). Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ (Clinical research ed.), 345, e5339. https://doi.org/10.1136/bmj.e5339Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2019). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British journal of sports medicine, 53(20), 1268–1278. https://doi.org/10.1136/bjsports-2018-099257Horga, L. M., Hirschmann, A. C., Henckel, J., Fotiadou, A., Di Laura, A., Torlasco, C., D'Silva, A., Sharma, S., Moon, J. C., & Hart, A. J. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal radiology, 49(7), 1099–1107. https://doi.org/10.1007/s00256-020-03394-zJill cook, SESSION 3A: MSK & RHEUMATOLOGY| VOLUME 45, SUPPLEMENT 1, S16-S17, JANUARY 01, 2019, The role of imaging in diagnosing and managing tendinopathy. https://doi.org/10.1016/j.ultrasmedbio.2019.07.464https://www.mayoclinic.org/tests-procedures/mri/about/pac-20384768Grover, V. P., Tognarelli, J. M., Crossey, M. M., Cox, I. J., Taylor-Robinson, S. D., & McPhail, M. J. (2015). Magnetic Resonance Imaging: Principles and Techniques: Lessons for Clinicians. Journal of clinical and experimental hepatology, 5(3), 246–255. https://doi.org/10.1016/j.jceh.2015.08.001Katsumi Kose (2021) Physical and technical aspects of human magnetic resonance imaging: present status and 50 years historical review, Advances in Physics: X, 6:1, DOI: 10.1080/23746149.2021.1885310
Back MRI- Shoulder MRI- Neck MRI- Knee MRI
Disc herniation - Disc degeneration - Osteoarthritis - Torn meniscus - Osteophytes - Bursitis - Rotator Cuff - Torn labrum