As physiotherapists, we regularly encounter patients who come with scan reports laden with structural findings — disc bulges, meniscal tears, rotator cuff pathology, degeneration, etc. It’s tempting to assume that “something showed up on the image, therefore that’s what’s causing your pain.” But the evidence suggests it’s not always that simple.
1. Imaging findings commonly occur in people without pain
• In a landmark systematic review and meta-analysis, Brinjikji et al. (2015) examined degenerative imaging features (disc degeneration, bulges, protrusions, facet changes) in adults both with and without low back pain. They found that many of these “abnormalities” are actually common in the asymptomatic population — and their prevalence increases with age. This means that just because a scan shows something, it doesn’t necessarily mean it’s the root cause of someone’s back pain.
• In the knee, Horga et al. (2020) studied a cohort of 230 knees and reported the prevalence of “abnormal findings” even in knees that were (or had been) asymptomatic. Their work underscores that meniscal lesions, cartilage defects, bone marrow lesions, and other structural changes may not always correlate with pain.
• For the shoulder, Barreto et al. (2019) performed bilateral MRI scans on individuals presenting with unilateral shoulder pain (i.e. only one shoulder was symptomatic). Remarkably, many “abnormal” imaging features (such as tendinopathy, partial tears, acromioclavicular joint changes) were evident in both the symptomatic and the asymptomatic shoulders. Only a few findings — notably, full-thickness rotator cuff tears and glenohumeral osteoarthritis — were significantly more common on the painful side.
Together, these studies illustrate a key principle: imaging findings may not equal pain generators. Many structural changes seen on MRI or other scans are incidental, age-related, or asymptomatic.
2. What does this mean for your assessment and treatment?
As physiotherapists, our role is not simply to “treat the scan” but to treat the person. Here’s how we integrate imaging into a holistic assessment:
A) History-taking & symptom detail:
• We ask when and how the pain started, what aggravates or eases it, whether there is night pain, referred symptoms, functional limitations, and so on.
• Red flags (e.g. unexplained weight loss, fever, night pain) may prompt earlier imaging or referral.
B) Physical examination & movement tests
• We assess range of motion, strength, joint mobility, neural mobility, load tolerance, movement patterns, and neuromuscular control.
• We look for reproducibility of the patient’s pain with certain movements or loading positions.
C) Interpret imaging in the clinical context
• If the scan shows a structural finding (e.g. a small disc bulge, partial rotator cuff tear, meniscal change), we compare it with the patient’s symptoms, the physical exam, and functional limitations.
• If the same or similar findings exist in asymptomatic individuals (per the studies above), we are cautious about over-attribution. That is, we avoid reflexively declaring “that MRI finding is the problem,” especially for mild or common changes.
D) Diagnosis & treatment plan
• We arrive at a working diagnosis that combines the clinical picture and imaging findings, assigning appropriate weight to each.
• The plan is directed toward movement restoration, load management, strength, motor control, pain modulation, functional rehabilitation — not just “fixing” structural anomalies.
3. What you as a patient should know
• A structural change on a scan does not always mean it’s the source of your pain. Many people live with “abnormalities” and never have symptoms.
• Imaging is a tool — helpful in certain cases — but it has limitations.
• A good physiotherapist will use imaging to inform (not dictate) treatment, and always correlate it with your story and your movement exam.
• If someone tells you “your MRI is terrible, that’s why you hurt,” it may not be the full picture.
• Conversely, if your scan looks “normal,” that doesn’t mean there’s nothing wrong — many sources of pain are not visible on MRI (e.g. nociplastic pain, soft tissue irritations, small nerve sensitisation, etc.).
References:
Brinjikji, W., Diehn, F. E., Jarvik, J. G., Carr, C. M., Kallmes, D. F., Murad, M. H., & Luetmer, P. H. (2015). MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A systematic review and meta-analysis. AJNR American Journal of Neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173
Horga, L., Cerezal, L., Maldonado, V., Beltrán, J., & Pedrera-Zamorano, J. D. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults via MRI. [Journal name if available].
Barreto, R. P. G., 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.2019.04.001
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