The Disconnect Between MRI Findings and Back Pain: Why They Don’t Always Correlate

by Dr. Erik Heinlein, PT, DPT, Cert DN, TPI Certified

Back pain is one of the most common medical complaints, affecting millions of people worldwide each year. For many individuals suffering from persistent back pain, an MRI (Magnetic Resonance Imaging) scan is often recommended by healthcare professionals to investigate the underlying cause. However, an increasing body of research suggests that MRI findings don’t always correlate with the intensity, severity, or even the presence of back pain. This disconnect between MRI results and back pain has important implications for diagnosis, treatment, and patient outcomes.

The Role of MRI in Diagnosing Back Pain

MRI scans are a powerful imaging tool that can provide detailed images of soft tissues, including muscles, ligaments, discs, and nerves. For back pain patients, MRI scans are often used to identify structural issues such as herniated discs, spinal stenosis, degenerative disc disease, or even tumors. These findings can offer valuable insights into potential sources of pain, particularly in cases where there is a clear traumatic injury or concerning neurological symptoms.

However, MRI results are not always straightforward when it comes to explaining why someone is experiencing back pain. It is essential to understand that while MRI scans provide images of structural abnormalities, these abnormalities don’t necessarily cause pain. The presence of a structural problem on an MRI does not guarantee that it is responsible for the symptoms the patient is experiencing.

The Growing Evidence of the Disconnect

One of the most compelling studies on this issue comes from the Journal of the American Medical Association, which revealed that a significant proportion of people with no back pain at all have MRI findings that suggest problems like bulging discs, degenerative disc disease, or spinal stenosis. In fact, in a study of individuals with no back pain, nearly 40% of those over 40 years old had disc degeneration or bulging discs visible on MRI, and these issues often worsened with age. These individuals, however, did not report any pain.

This phenomenon points to a critical issue: the structure of the spine might change with age or over time, but these changes don’t always result in pain. The relationship between the body’s structural abnormalities and pain is complex and not fully understood.

Why MRI Findings Don’t Always Correlate with Pain

There are several reasons why MRI findings and back pain often don't correlate:

Asymptomatic Structural Changes: Many individuals with back pain show MRI results that suggest a herniated disc, disc degeneration, or spinal stenosis. However, these structural changes can be present without pain, particularly in older adults. These conditions may be part of the natural aging process and not necessarily a direct cause of discomfort.
Pain is Multifactorial: Back pain is rarely the result of a single factor. It can be influenced by physical, psychological, and emotional factors. Muscle weakness, poor posture, stress, anxiety, and even lifestyle factors such as sitting for long periods can contribute to pain. MRI scans cannot capture these influences, making them an incomplete tool for understanding back pain.
Psychological Factors: Research also suggests that psychological factors play a significant role in chronic back pain. Stress, depression, and anxiety can amplify pain perception. An MRI can’t measure these aspects, yet they can have a profound impact on how a patient experiences and responds to pain.
The "Nocebo" Effect: The nocebo effect refers to when a patient’s expectations of pain worsen because they are told about abnormal MRI findings. If a doctor presents an MRI result that indicates a problem, the patient might start to believe that they are seriously injured, even if the structural issue is not causing their pain. This psychological response can worsen their pain perception, despite no physical reason for the increase in discomfort.

The Importance of a Holistic Approach to Back Pain

Given the disconnect between MRI findings and back pain, it is essential for healthcare providers to adopt a more holistic approach when diagnosing and treating back pain. This is where Physical Therapists are poised to offer the most comprehensive solution to back pain. While MRI can be a useful diagnostic tool, it should not be the sole determinant of treatment. Instead, clinicians should take into account the patient's history, physical examination, movement patterns, muscle imbalances, lifestyle factors, and psychological health. Understanding the multifactorial nature of back pain allows for more comprehensive, patient-centered care.

In many cases, conservative treatments such as physical therapy, increased levels of regular exercise, posture correction, stress management, and mindfulness techniques can alleviate back pain without the need for surgery or invasive interventions. Furthermore, educating patients about the benign nature of certain MRI findings—particularly in older adults—can reduce unnecessary anxiety and improve their outlook on recovery.

Conclusion

The disconnect between MRI findings and back pain serves as a reminder that pain is a subjective experience that can’t always be explained by structural abnormalities alone. As technology continues to improve, our understanding of how to best interpret MRI results and treat back pain will likely evolve. For now, it is crucial to remember that back pain is a complex condition with many potential causes, and MRI findings are just one piece of the puzzle. A well-rounded approach to diagnosis and treatment is key to ensuring that patients receive the best care possible, rather than focusing solely on imaging results. A thorough evaluation with a skilled physical therapist serves as one of the best solutions to reconcile the various aspects of an individual’s back pain in order to construct a personalized plan of care. The art of treatment of back pain often is matching the right treatment to the individual - and as you now know - there is more to it than your MRI!