Obtaining the correct diagnosis for a patient’s pain is extremely important in determining the best treatment options. This cannot be stressed enough. Very often, patients come in telling me, “Doctor, I have a herniated disc. That’s why I have this back pain,” or, “My knee hurts because I have a torn meniscus.” They identify the cause of their pain based on the results of an imaging study such as an MRI (magnetic resonance imaging) scan. As it turns out, and as discussed below, while an MRI does provide information, it doesn’t tell the whole story.

MRIs can be misleading in diagnosing musculoskeletal pain

The simple truth is that abnormalities that show up in an MRI or X-ray could have occurred at some point in the past and may not be the source of a person’s current pain. For example, let’s say an MRI reveals a disc bulge. Sure, that bulge exists, but it is possible that the bulge already existed before the patient experienced any pain. The only way to know how long an abnormality has been present would be if the area had been scanned previously several times over the years, which is rare in a healthy person. In fact, a large number of studies have documented that individuals experiencing no pain can have abnormal MRI findings.[1] A well-known study published in the New England Journal of Medicine showed that out of 98 pain-free people, 64 percent had abnormal back scans.[2] These were people with no pain! Many other studies have shown this same thing: abnormal findings exist in people with no pain. Shoulder rotator cuff tears and other shoulder abnormalities exist in MRIs for people with no pain or symptoms (medically referred to as “asymptomatic”),[3] including professional baseball pitchers.[4] Abnormal neck MRIs have also been found in asymptomatic individuals in multiple studies,[5] as well as abnormal knee MRIs in asymptomatic patients,[6] including in asymptomatic athletes.

Another study looked at the value of MRIs in the treatment of knee injuries and concluded, “Overall, magnetic resonance imaging [MRI} diagnoses added little guidance to patient management and at times provided spurious [false] information.”[8] Therefore, one cannot assume when evaluating someone with musculoskeletal pain that an abnormality that appears on an MRI is automatically the cause of a person’s pain. If every irregularity revealed in an MRI were the true cause of a person’s pain, every surgery performed because of an MRI would result in a cure, but this is of course not the case.

On the other end of the spectrum, sometimes with musculoskeletal pain, X-rays or MRIs are negative or inconclusive and blood tests are normal. Yet the pain is real. There is a problem; it’s just that the results, medical tests, and scans may not reflect a reason. Therefore, the physician has to go deeper into the history, or use other tools, such as diagnostic ultrasound, to arrive at a diagnosis. To determine the cause of a patient’s pain accurately, it is very important to understand what happened prior to the problem starting, and other aspects of the pain pattern to determine a possible origin. An imaging study should only supplement—not replace—a diagnosis based on how the problem started, symptom progression, and pain pattern.