You are not your MRI

Magnetic Resonance Imaging (MRI) scans are a form of diagnostic imaging that uses magnets and radio waves in order to look at structures inside your body.

An MRI scanner shows us inside our bodies at a fixed point in time

MRI scans can help to diagnose a multitude of problems, as they show detailed information about the brain and spinal cord, joints, soft tissue structures like muscles and ligaments, and internal organs. Once someone has an MRI scan, a report on the findings is written up and used to diagnose a problem and/or plan treatments for a condition. With advances in technology, MRI scans are able to show us more detail and information than ever before about what’s inside our bodies.

But is that information all helpful and useful in terms of managing aches and pains?

The use of MRI scans in the treatment of musculoskeletal pain has been called into question in recent years due to increasing overdiagnosis. Overdiagnosis means ‘an unwarranted diagnosis that leads to unnecessary treatments that do not benefit patients and that wastes health resources that could be used better elsewhere’ (Maher et al. 2019). Often it is thought that MRI scans will detect the cause of a person’s pain and therefore be a target for the treatment of the pain. This is largely a reductionist perspective as it assumes that pain is only related to structural changes in the body. Looking at pain through this lens is referred to as a biomedical approach (Quintner et al. 2008). What we now know about pain is that it has influences from multiple factors, including biological ones (ie tissue injury, inflammation), psychological ones (ie stress, anxiety, beliefs about pain), and social ones (ie cultural beliefs, impact of pain on family life, friendships, hobbies) (Malpus, 2019).

Only 1% of back pain is related to serious pathologies which require further investigation (such as cancer, infection, fracture, etc). But a large issue is that people in pain - especially severe acute pain or long-term chronic pain - are worried and want to know what is wrong, so seek answers from a healthcare provider and diagnostic imaging. Recent research has shown that patients believe that pathological findings on diagnostic imaging provide evidence that pain is real, and will locate the source of their pain. Furthermore, clinicians are afraid of missing a serious diagnosis and want to meet the patient’s expectations (Sharma et al. 2020). However, it has now become clear that overuse of imaging in the treatment of musculoskeletal pain causes harm to patients by way of overdiagnosis.

“Recent research has shown that patients believe that pathological findings on diagnostic imaging provide evidence that pain is real, and will locate the source of their pain”

In low back pain, imaging is cautioned against unless red flags are present (signs of potentially serious pathology such as weight loss, loss of bowel/bladder control, recent trauma, etc). Pain severity, although difficult for a patient experiencing it, is not a red flag. In fact, findings on MRI scans are common amongst people with no symptoms. A large systematic review of asymptomatic people who had CT or MRI scans on their lower backs showed that the prevalence of disc degeneration was 37% in 20 year-olds and increased up to 96% in 80 year-olds. Disc bulges, which are a common source of fear in relation to back pain, were also very common – 40% of 30 year-olds and 60% of 50 year-olds had them! (Brinjikji et al. 2015).

These findings should help reassure us that the vast majority of us have these findings in our backs without pain – therefore they may not relate to a current pain problem. It is important when considering the results of scans to interpret the findings in relation to the person’s symptoms. Finding disc degeneration in someone with acute back pain is unlikely to explain their symptoms - the scan findings have probably been there for a while already! It is my opinion, and that of the surrounding literature, that ‘degenerative changes’ should be treated as incidental findings in the majority of cases and likened to the normal changes we see as we age in other areas of the body – such as wrinkles on our skin and grey hairs. Nobody I know refers to grey hairs as ‘degenerative hair disease’!

““It is important when considering the results of scans to interpret the findings in relation to the person’s symptoms””

These findings are not unique to back pain. Knee pain is a substantial cause of disability and disruption to physical activity levels. Beliefs about knee pain being related to ‘bone on bone’ and ‘wear and tear’ are common (Darlow et al. 2018). Furthermore, knee arthroscopy as a treatment for degenerative changes seen on MRI is common, but is now strongly recommended AGAINST under clinical practice guidelines for the treatment of knee arthritis as the risks may outweigh the benefits and it is no more effective than sham surgery or physiotherapy (Siemieniuk et al. 2017, Katz et al. 2014). A recent large study of individuals with no knee pain but scanned with detailed MRI scans demonstrated that 97% of knees had ‘abnormalities in at least one knee structure, for example, the meniscus, cartilage, tendons, ligaments (Horga et al. 2020). 62% of those scanned had a cartilage abnormality, 30% had a meniscal tear and 46% had tendon abnormalities. This supports a large systematic review that demonstrated that 43% of asymptomatic over 40s had cartilage defects and 25% of those in the review had osteophytes which increased prevalence with age (Culvenor et al. 2019).

Do you see a young woman or an old woman?

I suspect that you will see an old woman. Vision, like pain, is an output of the brain and depends on your perspective. Your perspective was influenced by the start of this article and had we shown you the young woman first (click right), what you would have seen here would have been very different (even though the lines are identical)

Hopefully, you had an epiphany there and can see that things look differently depending on your perspective! Now back to the article!

Similar studies and reviews have been done on the shoulder. These also showed a high prevalence of abnormalities on diagnostic imaging in asymptomatic subjects such as rotator cuff tears and bursal thickening, acromioclavicular joint arthritis (Girish et al. 2011, Gill et al. 2014). Similarly, in scans of asymptomatic hips, 73% of those in one study had some abnormalities (Register et al. 2012). In comparison between asymptomatic volunteers and those with symptomatic femoroacetabular impingement syndrome, a higher percentage of symptomatic patients had imaging findings, but the asymptomatic volunteers also had a high prevalence (e.g. labrum defects seen in 44% of asymptomatic versus 61% of those with pain) (Tresch et al. 2016).

So what does this all mean?

Imaging findings aren’t the be-all and end-all in terms of aches and pains. We can’t be certain that the findings on scans are the cause of pain – they might be, but most of the time it doesn’t change how they are treated. Overdiagnosis of findings seen on imaging can cause more harm than good, especially if they cause worry and fear in a person. For example, if a 35-year-old is told they have disc degeneration but are not informed that this is most likely a normal finding, they may avoid moving their back normally and increase their fear and concern regarding their back, which may lead them to experience chronic pain and believe their back is damaged for the rest of their lives. This is called a ‘nocebic’ effect (which is the opposite of the ‘placebo’ effect). If you’ve had imaging that has told you some scary-sounding findings, make sure you ask your healthcare provider if they are common in everyone, symptomatic or not. And remember, some people in pain have normal-looking scans too!

Best practice guidelines for the treatment of musculoskeletal pain suggest that imaging should be used ‘selectively’ (Lin et al. 2020). Of course, there is a time and a place for imaging studies – they are fantastic for detecting problems that need urgent attention and for diagnosing more serious conditions. But for the vast majority of our musculoskeletal aches and pains, it’s best to leave imaging behind and focus on understanding our pain, doing physical activity and getting moving back to our normal activities, and even trying new ones!

Closing thoughts

So what’s the point of all this? The reality is, that a scan is a fixed point in time, and the findings of ‘degeneration’ are normal in people with and without symptoms and most importantly aren’t going to change. Our aches and pains, however, can fluctuate day-to-day and we can have influence and control over them. By interpreting the results of scans in a more positive light, we can have belief and optimism that things will improve, as long as we look through a BioPsychoSocial lens, not a biomedical or structural one. The real take-home message is that you are not your scan, it’s just a picture of you and we should be treating you as a person who has had a scan and focusing on things we can control - like getting you back to your meaningful goals and valued activities. We’ve most likely all got some of these ‘degenerative’ changes in our backs, but we’ve also probably got some wrinkles and grey hairs too, which is just a part of life!