Abnormal MRI? Why Most Findings Show Up in People Without Pain

An abnormal MRI is the most persuasive page in a pain patient’s chart, and very often it is describing a normal body. The findings are real. What they mean for your pain is the part the report cannot tell you.

The video for Chapter 3 of The Pained Brain, Your MRI Is Lying to You, gives the short version. The book is by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. This is the longer one: which findings appear in people who feel fine, which ones actually separate people in pain from people without it, and what the scan is recording when it is not recording the cause.

How common is an abnormal MRI in people with no pain?

The experiment began in 1990, when neuroradiologists read lumbar scans from 67 people aged 20 to 80 who had never had back pain. About one-third carried a substantial abnormality. The modern age curve pools 33 studies and 3,110 people without symptoms: disc degeneration in 52 percent at thirty, 68 percent at forty and 88 percent at sixty. Facet degeneration climbs from 4 percent to 83 percent across the same span of life.

The words that appear most often on a report are the ones pain-free people carry most often. In 98 people without back pain, a bulge showed up in 52 percent and an extrusion in only 1 percent. The rarer words are rare for a reason. Common is not the same as meaningless, either. In 1,211 healthy volunteers, cervical disc bulging was nearly universal, but cord compression appeared in 5.3 percent, and that finding matters.

Every joint tells the same story, which is how you know it is a property of imaging rather than of the spine. Across 63 studies and 5,397 knees with no symptoms and no injury, cartilage defects appeared in 43 percent of people forty and older. In hips, labral tears were nearly as common without pain as with it, 54 percent against 62 percent, while cartilage defects separated the two groups sharply, 12 percent against 64 percent. The report prints both findings in the same font.

Which findings actually track pain

Structure is not irrelevant. It is insufficient. Compare one person’s two knees and structure predicts pain strongly, because that comparison strips out weight, mood, sleep and the sensitivity of the nervous system. Across different people, those factors swamp the picture. In 4,796 people with knee osteoarthritis, MRI features explained at most 28 percent of the variation in pain, and prediction got worse as symptoms grew more severe.

Some spine findings really are more common in people who hurt. Among adults 50 and under, disc extrusion carried an odds ratio of 4.38 for back pain and Modic type 1 change 4.01. Even the reading is uncertain: on the same 53 pain-free shoulders, one expert radiologist saw a labral tear in 55 percent and another in 72 percent. We have written more on why an MRI report is not a diagnosis.

The cascade an early scan sets off

Early imaging without a red flag does not improve outcomes. Six randomized trials with 1,804 patients showed no benefit for pain or function. In 5,239 adults aged 65 and over with new back pain, early imaging did not change disability at 12 months either.

What the early scan changes is what happens next. Among 1,226 Washington State workers, an early MRI for a back sprain roughly doubled the adjusted risk of still being on work disability at one year, at 2.03. In workers’ compensation claims, less severely injured workers who got an early MRI received injections at 38.9 percent against 1.4 percent. Payment incentives do not fully explain it. Inside the Veterans Administration, 405,965 matched episodes showed lumbar surgery within a year in 1.48 percent after an early scan against 0.12 percent without one.

Part of the cascade runs through words. When 1,375 people read the same back pain scenario, the label degeneration raised their perceived need for imaging to 5.7 out of 10, against 4.2 for an episode of back pain. In 660 people randomized online, a scan report left more fear of movement than best-practice information with no scan, 24.0 against 22.0 on a kinesiophobia scale. A person afraid to move stops moving, and that fear becomes a driver of its own.

What sham surgery trials showed

Across 53 trials comparing an operation with a placebo procedure, the placebo arm improved in 74 percent, and the real operation did no better in 51 percent. In chronic pain specifically, across 25 sham-controlled trials, improvement in the sham arm accounted for 87 percent of the improvement in the active arm, while any adverse event ran 12 percent against 4 percent. Those trials cover less-invasive procedures, since no one has sham-tested an open fusion.

Arthroscopic trimming of a degenerative meniscus matched the sham at one year and left more catching and locking at five years. The vertebroplasty trials used a needle to the bone surface with local anesthetic as the sham, so they tested the cement rather than the act of doing something, and the cement did not win. Spinal fusion, tested against intensive rehabilitation across three trials, showed a disability difference of 0.7 points at a mean of 11.4 years. The one trial that clearly favored fusion compared it with routine physiotherapy. Fusion beats doing very little. It does not beat doing something well.

It is humbling to count those operations. Surgery still has a place, and the image can help pick who benefits: in lumbar central stenosis, patients with the narrowest canals had 4 to 13 times the odds of a good result at twelve months, although a larger trial has since failed to reproduce that. An operation that removes tissue should come last, because it is the one step that cannot be taken back.

Where the pain lives when the picture stays the same

Inflammation lowers the pain threshold across the whole body. In 40 healthy volunteers, a trace of bacterial endotoxin lowered pressure pain thresholds at every muscle tested, and larger rises in tumor necrosis factor predicted larger drops. In healthy adults, two nights of broken sleep lowered the heat pain threshold, and 34.9 percent of that effect ran through cellular inflammation. In 64 pain-free adults, one glucose load weakened the nervous system’s ability to inhibit pain, in step with waist-to-hip ratio.

It runs backward too. A year after bariatric surgery, pressure pain thresholds rose 30.9 percent at the wrist, a joint that carries no weight, and weight change did not correlate with that wrist change at all, r = -0.04. The whole nervous system reset, not only the loaded knee. That is the physiological reason sleep, weight and blood sugar are part of treatment in our practice rather than advice at discharge, and why we sort structure, mechanism and terrain before treating.

What your scan is really recording

The degeneration on a report sits downstream of the same terrain. Pooling 20 Mendelian randomization studies, genetically higher body mass index, waist circumference, triglycerides and type 2 diabetes each raised the odds of disc degeneration. Genetic liability to diabetes raised them even with body mass held constant, at 1.080. In 928 Japanese community residents, the odds of lumbar disc degeneration rose with the number of metabolic syndrome components carried, from 1.58 with one to 2.62 with three or more, though the clearest metabolic signals sat in the thoracic spine.

The disc has no blood supply of its own and is fed by diffusion from nearby vessels. In Framingham participants followed for 25 years, calcification of the aorta in front of a vertebra predicted disc deterioration at that level, at an odds ratio of 1.5. The shoulder follows suit: diabetes carries 3.69 times the odds of frozen shoulder. That is why the insulin nobody measured matters to your joints and nerves.

None of this means never scan. Among 1,172 primary care patients with back pain, 0.9 percent had a serious cause, and age over 70 raised the likelihood of a vertebral fracture more than any other red flag. A red flag is a reason to image. Otherwise, in our practice the history comes first, then the examination and the blood, and the image is read last against all three. When they disagree, a controlled block settles it. Ask to go through your report finding by finding, with your age’s prevalence beside each one. The full evidence is in the Technical Supplement to Chapter 3, written for your physician.

Frequently asked questions

Can a herniated disc heal on its own?

Often, yes. Across 16 studies of 360 symptomatic lumbar herniations managed without surgery and rescanned about 11.5 months later, spontaneous regression occurred in 52.5 percent of protrusions, 70.4 percent of extrusions and 93.0 percent of sequestered fragments. The more dramatic the finding, the more likely it shrinks, and a herniation still visible on a later scan does not by itself mean a poor outcome. What a selective nerve root block proves about a bulging disc.

Is degenerative disc disease on an MRI normal?

In most adults, yes. Among people with no back pain, disc degeneration appears in 37 percent at age twenty and 96 percent at eighty, and disc bulges climb from 30 percent to 84 percent. That makes the finding common, not proof that it causes your pain. The examination, and when needed a controlled block, decides that. Deep back pain with a normal MRI: internal disc disruption.

Does arthroscopic knee surgery help arthritis or a worn meniscus?

In sham-controlled trials, not more than placebo. Debridement for knee arthritis matched a simulated operation at one and two years. Trimming a degenerative meniscal tear matched a sham and left more mechanical symptoms at five years, 29 percent against 12 percent. Truly locked knees and traumatic tears were excluded, so those trials do not speak to them. Where knee arthritis pain actually comes from.

When should I get an MRI for back pain?

Radiology’s own criteria say uncomplicated acute low back pain does not warrant imaging. A scan is considered after up to 6 weeks of care with little or no improvement, or sooner for signs of cauda equina syndrome, cancer, fracture or infection. If you do have a red flag, ask for the scan: 65.6 percent of patients with one were never imaged. What happens at a first interventional pain appointment.

What is sham surgery?

Sham surgery is a placebo procedure: the same anesthesia, incision or needle and recovery, with nothing done inside. It is the only way to learn whether the operation itself, and not everything around it, relieves pain. Across 53 such trials, the real operation did no better than the placebo in 51 percent, mostly in less-invasive procedures. Why leg pain can persist after a back surgery that worked.

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Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, board certified in anesthesiology, pain medicine, interventional pain management, addiction medicine and obesity medicine. Adapted from Chapter 3 of The Pained Brain by Dr. Padda and Dr. KrisJay Fucanan, MD. Last reviewed September 2026.

Dr. Gurpreet Singh Padda, MD, MBA, MHP