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. Neuroradiologists read low back scans from 67 people aged 20 to 80 who had never had back pain. About one-third had a major abnormality. The modern age curve pools 33 studies and 3,110 people with no symptoms. Disc wear shows up in 52 percent at thirty, 68 percent at forty and 88 percent at sixty. Facet joint wear climbs from 4 percent to 83 percent across the same years.

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. That is how you know it comes from imaging, not from the spine. Across 63 studies and 5,397 knees with no symptoms and no injury, cartilage defects showed up 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. Cartilage defects, though, split 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 just not enough. Compare one person’s two knees, and structure predicts pain strongly. That is because that comparison strips out weight, mood, sleep and how touchy the nervous system is. Across different people, those factors swamp the picture. In 4,796 people with knee osteoarthritis, MRI features explained at most 28 percent of the differences in pain. And prediction got worse as symptoms got worse.

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 gain 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 about doubled the adjusted risk of still being on work disability at one year, at 2.03. In workers’ comp claims, less badly hurt workers who got an early MRI got injections at 38.9 percent against 1.4 percent. Payment incentives do not fully explain it. Inside the Veterans Administration, 405,965 matched cases showed low back surgery within a year in 1.48 percent after an early scan. Without one, it was 0.12 percent.

Part of the cascade runs through words. In one test, 1,375 people read the same back pain story. The label degeneration raised how much they felt they needed a scan to 5.7 out of 10. The label “an episode of back pain” scored 4.2. In 660 people randomized online, a scan report left more fear of movement than good advice with no scan, 24.0 against 22.0 on a fear-of-movement (kinesiophobia) scale. A person afraid to move stops moving. That fear becomes a driver of its own.

What sham surgery trials showed

Across 53 trials, researchers compared an operation with a fake (placebo) procedure. The placebo group improved in 74 percent. In 51 percent, the real operation did no better. In chronic pain alone, across 25 sham-controlled trials, the fake arm got 87 percent of the improvement the real arm got. Side effects of any kind ran 12 percent against 4 percent. Those trials cover less invasive procedures, since no one has sham-tested an open fusion.

Scope trimming of a worn meniscus matched the sham at one year. At five years it left more catching and locking. The vertebroplasty trials used a needle to the bone surface with numbing medicine as the sham. So they tested the cement, not the act of doing something, and the cement did not win. Spinal fusion was tested against intensive rehab in three trials. The disability gap was 0.7 points at an average 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 gains. In central narrowing of the low back canal (lumbar central stenosis), patients with the tightest canals had 4 to 13 times the odds of a good result at twelve months. A larger trial has since failed to repeat that. An operation that removes tissue should come last, because it is the one step you cannot take 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 toxin (endotoxin) lowered pressure pain thresholds at every muscle tested. Bigger rises in tumor necrosis factor, an inflammation signal, predicted bigger drops. In healthy adults, two nights of broken sleep lowered the heat pain threshold. And 34.9 percent of that effect ran through inflammation in the cells. In 64 pain-free adults, one dose of sugar (glucose) weakened the nervous system’s power to block pain. The bigger the waist-to-hip ratio, the weaker the block.

It runs backward too. A year after weight loss surgery, pressure pain thresholds rose 30.9 percent at the wrist, a joint that carries no weight. Weight change did not track that wrist change at all, r = -0.04. The whole nervous system reset, not just the loaded knee. That is the body-based reason sleep, weight and blood sugar are part of treatment in our practice, not advice on the way out. It is also why we sort structure, mechanism and terrain before treating.

What your scan is really recording

The wear on a report sits downstream of the same terrain. Researchers pooled 20 Mendelian randomization studies, which use genes to test cause. Genetically higher body mass index, waist size, triglycerides and type 2 diabetes each raised the odds of disc wear. Genetic risk for diabetes raised them even with body mass held steady, at 1.080. In 928 Japanese community residents, the odds of low back disc wear rose with each metabolic syndrome trait a person carried. They went from 1.58 with one to 2.62 with three or more. The clearest metabolic signals, though, sat in the mid-back (thoracic) spine.

The disc has no blood supply of its own. It is fed by seepage from nearby vessels. In Framingham participants followed for 25 years, calcium buildup in the aorta in front of a vertebra predicted disc breakdown 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 Deep Dive to Chapter 3, written for your physician.

Frequently asked questions

Can a herniated disc heal on its own?

Often, yes. Across 16 studies, 360 low back herniations causing symptoms were managed without surgery and rescanned about 11.5 months later. They shrank on their own in 52.5 percent of protrusions, 70.4 percent of extrusions and 93.0 percent of loose (sequestered) fragments. The more dramatic the finding, the more likely it shrinks. A herniation still seen 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, no more than placebo. Clean-out surgery for knee arthritis matched a fake operation at one and two years. Trimming a worn meniscal tear matched a sham and left more catching and locking at five years, 29 percent against 12 percent. Truly locked knees and injury tears were left out, 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 rules say simple, new low back pain does not need imaging. A scan is considered after up to 6 weeks of care with little or no improvement. It comes 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. It has the same anesthesia, cut or needle, and recovery, with nothing done inside. It is the only way to learn whether the operation itself relieves pain, and not everything around it. 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