Despite the enormous advances in the understanding of pain over the last 50 years or more, so-called modern healthcare still appears unable to distance itself from the now questionable bio-medical dogma of yesteryear where we believed that tissue damage was directly responsible for pain. Modern neuroscience teaches us that pain has very little to do with tissue quality at all and increasingly less so as time goes on. Around 95% of the people who come to see me for chronic pain treatment do not describe any sudden, forceful event that directly precedes the onset of their pains and so we are not dealing with damage in the vast majority of cases. Even if damage did precede their pain onset, pain that far outlives any reasonable timescales for tissue healing must have an alternative explanation.

Sadly, medical professionals still search for tissue pathology as an explanation for pain as a matter of routine, even though only a very small number of patients have an underlying disease process that explains their symptoms. Patients continue to buy into this idea, demanding to see a consultant and wanting an MRI scan at the first sign of any aches or pains. Research demonstrates that the use of MRI scans in the early stages of routine presentations such as low back pain can actually make patients symptoms worse. This is a small but measurable effect.

MRI is a wonderful imaging tool and, as such, a useful diagnostic aid but it has become so sensitive that it will detect what is described as ‘pathology’ in populations who do not even have any symptoms. As with any medical investigation, MRI should be viewed as just part of the information-gathering process and clinicians should always treat the whole patient rather than images of their body parts.

For many years now, we have used MRI to study asymptomatic populations to see what differences, if any, there are between the tissues of patients in pain and the same tissues of people functioning at a normal level without pain. Sure, we can point out limitations and flaws in these studies, but time and again, the results are clear - that tissue quality really isn’t a good indicator of pain.

‘Responsible’ reporting is therefore needed with appropriate use of language - which of these scenarios is a more threatening idea for your brain to make sense of? “I’m sorry but you have degenerative disc disease and signs wear and tear in your spinal joints”, or being told, “good news; all we can see are normal signs of tissue adaptation that are seen in most people of your age with or without any back pain and so that there is no reason at all to be concerned. These adaptations are just normal reactions to tissues under stress over time, just the same as skin on the sole of the foot getting thicker if you walk bare foot enough.” One of these narratives is likely to increase a patient’s pain, the other is likely to decrease it. “Do you know what, doctor, I feel better already". Hear that before in your career without actually having administered any treatment? So, if radiological findings tell us that tissue quality does not correlate well with a patient’s pain and the

available research indicates that surgical and other medical interventions are relatively ineffective in reducing pain, why are we still unable to move away from this out-dated healthcare model?

The following are just some of the many studies that indicate the presence of tissue ‘abnormalities’ on MRI scans in people without any pain and happily functioning at a high level. In many of these studies, the researchers also followed these people up over many years and found that they did not go on to develop pain.

Partial thickness (52%) and full-thickness (19%) rotator cuff tears tears and labral tears (~50%) were seen in the shoulders of major league baseball pitchers without previous shoulder symptoms (Lesniak et al., (2013). Importantly, these findings also did not predict future injury over the next season.

Reuter et al., (2008) also found that there were no significant differences in the appearance of the shoulders of symptomatic and asymptomatic Ironman triathletes. Partial thickness tears of the rotator cuff, rotator cuff tendinopathy and AC joint arthrosis were common findings in both triathletes with and without pain.

The story is the same with lower back pain. 80% of people aged 50 without back pain have disc degeneration and around 60% of them will also have ‘significant disc bulges’ (Brinjikji et al., 2015).

Runners are another group that should feel similarly reassured: Achilles tendonopathy (Haims et al., 2000), hamstring pathology (Thompson Fung & Wood, 2017), common knee joint pathology (Stahl, et al., 2008) and even tibial stress reactions (Bergman, Fredericson & Matheson, 2004) were all common findings in asymptomatic athletes and, where studied, not a good indicator of future pain or injury either.

Important Footnote

You certainly should have a scan if there is any reason to suspect that there may be a serious medical reason for your pain. The vast majority of patients in pain (less than 1%) do not have any diagnostic tests that indicate this.

The conundrum for clinicians is potentially scanning lots of their patients who, in hindsight, do not have anything wrong with them versus missing the one in a hundred that may have a serious underlying medical condition. As long as clinicians report the MRI findings responsibly within the biopsychosocial framework, it would clearly be better to err on the side of caution. It is important that patients with red herrings on the scan results are given adequate explanation including the prevalence of the same findings in people without pain. Failure to do this can easily lead to increased anxiety about their condition which in turn can lead to further increases in pain.