Do I need an MRI?

“But shouldn’t I get an MRI, just to see what’s really going on in there?”

This is a question every therapist hears very regularly.  Often times more than once a week.  We used to try to explain to our patients that the findings of an MRI don’t much change the course of physical therapy and, unless there are very specific indications for MRI imaging, we are fully able to do our jobs without the results of these scans.  All of that is still true, but we also now have lots of research to support that.

Over the past several years, researchers have been taking MRIs of patients who do not have pain and cataloguing the “abnormal findings” that show up.  The original of these studies looked at the lumbar spine, which is the part of the spine in the low back.  Historically, when a patient ended up getting an MRI which showed a bulging disk, a surgeon would tell them that surgery would fix the disk bulge which would fix their pain.  So the patient would sometimes go through with the surgery, but often would not find relief from their symptoms.  This was the catalyst for MRI studies of pain free healthy spines. Researchers looked at MRI images of non-painful lumbar spines of people across the lifespan.  What they found was fascinating.  Some of the lumbar pathologies which were previously thought of as “abnormal” actually ended up being very common findings in certain age groups.  For example, the finding of “disk degeneration” shows up in over a third of people at the age of 20.  That’s a pretty high number of really young people showing signs of disk degeneration.  By the age of 50 years, 80% of people in the study were showing signs of disk degeneration.  These are people with no complaints of back pain.  What this tells us is that if disk degeneration can be present without the presence of pain, then disk degeneration is not likely to be a pain generating physical abnormality.  Instead, it’s probably more analogous to getting wrinkles on your face.  Some of us will get wrinkles sooner than others, but eventually most of us get some wrinkles as a normal part of the process of living.

My personal favorite finding of the study of healthy lumbar spines relates to bulging disks.  Patients get very scared when they are told they have a bulging disk and often have the notion that to resolve their symptoms they must have surgery to fix the disk bulge.  This MRI study clearly dispels that notion.  By the age of 40 years, a full half of people in the study showed signs of a disk bulge on their MRI.  Remember- that’s WITHOUT having reports of back pain.  I don’t know if that blows your mind but it sure blew my mind when I saw those numbers!  If we know that this many people can have a bulging disk without pain, then we can safely say we don’t need to fix a bulging disk in order to fix a patient’s pain.  This is great news!  This means that not nearly as many people need to undergo back surgery to resolve, or at least dramatically lessen their symptoms!  Take a look at the table below for the full findings from this study. 

Now, you might think to yourself- “That’s great news for people with back pain, but I have pain in my [insert some other body part here.]”  But guess what?  There are very similar studies to this in several body regions now.  These body regions include the knee, the shoulder, the foot and ankle, the hip, and the cervical spine (neck).  These studies indicate that, among other injuries, rotator cuff tears in the shoulder and meniscus tears in the knee are actually quite common by the time an individual is in their late 30s to early 40s.  This indicates, just as the study of pain free lumbar spines did, that we don’t necessarily need to rely on imaging because the results of those images might just be showing us things that have nothing to do with your symptoms.  These images usually will not change what a physical therapist is doing with you in the clinic.

Instead, most physical therapists will assess your strength, range of motion, and movement patterns to look for the factors that are leading to your pain.  There are SO many ways to address weakness, tightness, or poor movement that will have dramatic effects on pain regardless of what might (or might not) show up on an MRI.  

Therefore, the answer to the age-old question “do I need an MRI?” is often going to be “nope!”

Author: Heather Shaughnessy, PT, DPT

1. Brinjikji W;Luetmer PH;Comstock B;Bresnahan BW;Chen LE;Deyo RA;Halabi S;Turner JA;Avins AL;James K;Wald JT;Kallmes DF;Jarvik JG; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology. https://pubmed.ncbi.nlm.nih.gov/25430861/. Accessed October 13, 2021.