Your MRI is not a diagnosis: what scans show in people without pain

In 2015 a team of neuroradiologists pooled 33 studies reporting the scans of more than three thousand people who had no back pain at all, and tabulated how often 'abnormal' findings appeared at each age. The result overturns the everyday reading of a radiology report: at age twenty, roughly one in three pain-free people already shows disc degeneration, and by age eighty it is nearly everyone. Disc bulges follow the same curve — present in about thirty per cent of asymptomatic twenty-year-olds and in more than eighty per cent of eighty-year-olds (Brinjikji 2015).

In other words, most of the findings that frighten patients — degeneration, bulging, disc space narrowing — behave like grey hair: they accumulate with age whether or not anything hurts. A scan can describe the architecture of a spine in remarkable detail, but architecture alone does not tell you where pain comes from.

For the terminology and interpretation used here, compare What are trigger points?; Primary vs secondary trigger points; How to read referred pain maps. These guides distinguish the definition of a trigger point, its classification and the limits of a referred-pain map.

A trigger point is a functional disturbance — a small segment of muscle locked in a sustained contraction, with disturbed local chemistry — not a structural lesion. It does not tear, wear or displace anything, so standard imaging was never going to show it. The identification of a trigger point remains a clinical act: a skilled examiner finds a taut band, a spot of exquisite tenderness inside it, and pain that the patient recognises as their own when the spot is pressed (Simons 2004).

That clinical exam has limits worth stating honestly. Systematic reviews of palpation reliability found that agreement between examiners ranges from poor to good depending on the muscle, the criteria used and the training of the examiner — the landmark 2009 review judged the overall evidence mixed, and a 2017 meta-analysis reached similar conclusions (Lucas 2009; Rathbone 2017). Diagnostic criteria themselves vary widely between studies (Tough 2007). None of this makes trigger points imaginary — it makes trained hands and a clear hypothesis essential, exactly as in every other branch of musculoskeletal medicine.

There is a quieter cost to scanning first and thinking later. A report that lists 'multilevel degenerative changes' in a frightened patient does not stay neutral information: it becomes an explanation, and often a sentence. People told their spine is worn out move less, guard more, and predict a worse future for themselves — three behaviours that feed chronic pain far more reliably than the bulge itself does.

This is not an argument against imaging. Scans are essential when the story suggests fracture, infection, cancer, progressive nerve damage or surgical instability. It is an argument for order: history first, examination second, imaging to answer the questions the first two raise — not as a fishing expedition whose catch will need to be explained away.

Put the evidence together and a practical sequence emerges. The history narrows the field: when the pain started, what provokes and eases it, how it behaves at night, whether anything neurological or systemic accompanies it. The examination tests the working hypotheses hands-on — joint by joint, muscle by muscle — including the search for trigger points whose pressure reproduces the familiar pain. Imaging enters only when the first two steps cannot explain the picture, or when red flags demand it.

When that order is respected, the report stops being a verdict and becomes what it should be: one more piece of evidence, weighed against what the patient reports and what the clinician finds. A disc bulge in a sixty-year-old is, statistically, wallpaper. A taut band in the quadratus lumborum that reproduces the exact pain is a lead you can treat.

If your scan came back with alarming words and your pain has a muscular character — localised, reproducible by pressure, changing with posture and use — the two facts may be unrelated. Before accepting a structural explanation for muscular pain, ask for a muscular examination. The evidence base says the scan was always the weaker witness.