Why Your Pain Isn't Showing Up on Scans

You’ve been in pain for months. Your GP finally refers you for an MRI. You’re convinced they’ll find the problem — maybe a slipped disc, a torn muscle, something concrete that explains why you can’t sit through a meeting or sleep through the night.

The scan comes back “normal”. Nothing major. Maybe some “age-appropriate degenerative changes”. You’re relieved for about five minutes, then the frustration hits: if there’s nothing wrong, why does it still hurt?

Or the opposite happens. Your scan shows a bulging disc, a rotator cuff tear, meniscal damage — and the report reads like a car crash. But here’s the thing: you might have had that “damage” for years without knowing it. I see this all the time across Liverpool, Chester, and Queensferry. People walking around pain-free with scans that look terrible, and people in agony with scans that look pristine. The disconnect is real, and it’s confusing. Let me explain why.

The Scan-Pain Disconnect: What the Research Actually Shows

Here’s what most people don’t know: if you scan enough pain-free people, you’ll find “abnormalities” everywhere.

A landmark study scanned 3,110 people with no back pain and found (Brinjikji et al., 2015):

• 30% of 20-year-olds had disc bulges
• 60% of 50-year-olds had disc bulges
• 84% of 60-year-olds had disc degeneration
• 96% of 80-year-olds had disc degeneration

None of these people were in pain. They volunteered for research. Their backs were fine.

For shoulders, the numbers are similar. Studies on pain-free adults found:

• 15% of 40-year-olds had rotator cuff tears on MRI
• 26% of 50-year-olds had tears
• 50% of 60-year-olds had tears

Same story for knees. Meniscal tears show up in 35% of pain-free people over 50.

So when your scan report mentions a bulging disc, degenerative changes, or a small tear, that doesn’t automatically mean it’s causing your pain. It might just be… you. Your age. Wear and tear. The same way you’ve got a few grey hairs or your knees creak a bit on the stairs.

Research on cervical spine findings shows similar patterns — MRI changes are found in 87% of asymptomatic adults over 60 (Nakashima et al., 2015). These findings are common, not pathological.

The Incidentaloma Problem

“Incidentaloma” is medical slang for something found incidentally on a scan that wasn’t the reason you got scanned in the first place.

You come in with back pain after lifting a heavy box. We send you for an MRI to rule out anything serious. The scan comes back showing a disc bulge at L4/5… but also mentions a small cyst on your kidney, some sinus inflammation, and “mild degenerative changes” at three other levels.

Now you’re worried about your kidney. Your sinus. Your whole spine. None of it was causing your back pain — but once you see it on paper, it’s hard to un-see.

I’ve had clients across Cheshire come in with scan reports listing five or six findings, only one of which is remotely relevant to their actual problem. The rest? Noise.

This is why clinical assessment matters. I need to know:

• When did the pain start?
• What makes it better or worse?
• Where exactly does it hurt?
• What can you not do because of it?

Then I test movements, strength, range, neural tension. That tells me far more than a static image of your insides.

When Scans ARE Useful

Don’t get me wrong — imaging absolutely has a place. But it’s not a first-line tool for most musculoskeletal pain.

For most people walking through my door with shoulder pain, knee pain, or non-specific back pain, we don’t need a scan straight away. We need a proper assessment, a treatment plan, and time to see if the body responds.

The Nocebo Effect: How Scary Reports Make Pain Worse

Words matter.

When your MRI report says you have “degenerative disc disease”, it sounds like your spine is crumbling. Like you’re broken. It’s terrifying.

But “degenerative disc disease” isn’t a disease. It’s age-related change. Discs dry out a bit as we get older. They lose height. The body adapts. For most people, this causes zero problems.

Research shows that people who receive scary-sounding scan reports are more likely to:

• Avoid movement (because they think they’ll make it worse)
• Catastrophise their pain (assume it’s permanent or progressive)
• Seek more interventions (injections, surgery) even when conservative care would work

This is called the nocebo effect — the opposite of placebo. The language used in your scan report can literally increase your pain and disability.

I’ve seen this play out countless times. Someone comes in with acute back pain, gets an MRI too early, sees “multilevel degenerative changes” and “broad-based disc bulge”, and suddenly they’re convinced they’re one wrong move away from paralysis.

They stop exercising. They stop playing with their kids. They take time off work. Their pain gets worse because they’re not moving.

Why I Use Diagnostic Ultrasound (and When I Don’t)

One of the reasons I offer diagnostic ultrasound as part of initial assessments is because it gives me real-time, dynamic imaging. I can see tendons moving, muscles contracting, fluid around joints — things an MRI can’t show because it’s a static snapshot.

Ultrasound is brilliant for:

• Acute tendon injuries (I can see if it’s a tear or just reactive tendinopathy)
• Muscle strains (how much of the muscle belly is involved?)
• Joint effusions or bursitis (is there fluid? How much?)
• Guiding injections (if we go down that route, I want to know the needle’s in the right place)

But even ultrasound has limits. It won’t show you a disc bulge. It won’t image deep bone. And just like MRI, it can find things that aren’t causing your pain.

The key is correlation. Does the scan finding match your history? Does it match my clinical tests? If yes, great — we’ve got a clear target. If no, the scan finding is probably irrelevant.

What Actually Matters: Movement, Function, and Context

I don’t treat scans. I treat people.

Your pain is influenced by:

• How you move
• How strong you are
• How well you sleep
• How stressed you are
• What you believe about your pain
• Whether you’re still doing the things that matter to you

None of that shows up on an MRI.

I’ve worked with people who have “terrible” scans but respond brilliantly to treatment because they trust the process, they do their rehab, and they gradually rebuild confidence in their body.

I’ve also worked with people who have “perfect” scans but struggle because they’re terrified of movement, or they’ve been told by three different practitioners that they’re “broken”, or they’ve been in pain so long that their nervous system is stuck in a hypersensitive state.

This is why a thorough assessment matters. I need to understand your pain, not just what’s on a piece of paper.

If you’ve been told your pain is “all in your head” because your scan is normal, that’s nonsense. Pain is real. It’s just that scans don’t show everything that can cause pain — especially when pain becomes persistent.

Conversely, if you’ve been told you need surgery because your scan shows “damage”, get a second opinion. Plenty of people live full, active lives with bulging discs, meniscal tears, and rotator cuff issues. Surgery should be a last resort, not a knee-jerk reaction to an MRI finding.

When to Get Help

If you’re in pain and you’re not sure whether you need a scan, here’s my advice:

Start with assessment. A good physio (or sports therapist, or osteopath) should be able to give you a working diagnosis based on history and examination. Most of the time, that’s enough to start treatment.

Give treatment time to work. If we’ve identified the problem and we’ve got a clear plan, you should see some progress within 4-6 weeks. Not necessarily pain-free, but moving better, doing more, feeling more confident.

If you’re not improving, imaging might help. Especially if we’re missing something, or if your symptoms don’t fit the pattern we’d expect. But even then, the scan is just one piece of the puzzle.

If you’ve got red flags, don’t wait. Severe trauma, progressive weakness, unexplained weight loss, night pain that’s getting worse — get checked out properly. Scans can rule out the nasty stuff, and that’s when they’re worth doing early.

And if you’ve already got a scan report that’s freaking you out, bring it in. I’ll walk you through what it actually means, what’s relevant, and what’s just background noise. Half the time, the scariest-sounding findings are the least important ones.

You can book an initial assessment or an initial assessment with ultrasound if you want a deeper look. Either way, we’ll figure out what’s actually going on — scan or no scan.

Because at the end of the day, the goal isn’t a perfect MRI. It’s getting you back to doing what you love, without pain holding you back. And you don’t need a clean scan to do that.

Further Reading

If you’re dealing with persistent pain and want to understand more about why it sticks around (and what actually helps), check out my post on tendonitis vs tendinopathy — another area where scans can be misleading.

Or if you’re trying to work out whether your specific issue warrants imaging, have a look at the condition pages for back pain, shoulder pain, or knee pain. I’ve broken down when scans are useful and when they’re not for each of those.

And if you’ve got questions, just ask. I’d rather spend 10 minutes talking through your scan report than have you lose sleep over “degenerative changes” that half the population has.