Why Imaging Findings Don’t Always Mean Pain: The Disconnect Between Scans and Symptoms
In modern medicine, imaging tools like MRI and ultrasound have revolutionized the way we assess musculoskeletal conditions. However, one of the most common misconceptions in both the medical field and among the general public is that if something abnormal appears on an imaging scan, it must be the cause of pain or dysfunction. The reality, as demonstrated by numerous studies, is that imaging findings often do not correlate well with actual symptoms.
The Eye-Opening Reality: Imaging Abnormalities Are Surprisingly Common
Imagine stepping into a world-class sports facility where elite athletes train at peak performance. Now, picture scanning their bodies with MRI machines. What if you found that a majority of them had structural abnormalities—yet they continued to play without pain or limitation? This isn’t just a hypothetical scenario; it’s a documented reality.
Medical research has repeatedly shown that imaging findings often reveal so-called 'abnormalities' even in people who have zero pain or dysfunction. The implications are profound: just because an MRI or ultrasound shows a tear, bulge, or degeneration doesn’t mean it's the root cause of pain or physical limitation. Let’s take a closer look at what the research actually reveals.
Hip and Groin Abnormalities: Part of the Norm
Hip and groin abnormalities are incredibly common in high-performing athletes, yet most experience no pain. A study of professional hockey players found that 77% had abnormal MRI findings in their hips and groin despite being completely asymptomatic (Gallo et al., 2014). Similarly, research on asymptomatic collegiate and professional hockey players revealed that 64% had signs of hip pathology (Silvis et al., 2011). Even among the general population, labral tears and other hip abnormalities are frequently found—69% of asymptomatic individuals had labral tears, while 73% showed some form of abnormal MRI finding (Register et al., 2012).
Shoulder Abnormalities: More Common Than You Think
Shoulder abnormalities are often feared by athletes and the general public alike, but they’re far more common than most realize. In a study of asymptomatic overhead athletes, 40% had MRI findings suggesting rotator cuff tears, yet none experienced symptoms over a 5-year follow-up period (Connor et al., 2003). Even in the general population, imaging studies show that 96% of asymptomatic individuals have some form of shoulder abnormality on ultrasound (Girish et al., 2011). Another MRI study found that 23% of young, healthy individuals had significant rotator cuff abnormalities—yet they functioned without pain (Miniaci et al., 2005).
Knee Abnormalities: Nothing to fear
The knees endure a tremendous amount of stress, especially in sports, yet MRI findings don’t always mean pain or dysfunction. A study of collegiate basketball players found that 41% had bone marrow edema, 41% had abnormal cartilage signals, and 35% had joint effusions—yet none reported pain (Major & Helms, 2002). Even at the professional level, imaging findings don’t necessarily equate to dysfunction. Nearly 50% of professional basketball players had meniscal or cartilage lesions on MRI, yet they continued competing at the highest level without symptoms (Kaplan et al., 2005).
Lumbar Spine: Age-Related Changes That Don't Always Matter
Spinal abnormalities are often alarming to patients, but many findings are simply part of the aging process and have no direct link to pain. MRI studies of asymptomatic young adults have shown high rates of disc degeneration, herniation, and other spinal changes, yet these individuals reported no pain (Siivola et al., 2002). A 20-year follow-up study found that over 80% of asymptomatic individuals had progressive spinal disc changes, but these changes did not correlate with clinical symptoms (Okada et al., 2018). A systematic review of 33 studies covering 3,110 asymptomatic individuals found that:
Disk degeneration was present in 37% of 20-year-olds and increased to 96% in 80-year-olds.
Disk bulge prevalence ranged from 30% in 20-year-olds to 84% in 80-year-olds.
Disk protrusions were found in 29% of 20-year-olds and increased slightly to 43% in 80-year-olds (Brinjikji et al., 2015).
Cervical Spine: Structural Findings vs. Functional Reality
Cervical spine imaging often reveals abnormalities, but these findings don’t necessarily indicate a problem. A large-scale study of 1,211 asymptomatic individuals found that 87.6% had disc bulging, even in their 20s, with prevalence increasing with age (Nakashima et al., 2015). Additionally, a study on young adults found that cervical spine abnormalities, including disc degeneration and annular tears, were common even in asymptomatic individuals, further proving that these findings do not necessarily correlate with pain (Siivola et al., 2002).
Professional Athletes and Imaging Abnormalities
Many elite athletes have undergone imaging that revealed significant abnormalities, yet they continue to perform at the highest levels without pain or dysfunction. These cases provide real-world evidence that structural abnormalities do not always correlate with symptoms:
Peyton Manning (NFL): The Hall of Fame quarterback played most of his career with significant cervical spine issues, including disc degeneration and multiple surgeries. Despite these findings, he returned to win a Super Bowl before retiring.
Roger Federer (Tennis): Federer has dealt with meniscus issues in his knee, yet he remained one of the most dominant tennis players well into his late 30s, defying expectations based on MRI findings.
Kobe Bryant (NBA): Bryant played for years with known knee abnormalities, including degenerative changes in his cartilage and meniscus. His performance remained elite until his retirement.
Tom Brady (NFL): Brady has shown signs of joint and spinal degeneration on imaging but has maintained peak performance well into his 40s, setting records for longevity in professional football.
These examples illustrate that imaging abnormalities do not dictate function, performance, or pain levels. Functional capacity, strength, and adaptability play a much larger role in determining whether an athlete—or any individual—experiences symptoms.
Structural Abnormalities: Just One Piece of the Puzzle
While structural abnormalities can contribute to pain in some cases, they are only one factor among many that shape the experience of pain. Pain is a complex and multifaceted phenomenon influenced by numerous biological, psychological, and social factors, including:
Nervous System Sensitization: The nervous system can become more sensitive over time, amplifying pain signals even when there’s no significant injury.
Emotions & Stress: Anxiety, depression, past trauma, and chronic stress can heighten pain perception by increasing nervous system reactivity.
Sleep Quality: Poor sleep can lower pain tolerance and increase pain sensitivity by altering how the brain processes pain signals.
Beliefs & Expectations: Fear of movement (kinesiophobia), negative pain beliefs, and catastrophic thinking can worsen pain and lead to avoidance behaviors.
Inflammation & Immune System Activity: Systemic inflammation, autoimmune responses, and immune dysregulation can all contribute to persistent pain.
Lifestyle Factors: Physical activity, nutrition, hydration, and metabolic health all play roles in pain regulation and recovery.
Social & Environmental Influences: Work stress, lack of social support, financial pressures, and overall life satisfaction can impact how pain is experienced and managed.
Past Pain Experiences: Previous injuries, surgeries, and medical interventions can shape how the nervous system responds to pain in the future.
What This Means for Patients and Clinicians
These findings highlight a crucial point: just because something appears abnormal on a scan does not mean it is causing pain or dysfunction. This has significant implications:
Overdiagnosis and Unnecessary Treatment: Patients may undergo unnecessary surgeries or interventions based solely on imaging findings rather than actual clinical symptoms.
Pain Catastrophizing: When patients are told they have a “torn rotator cuff” or “degenerative discs,” they may become fearful of movement, leading to pain-related anxiety and disability.
Clinical Correlation is Key: Imaging should be used in conjunction with a thorough clinical examination and patient history, rather than as a standalone diagnostic tool.
Conclusion: The Human Body is Resilient
The high prevalence of imaging abnormalities in asymptomatic individuals suggests that many so-called “structural issues” may simply be normal variations or adaptations to physical activity. The body is highly adaptable, and changes on an MRI or ultrasound do not necessarily mean dysfunction or pain.
For clinicians, this means emphasizing patient-centered care, focusing on functional assessment rather than just imaging results. For patients, it means understanding that a scary-sounding MRI report doesn’t always mean something is wrong. In many cases, the best treatment is reassurance, education, and movement-based therapy rather than aggressive medical intervention.
References
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36(4), 811–816.
Connor, P. M., Banks, D. M., Tyson, A. B., Coumas, J. S., & D’Alessandro, D. F. (2003). Magnetic Resonance Imaging of the Asymptomatic Shoulder of Overhead Athletes - 5-year Follow-up Study.
Gallo, R. A., Silvis, M. L., Smetana, B., Stuck, D., Lynch, S. A., Mosher, T. J., & Black, K. P. (2014). Asymptomatic Hip/Groin Pathology Identified on Magnetic Resonance Imaging of Professional Hockey Players: Outcomes and Playing Status at 4 Years’ Follow-up.
Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the Shoulder: Asymptomatic Findings in Men.
Kaplan, L. D., Schurhoff, M. R., Selesnick, H., Thorpe, M., & Uribe, J. W. (2005). Magnetic Resonance Imaging of the Knee in Asymptomatic Professional Basketball Players.
Major, N. M., & Helms, C. A. (2002). MR Imaging of the Knee: Findings in Asymptomatic Collegiate Basketball Players.
Miniaci, A., Dowdy, P. A., Willits, K. R., & Vellet, A. D. (2005). Magnetic Resonance Imaging Evaluation of the Rotator Cuff Tendons in the Asymptomatic Shoulder.
Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine, 40(6), 392–398.
Okada, E., Daimon, K., Fujiwara, H., Nishiwaki, Y., Nojiri, K., Watanabe, M., et al. (2018). Twenty-year Longitudinal Follow-up MRI Study of Asymptomatic Volunteers: The Impact of Cervical Alignment on Disk Degeneration.
Register, B., Pennock, A. T., Ho, C. P., Strickland, C. D., Lawand, A., & Philippon, M. J. (2012). Prevalence of Abnormal Hip Findings in Asymptomatic Participants: A Prospective, Blinded Study.
Siivola, S. M., Levoska, S., Tervonen, O., Ilkko, E., Vanharanta, H., & Keinänen-Kiukaanniemi, S. (2002). MRI Changes of the Cervical Spine in Asymptomatic and Symptomatic Young Adults.
Silvis, M. L., Mosher, T. J., Smetana, B. S., Chinchilli, V. M., Flemming, D. J., Walker, E. A., & Black, K. P. (2011). High Prevalence of Pelvic and Hip Magnetic Resonance Imaging Findings in Asymptomatic Collegiate and Professional Hockey Players.
