Can you trust an MRI for back pain?

Back pain is one of the most common complaints in the modern world. It’s irritating. It’s debilitating. I know from personal experience. But with hindsight, I am grateful I never got an MRI for back pain.

In this article, I’ll explain why an MRI for back pain may not be worth your time, money, or energy.

It’s not just doctors who see lots of back pain

We’re in a unique position as personal trainers because a lot of our clients get an MRI for back pain (as well as x-rays) before coming to see us for their training (and after rest and perfunctory physical therapy doesn’t do much to help).

We have seen a ton of clients with back pain get better with smart training and gradual relearning of better movement patterns. And we have also seen a lot of people who are wondering if they need an MRI for back pain. It’s a topic that comes up all the time with new clients.

To be clear, we aren’t doctors. But the good news is you don’t have to be a doctor to understand the research that’s been coming out on back pain.

You also don’t have to be a doctor to care about this information. As trainers, we want to stay informed so that we know what to worry about and watch out for with our clients. As someone with back pain, you probably want to know the truth about back pain and MRIs.

The medical literature and the direction of a lot of medical treatment is getting clearer and clearer on the value of an MRI for back pain. As the medical research gets clearer on MRIs and back pain, the case for exercise to beat back pain is getting stronger and stronger.

An overview of back pain and why you might get an MRI for back pain

Back pain is one of the most common complaints in the developed world.

In fact, about two thirds of us will have some back pain at some point in our adult lives. It makes your life harder…it may be more challenging to sit comfortably during your commute, concentrate at work, lift your kids up, do simple housework, or attempt to exercise.

It’s definitely frustrating, so when you head to your doctor to find out what’s going on, you are probably ready for answers and solutions.

Because of all the incredible things you may have heard about MRIs, you may think that getting an MRI for back pain will help you really ‘see’ what the problem is.

But will an MRI for back pain show you anything useful? That’s a big question with a surprising answer.

An MRI on your back will definitely show you a lot of things. The question is whether the things you see in an MRI have anything to do with your back pain.

You can have spinal pathology in an MRI scan and have no symptoms at all

Before we begin, let’s be clear about when an MRI for back pain might be helpful.

If you have a situation where your back pain gets worse and worse, and you’re losing feeling and control of your legs, you want to talk to your doctor ASAP. It’s EXTREMELY RARE, but you may have a very rare type of cancerous growth (like this guy). 

But if you’ve got run of the mill chronic or recurring back pain and/or have already had an MRI and have no signs of cancer, then what you see in an MRI can be really misleading.

To investigate the importance of MRI findings and back pain, one 1994 study looked at the MRI’s of 98 people with NO back pain. These were people without back problems at all. These people were completely asymptomatic.

They found that only 36% of the people in the study had a “normal spine.”

More than half of these people had a disc bulge. Over one-third had more than one disc bulge. More than one-fourth had disc protrusions. 14% had annular defects.

If the pathologies that show up on MRI do cause pain, you would not expect to see so many pathologies in people without symptoms.

This is pretty amazing. Of 98 people with pain-free spines, only 36% had “normal” spines! That really speaks to a weakness in the belief that spinal pathologies are the cause of people’s back pain.

If, for example, we believed blue eyes caused cancer, we’d want to look for a relationship between blue eyes and cancer. Of course we would see that the vast majority of people with blue eyes do NOT have cancer and do not GET cancer. So our theory about blue eyes and cancer wouldn’t hold up. In the same way, theories about these spinal pathologies and pain don’t seem to hold up either. Of course this isn’t the only study to show this discrepancy.

Another study reviewed 33 articles, including 3110 asymptomatic people, to see how important the findings were in MRIs for back pain. They looked at the prevalence of certain abnormalities on MRI.

They found that common abnormalities were mostly correlated with age. They also found, again, that the abnormalities had no clear relationship with back pain. All the people in the study had no back pain but they had some pretty startling numbers of pathologies.

When comparing 20 year olds and 80 year olds, they found some pretty interesting numbers.

“For 20 year olds, 37% had disc degeneration. 29% had disc protrusion. 10% had annular fissures.
For 80 year olds, 96% had disc degeneration. 43% had disc protrusion. 29% had annular fissures.

Brinjikji 2015

The prevalence of disc protrusion and annular fissures is the most surprising. Those conditions are believed to be extremely painful spine conditions. But a high percentage of people have these conditions and have absolutely no symptoms!

So what does that mean?

The conclusion of the study spells it out in plain language: “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. “

In essence: what shows up as “abnormal” in MRI are normal parts of the aging process and have nothing to do with pain.

But what if you have abnormalities in the MRI scan AND you have back pain?

So we have already seen that the abnormalities exist in high numbers for people who have no back pain problems. But what about if you have back pain and you have abnormalities/pathologies that show up in an MRI on your back? Doesn’t that mean you can see the cause of your back pain? Can you rely on what you see to help you make a decision about how to solve your back pain?

It’s worth looking at more in depth. A study done in 2006 looked at 57 people with symptomatic back problems. They diagnosed these people with LRS, lumbosacral radicular syndrome. All 57 of these people had symptoms on ONLY ONE SIDE.

They had two doctors look at the MRIs of the patients’ backs and had them predict where the patient was experiencing pain.

In an ideal situation, the doctors would be able to say something like, “Well, I see the disc protrusion here. So they must be experiencing pain on this side and in this area of the back.”

In reality, the doctors were not able to say that. They couldn’t really make any useful determinations or predictions based on the images. Why?

MRI showed abnormalities in 33% of the patients – ON THE PAIN FREE SIDE. 23% of the patients had root compression that was completely asymptomatic!

In more than two-thirds of the patients with unilateral LRS there was no exact match between the level predicted by clinical examination and MRI findings. These discrepancies complicate the decision whether or not to operate.

The conclusion to the study is in dry scientific language, but it’s worth reading carefully: “In more than two-thirds of the patients with unilateral LRS there was no exact match between the level predicted by clinical examination and MRI findings. These discrepancies complicate the decision whether or not to operate.”

Imagine the situation. You have back pain. An MRI scan on your back tells you that you have some kind of abnormality. The abnormality is on the other side of where you feel your pain!

Do the abnormality and the pain have anything to do with each other? Doesn’t seem like it.

What if the abnormality is on the same side of your pain? While it’s easy to THINK it does, studies like this show that the relationship just isn’t there.

What you see in an MRI – unless you have an unfortunate and rare issue like cancer – doesn’t explain your back pain.

If an MRI for back pain isn’t that useful, what is?

As trainers, you may think we’re biased to say “exercise.” And, really, we are biased. But it’s based on experience and observation.

We’ve seen people with scoliosis, spondylolisthesis, stenosis, and all kinds of other spinal pathologies improve with gradual, careful training. We’ve even seen people get better AFTER surgery has failed to provide back pain relief.

Exercise gives you the opportunity to see how you are moving, and how you are using muscles. If you use muscles poorly, they ‘complain.’ If you learn how to use muscles better, your body feels better. It’s not a terribly controversial proposition. And it’s also easy for any human being to test themselves. All you need to do is start exercising in careful ways, learning proper movement patterns.

This isn’t to suggest that everyone should go run a marathon or do Crossfit. The kind of exercise we suggest is more of a learning process. It’s about starting with very easy exercises and gradually building competence in key motions. Once you are competent in things like the deadlift and squat and are able to control your shoulders, you’ll find life starts getting a lot easier.

As you get better at those basic motions, you want to start mastering more complicated activities – like using the stairs, playing golf, jumping over hedges, dancing, doing martial arts, gymnastics, etc.

This is the most productive, safest way to approach exercise for long term success, and medical guidelines are finally heading in this direction.

For years, drugs and injections have been widely employed and recommended by the medical industry. But there have been big changes slowly creeping into the collective medical consciousness. In the United Kingdom, the NHS was a big leader in doing research into spinal pathology and spinal surgeries. As a result, the NHS has moved decidedly against surgery and invasive procedures to “fix” back pain.

And in 2017, the American College of Physicians released new recommendations for back pain. Strong medications like opioids have been pushed down the priority ladder. Massage, acupuncture, exercise, yoga, relaxation (of varying kinds), as well as stress reduction all take priority over medicating the problem.

Treat your spine as well as you treat your own car

Imagine you take your car to a mechanic because you hear squealing every time you come to a stop sign or red light. The mechanic looks at your car. “Well, I have a test we can run on your car. It will cost you $700. It’ll give us a good picture of the insides of your car.”

“Okay,” you say. “Will it show us what’s causing the squealing?”

“Well,” the mechanic says, “it’ll show us abnormalities in your car.”

“Right, but will it show us the cause of the squealing?”

“It’ll show us the abnormalities. And some of those abnormalities will appear to be related to the squealing. But about half of all cars have these abnormalities without any effect on the cars’ functioning. But we can still try to fix your car’s abnormalities, and that might fix your squealing.”

“And what will it cost to fix the abnormalities?” you ask.

“About $20,000. And we’ll have to keep your car on limited duty for one to six months. And there is no guarantee that’ll fix the squealing, but we’re pretty sure it might.”

A situation like this would not give you much confidence in the test your mechanic is proposing or the action plan that the test would put in motion.

If you would not subject your car to this kind of test, would you subject your spine to one? Hopefully your answer is no.

Resources for back pain

It’s taken decades for the research literature to work itself into the medical community, and there are still many years to go before the general public realizes that MRI scans for chronic back pain are not that useful. One challenge is that there are still plenty of physicians who will tell you an MRI for back pain is an excellent investigative tool, even though the research clearly shows that it is not (at least not for chronic back pain).

For people suffering with back pain, it can be tempting to seek out “certainty” by getting an MRI for your back. But it’s extremely important to remember that what you see in an MRI for back pain can have absolutely nothing to do with your back pain – and it often has nothing to do with your back pain!

If you’re suffering with back pain, our strongest piece of advice is to listen to the latest medical advice: go with a non-invasive approach.

Learn how to use your muscles differently. This may involve massage, stretching, and strength training. These are direct methods of affecting the way your body moves AND feels. There is no mystical magical voodoo involved. It’s just training new (and better movement patterns). This is cost-effective and puts the control of your back pain squarely in YOUR hands in the long run.

Find a massage therapist. Find a trainer. Find someone who will not be afraid to help you move. Speaking from personal experience, the worst thing you can do is simply give up and try to stay still.

It’s not always an easy journey. There are lots of things you need to learn about your body as you work your way out of back pain. Be patient with yourself and with your progress.

If you are looking for ideas to help yourself with back pain, be sure to check out some of these resources:

• Our playlist on back pain on YouTube
• Pain Science on Back Pain
• Vox: A comprehensive guide to the new science of treating lower back pain

Remember that PAIN SUCKS. LIFE SHOULDN’T.

Back Pain Citations

Brinjikji, W. et al (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, Vol 36 (4), 811-816. (link)

Qaseem, A. et al (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, Vol 166 (7), 514-530. (link)

Jensen, M.C. et al (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, Vol 331 (2), 69-73. (link)