I am not the first person to say that, and I will not be the last, but I feel like we have to keep repeating that statement because some healthcare professionals keep undermining this idea. Many healthcare professionals, especially in the orthopedic world, rely on imaging to create a diagnosis, which, in my opinion, is not the best current practice.
Don’t get me wrong, MRIs are a fantastic tool for getting a good idea of what is actually going on inside the body. But the problem lies within understanding how that image plays a role into the entire clinical picture.
Just because something was on your MRI doesn’t mean that is YOUR PROBLEM.
The easiest example for me to bring up is bulging discs. As a chiropractor, I do tend to see a lot of low back pain into my office (low back pain is the leading cause of disability worldwide, and somewhere around 31 million Americans suffer from some sort of low back issuer), and probably 30-40% of them have seen another practitioner for their pain, whether it is another chiropractor, physical therapist, orthopedic, or general physician. Many of these people also come in with a previous diagnosis of a bulging disc, because their last doctor sent them for an MRI.
What is a bulging disc? It is where the intervertebral disc that sits in between each of your individual vertebra (backbones) has either increased pressure or decreased height that causes the outside fibers to expand into the spinal canal (the space where your spinal cord sits). On a normal MRI, there should be little to no size difference between the bottom of one vertebra to the top of the next. If there is, this where we name a “bulging disc”. So when someone has back pain and their receive an MRI, it is easy to point to this and say “There’s the problem! Your disc is pressing on a nerve and that’s causing your back pain.”
Problem- this is more than likely NOT the case at all.
Anatomically speaking, very little of the spinal nerve actually comes into contact with the intervertebral disc, so when a disc bulges, it usually has to be a severe bulge or a direct lateral bulge to come close to “pressing” on a nerve. This is very much true though when we have a protrusion or disc rupture (which I will discuss later). But the average disc bulge is not pressing on a nerve.
Disc bulges also do not equal pain. Depending on whose study you read, somewhere around 35-75% of people with no history of back pain and currently have no symptoms have some sort of disc bulge in their spine. So millions of people are walking around with a bulging discs and have absolutely no idea and no symptoms. Crazy? It’s about to get crazier. Between 60-80% of bulging discs have spontaneous resorption, with or without conservative treatment. So just because you have a disc bulge does not mean that it is causing your pain, but if you do have pain, this can lead us to believe that it is causing the pain.
The problem with the low back MRI and misdiagnosis is because it does not take into account the clinical presentation. The history and presentation of pain plays a much larger role into the true diagnosis of the pain more than the imaging. If I have a patient with achy back pain that travels across the back, is relieved with stretching (or at least feels good) and seemed to be made worse with extension, then it is problem a mechanical issue that can be resolved very easily with conservative care, including manipulation, manual therapy, and exercises.
I also see patients come in with a true disc injury, where the fibers of the disc have been damaged and that causes pain. This takes a little more time, but also one that can be resolved with conservative care. The times I do get concerned about back pain is when the pain doesn’t seem to resolve after a few weeks of care, or the patient is presenting with neurological symptoms (pain running down the back of the leg, weakness in the leg and foot, numbness into toes, decreased of increased reflexes, etc), which can be caused by a disc protrusion or rupture. And in those cases, an MRI can be warranted to observe what is actually going on and possibly referred to a neurosurgeon.
But just because something hurts and an MRI points to something being there, that does not mean that it is always the case AND that it can never be fixed. Pathology does not necessarily dictate function, and in some cases, you can have an abnormality that causes zero issues. If you want to read more on this, research Dr. James Andrews and his study on baseball pitchers and labral tears. And how almost every single professional pitcher has a tear in their shoulder and can have zero pain or dysfunction.
Your MRI is not a death sentence. It is only a tool that has to be incorporated into the whole clinical picture, and so much in the exam can tell us more than a fancy, expensive MRI machine.