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A Picture is Not Always Worth 1000 Words

October 1, 2015

In the past couple of decades, health costs for common issues like low back and neck pain have increased 65%* (1, 5). The more frequent use of MRIs, X- rays, and CT scans contribute to a portion of the rising costs associated with low back and neck pain. As healthcare costs have increased, positive outcomes for low back and neck pain have decreased, drawing the attention of the healthcare community (2).


The American Pain Society (APS) and the American College of Physicians (ACP) do not recommend the widespread use of imaging (1).  The APS and ACP recommend imaging only for patients who have “severe or progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition” (examples: fracture, cancer, and infection) (1).  Most all of these issues have recognizable signs and symptoms that can be identified by a trained health care provider (1).

Based on empirical evidence, these groups believe that overuse of imaging is not only unhelpful in many cases, but can actually be harmful (1).  Patients are exposed to some level of radiation with x-rays and CT scans.  Additionally, in one study, patients suffering from back pain an average of 10 weeks who received an x-ray “were more likely to report low back pain at three months and had a lower overall health status scores and borderline higher” back disability and pain scores, as compared to patients who did not have an X-ray. However, those who did receive X-rays were more satisfied with their care (3).   In another study that included subjects with back pain of less than three weeks, those who received MRIs had lower general health scores than those who did not receive their MRIs (4).

But what if I have back pain and my MRI report said I had some abnormalities?

Many “abnormalities” that you may find on an MRI or CT scans are so common they could actually be considered the norm (6-8). In one study of people without back pain, 20% of the participants under 60 years old had herniated discs. Of the participants who were 60 and older, 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc” (9). In another study, 27 % of younger participants (between 20 and 49 years old) without back pain had multiple disc abnormalities (7).  And in yet another study, among participants who received MRIs before and after their onset of low back pain, 84% of their follow up MRIs showed no change or normal age related changes (10).  These studies show us that it is important to remember, a “finding” on your MRI may or may not be connected to your low back pain (6-10).


Figure 1. A Disk Protrusion in a 24-Year-Old Woman without Back Pain (7).

And it’s not only the back…

In the case of shoulder pain, 13-34% of people without shoulder pain have rotator cuff tears (11).  In a study of professional basketball players without pain, “the overall prevalence of articular cartilage lesions on MRI was 47.5%” (12).  Seventy-seven percent of asymptomatic hockey players also had some “abnormal findings” in their groin muscles or hip joint (13).  And the list goes on…. So don’t stress if you have had an image or scan with some “findings” on it. It may just be part of normal life.

*Adjusted for inflation.

For a quick recap check out this video:


  1. Chou R,Qaseem A,Snow V, Casey D, Cross JT Jr, Shekelle P, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians.  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-91.
  1. Martin BI,Deyo RA,Mirza SK, Turner JA, Comstock BA, Hollingworth W. et al.  Expenditures and health status among adults with back and neck problems. JAMA. 2008; 299:656-64.
  1. Kendrick D,Fielding K,Bentley E, Kerslake R, Miller P, Pringle M.  Radio-graphy of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001; 322:400-5.
  1. Ash LM,Modic MT,Obuchowski , Ross JS, Brant Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008; 29:1098-103.
  1. Martin BI,Deyo RA,Mirza SK, Turner JA, Comstock BA, Hollingworth W. et al.  Expenditures and health status among adults with back and neck problems. JAMA. 2008; 299:656-64.
  1. Jarvik JJ,Hollingworth W,Heagerty P, Haynor DR, Deyo RA.  The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) study: baseline data. Spine (Phila Pa 1976). 2001; 26:1158-66.
  1. Jensen MC,Brant Zawadzki MN,Obuchowski N, Modic MT, Malkasian D, Ross JS.  Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994; 331:69-73.
  1. Wiesel SW,Tsourmas N,Feffer HL, Citrin CM, Patronas N.  A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976). 1984; 9:549-51.
  1. Boden SD,Davis DO,Dina TS, Patronas NJ, Wiesel SW.  Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990; 72:403-8.
  1. Carragee E,Alamin T,Cheng I, Franklin T, van den Haak E, Hurwitz E.  Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006; 6:624-35.
  1. Placzek, J.d and Boyce, D.A. Orthopedic Physical Therapy Secrets. Second Addition. 2006. Mosby Elsevier.
  1. Kaplan, L.D., Schurhoff, M.R., Selesnick, H., Thorpe, M., Uribe, J.W. Magnetic Resonance Imaging of the Knee in Asymptomatic Professional Basketball Players. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2005; 21:5:557–561.
  1. Silvis, M.L, Mosher, T.J., Smetana, B.S., Chinchilli, V.M., Flemming, D.J., Walker, E.A., Black, K.P. Am J Sports Med. 2011;39(4):715-21. doi: 10.1177/0363546510388931. Epub 2011 Jan 13.


Other resources:

Lurie JD, Birkmeyer NJ, Weinstein JN.  Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976). 2003; 28:616-20.

Verrilli D, Welch HG.  The impact of diagnostic testing on therapeutic interventions. JAMA. 1996; 275:1189-91.