What an MRI Really Tells Us About Back Pain

Written By Jacob Coffman

For many people, back pain arrives suddenly and dramatically: one day you’re fine, the next you’re wincing when you stand up or rotate. It’s natural to want answers, and in modern healthcare, the answer often seems to be:

“Let’s get an MRI and see what’s going on.”

But here’s the surprising and reassuring truth:

Most MRI findings have little to do with why you’re hurting, and getting a scan too early can make recovery harder, not easier.

Over the last decade, research on back pain has evolved rapidly. What we now know about imaging, pain sensitivity, and movement has reshaped how clinicians think—and how patients should think—about persistent or sudden back pain.

This is a modern guide to understanding where back pain actually comes from, why imaging is usually not the key to solving it, and what helps people recover faster and more confidently.

The Myth That MRI Will “Show the Problem”

Imaging feels like certainty.

A picture. A diagnosis. Something to point at.

The reality is far messier and far more hopeful.

Most “abnormalities” on MRI are normal findings of aging.

One of the most influential imaging reviews examined MRI scans of more than 3,000 people without back pain. Across every decade of life, the researchers found:

  • Disc degeneration is present in over 50% of 30-year-olds, 80% of 50-year-olds, and almost everyone by age 80.

  • Disc bulges appear in about 1 in 3 people in their 20s and up to 70% in their 60s, all with no pain.

These patterns are so common that many radiologists now consider them the spinal equivalent of “wrinkles.” They reflect time, not necessarily trouble.

Newer research has strengthened this point even further.

  • A 2023 systematic review analyzing 40 studies concluded that the vast majority of MRI findings show no clear relationship with future pain or disability—even when controlling for age and other variables.

  • Another 2023 study using automated MRI analysis compared people with chronic low back pain to people with no pain and found nearly identical rates of degeneration across groups.

So if a scan shows “degenerative disc disease,” “disc bulges,” or “Modic changes,” that doesn’t automatically mean those findings are the cause of your pain.

In many cases, they’ve likely been there for years, quietly minding their own business.

When Imaging Helps & When It Quietly Makes Things Worse

Understanding when imaging is useful is critical, not just because unnecessary imaging is expensive, but because it can actually increase disability and fear.

Imaging is valuable when red flags are present:

  • Major trauma

  • Progressive neurological weakness

  • Bowel or bladder changes

  • Fever or signs of systemic illness

  • History of cancer

  • Unexplained weight loss

  • Severe, unrelenting pain not affected by position or movement

These situations represent a very small percentage of back pain cases—roughly 1–5%, depending on the setting.

For the other 95%? Early MRI usually does more harm than good.

Multiple large-scale studies in working adults have shown:

  • People who receive an early MRI (without red flags) are twice as likely to develop long-term disability.

  • They undergo more injections, more procedures, more surgeries—without better pain outcomes.

  • Total medical costs increase by $10,000–$13,000 per case, on average.

  • Pain levels and functional scores are no better than those who avoided early imaging.

How can a picture make things worse?

This brings us to one of the most important and overlooked findings in back pain research.

The Nocebo Effect: When Labels Create More Pain Than They Solve

It turns out that the language used in an MRI report can directly affect how much pain a person experiences, even weeks later.

A randomized controlled trial demonstrated this with striking clarity:

  • Two groups of patients had the exact same MRI findings.

  • One group received a traditional report loaded with terms like “degeneration,” “disc disease,” and “protrusion.”

  • The other group received a contextualized report describing the same findings as normal, age-related changes commonly seen in people without pain.

Six weeks later:

  • The “pathology-focused” group had more fear, more pain, and worse function.

  • The “normal change” group improved more across every measure.

Nothing about the patients changed—only the words describing their spine.

Researchers call this the nocebo effect: negative expectations, fueled by complex or alarming language, amplify pain and disability.

If you’ve been told your spine is “crumbling,” “compressed,” “degenerative,” or “worn out,” your brain reacts exactly as it should:
It becomes more protective.
It tightens.
It restricts.
It amplifies.

This is not psychological weakness—it’s physiology.

If the MRI Isn’t the Problem
What IS?

Most back pain, especially flare-ups that follow a sudden increase in activity, is driven by two major processes:

A. Tissue Overload (Capacity Mismatch)

When you suddenly increase twisting, lifting, bending, running, or sport-specific activities, tissues that haven’t been conditioned for that load can become irritated.

This does not mean the tissue is damaged or failing. It means you exceeded its current tolerance.

Just like running 6 miles after not running all winter would light up your calves, a sudden spike in spinal load lights up your back.

B. A Protective Nervous System (Increased Sensitivity)

Pain is not a perfect measure of tissue damage. It’s a protective alarm.

And alarms can be:

  • Appropriately calibrated

  • Too quiet (dangerous, but rare)

  • Too sensitive (very common in chronic pain or after sudden overload)

Fear, stress, poor sleep, alarming MRI language, or repeated flare-ups can all turn the volume knob up on the alarm system.

This is why:

  • A movement that felt fine yesterday suddenly feels sharp today.

  • Pain persists even after tissues have healed.

  • Rest feels good temporarily but doesn’t build lasting resilience.

Decades of research confirm that fear of movement, catastrophizing, and avoidance behaviors strongly predict long-term disability in back pain, not because pain is psychological, but because the nervous system adapts to whatever we repeatedly do.

If we avoid movement, the body becomes deconditioned and the nervous system becomes even more vigilant.

If we gradually reintroduce movement, the system recalibrates.

What Actually Helps People Recover

Here’s what consistently performs well in the research for both acute flare-ups and chronic low back pain:

1. Progressive, Graded Movement

Large analyses covering more than 5,000 participants show that:

  • Pilates

  • Yoga

  • Tai chi

  • Core strengthening

  • Strength training

  • Motor control exercises

…all outperform passive treatments and usual care.

There is no “perfect exercise.”
There is a perfect principle:

Start small. Progress gradually. Build capacity.

2. Pain Neuroscience Education (PNE)

Explaining how pain works; clearly, calmly, and with modern science - reduces:

  • Pain

  • Fear

  • Disability

  • Catastrophizing

Even a single 60-minute session can improve outcomes when combined with movement.

Understanding that “hurt does not equal harm” allows the nervous system to loosen its grip.

3. A Clear Plan Instead of Trial-and-Error Guessing

People with back pain repeatedly say the same things when asked why recovery feels impossible:

  • “I don’t know what’s safe.”

  • “Every time I push myself, I flare up.”

  • “I was told I have a degenerating spine.”

  • “I’m afraid I’ll make it worse.”

Research also shows the following is key for recvoery:

  • Education

  • A structured, stepwise progression

  • Support and reassurance

  • Guidance during flare-ups

Movement works, when paired with the right story and the right pacing.

A More Helpful Way to Think About Back Pain

Back pain is incredibly common, but the narrative around it is outdated.

Here’s the modern, evidence-based way to understand it:

  1. Your spine is resilient.
    It adapts. It strengthens. It does not spontaneously deteriorate because of age or activity.

  2. MRI findings rarely explain pain.
    They often reflect normal age-related changes—like wrinkles or gray hair.

  3. The nervous system, not the disc, is often the main driver.
    Sensitivity can go up or down based on load, beliefs, stress, sleep, and context.

  4. Movement is medicine—when dosed correctly.
    Not too much, not too little, and matched to your current capacity.

  5. Education reduces fear, and fear reduction reduces pain.

  6. The goal isn’t to “fix” a disc.
    It’s to rebuild confidence, capacity, and freedom of movement.

What This Means for You Right Now

If you’re dealing with back pain—whether it’s new or long-standing—here’s what the best current research suggests:

  • You’re not fragile.

  • Your spine is not crumbling.

  • Your MRI rarely predicts your outcome.

  • Your nervous system is doing its best to protect you—and sometimes it overreacts.

  • With a structured plan, you can regain strength, mobility, and confidence.

  • Avoiding movement makes recovery slower.

  • Early imaging without red flags is often counterproductive.

You don’t need to wait for a perfect scan to start moving forward.
The path out of pain is rarely in the image.
It’s in education, graded exposure, and rebuilding the capacity your life requires.

That’s what we help you do at Optimize Chiropractic.

 

Our clinical approach is supported by current research in pain neuroscience and rehabilitation. Click below to access the full bibliography and source materials.

▸ Click to view Scientific References & Evidence

Global Burden & Non-Specific Low Back Pain

Imaging ≠ Pain (Asymptomatic & Prognostic MRI)

Language, Reporting & Nocebo Effects

Early Imaging, Disability & Costs

Serious Pathology & Red Flags

Fear-Avoidance, Beliefs & Disability

Pain Neuroscience Education (PNE)

Exercise & Graded Activity

Jacob Coffman
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