When MRIs Don't Tell the Whole Pain Story

May 16

A friend called me this week with a familiar story. He was in excruciating pain and could barely sit up straight.

The cause?

After taking all winter off from golf, he hit the course with enthusiasm—200 balls at the driving range followed by 18 holes. Around hole 12 he shot for the moon and felt a spasm in his back. It was painful but he finished the last 6 holes.

The next day, he could barely get out of bed and he gave me a call.

After our conversation my biggest worry wasn't his back pain. It was what might happen next: the MRI his doctor would likely order, and the "degenerative disc disease" or "bulging disc" that would inevitably be discovered and labeled as "the problem."

Why I wasn't worried about his back.

The situation above is one I've seen all too often. We're cooped up inside all winter then the weather gets nicer and we:

Spend 4 hours in the garden twisting, turning, and pulling after months of putzing around indoors
Work on fine-tuning our golf game before our first time on the course and twist 200 times more than we have in the last three months
Head out for a nice long run and double the distance we've been managing

And because our body works on the simple principle of "if you don't use it, you lose it," over the winter we lost some strength, some mobility, some endurance. So all the moving that we do to start the summer or spring ends up being WAY too much and we end up getting really sore, or push ourselves to the point where our back has a muscle cramp, similar to a Charlie Horse. But since there are many pain-sensitive structures in the spine, we feel sharp pain, a grabbing sensation, maybe some tingling—and think this is the end of our activity for a long time.

Luckily, for around 99% of people it's not even close to the end. Rather, it's the body telling us we weren't prepared. This lack of preparation leads to tissue fatigue, pain-sensitive structures being compromised, and a myriad of symptoms from grabbing pain, to dull achiness, to sharp pain with certain movements.

The good news is that when this occurs, it's not the end of activity but rather a time to take a step back and approach movement going forward a little more intentionally.

The Research Reality: Normal "Abnormal" Findings

What typically happens in these spring flare-up situations? Many people end up in their primary care physician's office, where an MRI or x-ray is ordered. The radiologist report comes back with phrases like "degenerative disc disease," "disc bulging at L4-L5," and "mild facet arthropathy." The doctor points to these findings and says, "Here's your problem—your spine is showing signs of wear and tear."

But here's what most people don't realize: these so-called "abnormal" findings are incredibly common—even in people who feel perfectly fine. Our spine isn’t an old truck that simply breaks down from use.

A fascinating systematic review published in the American Journal of Neuroradiology examined MRI findings in 3,110 individuals across 33 studies—all people without any back pain. The percentage of pain-free people with "abnormal" findings was striking:

80% of 50 year olds and 52% of 30 year olds had disc degeneration.
30% of 20 year olds and 69% of 60 year olds had a bulging disc.

In the image on the right you can see that many of the “scary” sounding imagine findings are actually found in a large percentage of individuals with no pain.

Let that sink in. If you're over 50, you probably have disc degeneration and disc bulges—whether your back hurts or not. These aren't pathologies requiring intervention; they're simply age-related changes that most of us will experience.

The Problem with the Typical Approach

Too often, these incidental findings become the focus of treatment. People are told to rest, avoid certain movements, and sometimes even consider invasive procedures—all based on findings that likely existed before the pain started and may have nothing to do with the current problem.

This creates a cycle of fear, avoidance, and increasing disability. When you believe your spine is "degenerating," you move less. When you move less, you get weaker. When you're weaker, normal activities become more painful—confirming your fear that something is seriously wrong.

A Better Approach: Smart Reactivation

So what did I tell my friend? Rather than sending him for an MRI and focusing on what his discs might look like, we talked about rebuilding his capacity for golf after a winter of inactivity. Here's the approach we mapped out:

First 24-48 hours: Gentle movement to ease the acute spasm—walking, light stretching, and pain-free movements help reduce muscle guarding and promote blood flow
Days 3-7: Begin rebuilding specific capacity:
- Practice gentle rotational movements without a club
- Focus on breathing and relaxation during movements
- Add light resistance with bands.
Week 2: Progressive reintroduction to golf:
- Start with short, easy swings focusing on technique
- Begin with 10-15 easy swings, gradually increasing as tolerated
- Use mid-range clubs (7-iron, 9-iron) before drivers
Week 3-4: Graduated return to play:
- Add walking on the course (9 holes before 18)
- Gradually increase swing intensity and club selection
- Incorporate a proper warm-up routine before each session

I also gave him some advice to prevent this same scenario next spring:

Maintain 10 minutes of golf-specific movements 2-3 times weekly during winter
Focus on rotational mobility and maintaining the quick movements that come with golf
Gradually increase activity volume when spring arrives

Remember: your body adapts to the demands you place on it. The pain wasn't caused by a "degenerating spine"—it was caused by asking your body to do something it wasn't prepared for. With a smart, progressive approach to rebuilding capacity, we can return to the activities we love with less risk of recurrence.

When Imaging Really Matters

Now, I should clarify something important. While my friend's situation represents the vast majority of back pain cases I see—especially those seasonal, activity-related episodes—there are absolutely times when imaging is necessary and appropriate.

As a healthcare provider, we have to carefully screen every patient for certain "red flags" that would warrant immediate imaging:

Severe trauma (like a fall or accident)
Pain that wakes you from sleep or is unrelenting even at rest
Unexplained weight loss along with pain
History of cancer
Fever accompanying back pain
Progressive neurological symptoms (increasing weakness or numbness)
Bladder or bowel dysfunction

In these situations, imaging is an essential tool to rule out serious conditions that require specific medical intervention. However, these cases represent a small minority of back pain episodes—around 1-5% in most studies.

A good practitioner will screen for these red flags first, then make appropriate recommendations based on your specific situation rather than reflexively ordering imaging for every back pain patient.

Understanding Pain: Beyond the Structural Model

Why does reactivation work so well for most pain? The answer lies in modern pain science. Pain is more complex than we once thought:

Pain is protective, not just informative: Your nervous system produces pain as a protective mechanism, not simply as a damage report. When tissues are overloaded suddenly (like my friend's golf episode), the system can become more sensitive to protect you from further strain.
Multiple factors influence pain sensitivity: Beyond tissue load, factors like stress, sleep quality, past experiences, beliefs about pain, and even your expectations can all turn the volume up or down on pain. This is why the same activity might hurt one day but not the next.
The body adapts to what you do: Tissues strengthen in response to gradual, progressive loading. Movement also helps "desensitize" the nervous system, recalibrating what's interpreted as threatening versus safe activity.

This is why a gradual return to activity works so well for most pain—it addresses both the physical capacity issue (strengthening tissues) and the sensitivity issue (recalibrating the alarm system). Avoiding movement does the opposite, making tissues weaker and the system more sensitive over time.

Jacob Coffman