I Want A Scan – Why Imaging Isn’t The Simple Answer It Seems

“I think we should scan everyone”

When I first started out in physiotherapy, I honestly thought this was the best solution. Why wouldn’t we scan everyone? MRI, X‑ray, ultrasound, CT, surely if we could see inside the body, we’d know exactly what was causing the pain.

At the time, I assumed the only barriers were cost and practicality. Too many people, not enough scanners. Simple.

What I hadn’t really considered were two much bigger questions:

1. How would this scan actually change what I do next?

2. Could getting a scan ever make things worse?

   
   

I was also pretty naïve about pain itself. My thinking was very linear: pain = damage. Find the damage, fix the problem. Job done.

As I learned more through research, guidelines, podcasts, and clinical experience, my original idea started to fall apart.

Why do people want scans so badly?

Patients aren’t wrong for wanting imaging. In fact, research shows some very understandable reasons:

• A desire for certainty or a clear diagnosis

• “It’s hard to trust a person, it’s easier to trust an image”

• Fear that something serious is being missed

• Wanting proof that the pain is real

• Belief that the benefits of scanning outweigh any downsides

  
  

If you’re in pain and frustrated, this makes perfect sense. A scan feels like answers.

The problem I found is that scans don’t always give the answers we think they do.

How good are scans at identifying the cause of pain?

When I started regularly taking scans, speaking with those getting them and seeing MRI reports, something didn’t add up.

I saw people in severe pain with scans reported as “normal,” and others with very mild symptoms whose scans looked dramatic. That mismatch made me question how reliably scans actually explain pain.

It sparked my interest in why more pain doesn’t always mean more damage, and pushed me to explore what scans really show,  including how often so-called “abnormal” findings appear in people with no pain at all.

Research shows what are normal findings:

• Large spine studies show that disc bulges, degeneration, and other changes are very common in people with no back pain at all, and these changes increase with age. The image below shows normal age related changes in the spine.

• Around 60% of people have meniscal tears on knee MRI without any knee pain.

• Shoulder scans frequently show rotator cuff tears in older adults, yet many of these individuals have no shoulder pain.

The key takeaway is: if the same scan changes appear in people both with and without pain, we cannot assume that a finding is the reason for your pain.

Many scan findings are better thought of as internal wrinkles or grey hair, evidence of time and use rather than something broken or dangerous. Scans can absolutely show real damage when it’s there, fractures, ACL ruptures, significant ligament tears. They just don’t reliably tell us why someone hurts.

So the answer to the question is: scans are limited in identifying the exact cause of pain. They can show changes, but these changes often exist in people without pain, so a scan alone usually cannot pinpoint the source of your symptoms.

Which raises an important follow-up question:

If lots of people walk around pain-free with the same scan findings, why should that result automatically explain your pain?

So what’s the harm in getting a scan anyway?

If scans aren’t perfect, fine, but surely they can’t do any harm?

Unfortunately, they can. That became clear to me after a referral to physiotherapy following a scan, where the findings had already shaped expectations long before rehab began.

Scan reports are written for medical professionals, not patients. They’re full of technical language and worst‑case descriptions. Without careful explanation, they can easily be misinterpreted.

I’ve seen the impact of phrases like:

• “Bone on bone”

• “Severe degeneration”

• “The worst scan I’ve ever seen”

  
  

Even when movement, strength, and function tell a very different story.

When people are given scan results without proper context, it can lead to increased fear, anxiety, and catastrophising. Pain feels more serious. Movement feels more dangerous. Recovery feels unlikely.

This effect even has a name, the nocebo effect, where negative expectations actually worsen symptoms and slow recovery.

Research shows that people who receive imaging for certain MSK conditions can have longer recovery times than those who don’t, largely due to changes in beliefs and behaviour rather than physical damage.

And here’s the frustrating part: after that emotional roller‑coaster, most people are still told the same thing they would have been told anyway, recommending physio and remain active.

Except now they’re starting physio thinking:

“There’s no way this will help, didn’t you see my scan?”

That’s not a great place to begin.

Pain is more complex than a picture

Another layer to all of this is pain itself.

Pain isn’t a simple read‑out of tissue damage. It’s influenced by many factors, previous experiences, fear, beliefs, stress, sleep, confidence in movement, and more.

Over‑simplified explanations like:

• “It’s just a weak muscle”

• “Your pelvis is out of place”

• “It’s your sleeping position”

might sound reassuring, but they often fall apart when the quick fix doesn’t work.

Reducing pain to a single structure can actually leave people more confused and less confident when recovery isn’t immediate. The picture to the right shows a snapshot of different factors that can influence low back pain.

So when should scans be used?

Imaging absolutely has a place in musculoskeletal care, context is everything.

Scans are most useful when they:

• Help rule out serious or rare pathology

• Change the direction of treatment

• Guide decisions about surgery or injections

  
  

But they should sit alongside a thorough assessment, listening to how symptoms behave, understanding day‑to‑day patterns, checking strength, movement, and function.

A scan should be one piece of the puzzle, not the whole picture.

Final thoughts

The more you learn, the easier it is to understand why guidelines exist.

I used to think scans would show me the exact cause of pain. Now I know that pain is rarely that simple, and that scans can sometimes create more problems than they solve, especially if they’re used without clear explanation.

If you do have imaging:

• Ask what findings are normal for someone your age

• Ask which findings actually matter for what you’re feeling

• Be cautious of dramatic language that isn’t backed up by a proper physical assessment

  
  

Your body is far more adaptable and robust than most scan reports suggest. With the right input, movement, loading, confidence, and time, it’s very good at recovering.

A scan can help in the right situation. But it’s rarely the full answer people hope it will be.

Reference List:

Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., Chen, L.E., Deyo, R.A., Halabi, S., Turner, J.A., Avins, A.L., James, K., Wald, J.T., Kallmes, D.F. and Jarvik, J.G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36(4), pp.811–816. doi:https://doi.org/10.3174/ajnr.a4173.

CHOLEWICKI, J., BREEN, A., POPOVICH, J.M., REEVES, N.P., SAHRMANN, S.A., VAN DILLEN, L.R., VLEEMING, A. and HODGES, P.W. (2019). Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate. The Journal of orthopaedic and sports physical therapy, [online] 49(6), pp.425–436. doi:https://doi.org/10.2519/jospt.2019.8825.

Culvenor, A.G., Øiestad, B.E., Hart, H.F., Stefanik, J.J., Guermazi, A. and Crossley, K.M. (2018). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British Journal of Sports Medicine, 53(20), pp.1268–1278. doi:https://doi.org/10.1136/bjsports-2018-099257.

Englund, M., Guermazi, A., Gale, D., Hunter, D.J., Aliabadi, P., Clancy, M. and Felson, D.T. (2008). Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. The New England journal of medicine, [online] 359(11), pp.1108–1115. doi:https://doi.org/10.1056/NEJMoa0800777.

Wáng, Y.X.J., Wu, A.-M., Ruiz Santiago, F. and Nogueira-Barbosa, M.H. (2018). Informed appropriate imaging for low back pain management: A narrative review. Journal of Orthopaedic Translation, [online] 15, pp.21–34. doi:https://doi.org/10.1016/j.jot.2018.07.009

Yamaguchi, K., Ditsios, K., Middleton, W.D., Hildebolt, C.F., Galatz, L.M. and Teefey, S.A. (2006). The Demographic and Morphological Features of Rotator Cuff Disease. The Journal of Bone & Joint Surgery, 88(8), pp.1699–1704. doi:https://doi.org/10.2106/jbjs.e.00835.