Must an Injury Always Hurt?

Did you know…?

Over 40% of people without pain have a bulging disc on MRI (Turner et. el 2017).

80% of pain free people aged between 20 and 80 have disc degeneration seen on imaging (Brinjiki et al, 2015).

Up to 40% of the general population have asymptomatic (no pain) rotator cuff tears. On MRI 54% of people over the age of 60 years without shoulder symptoms demonstrate partial thickness or full thickness rotator cuff tears (Sheretal, 1995).

In a study of 710 people aged 51-89, 68% were shown to have cartilage damage and 72% have osteophytes (bone spurs) despite having no pain (Guermazi et al, 2012).


When medical imaging first started being used it was very exciting. Finally, we could see what was going on under the skin. People who had an injury and/or symptoms of pain would be sent off for a scan and it would come back with a report that said; “moderate level of disc degeneration”, “full thickness tear”, “evidence of tendon thickening” etc. etc. This meant that anything that looked different from “normal” must have been the cause of that persons problem.

In recent years there has been a shift in our line of inquiry and some clever researchers have started looking at things like – what is normal? and some very interesting information is coming to light. It turns out that people with no pain have the same kind of changes on imaging as people with pain. It also turns out that athletes with tendon thickening may be a sign of adaption rather than injury, and when people get better and their pain goes away the signs of structural pathology on imaging don’t go away! We are now understanding that in many if not most cases there really is no direct correlation between what we see and what it means clinically and ultimately  becomes a diversion away from effective care. Often this leads to more frequent and invasive investigations and types of treatment that can expose the consumer to undue risk of harm, emotional stress, or financial cost.

So what should we rely on? A good clinical history and thorough examination is enough to uncover a diagnosis, or at least a functional framework to treat the majority of musculoskeletal injuries. It is now recommended that a referral for medical imaging including x-rays and MRI should be avoided in the initial stages of care unless a suspected pathological cause is present (ie fracture, cancer etc.). Pain is a complex problem and often needs a complex solution. I write a bit more about understanding pain in a previous blog post which can be found here. If you are unsure weather you are getting the right care or receiving the right advice you are always entitled to a second opinion.