SPINE HEALTH · 6 min read
What Your MRI Actually Tells You — And What It Doesn’t
Most people with back or neck pain have imaging that shows “abnormalities.” Here’s why that rarely tells the full story — and what a mechanical exam can reveal that an MRI cannot.
By Meghan McConville, MSPT, OCS, Cert. MDT · KinetiQ Spine & Sport PT
You’ve been living with back pain for months. Your doctor orders an MRI. The report comes back listing findings like “disc bulge at L4-L5,” “mild facet arthropathy,” or “foraminal narrowing” — and suddenly you have a diagnosis. Or do you?
Here’s the uncomfortable truth that most patients never hear: imaging findings and pain are not the same thing. An MRI can tell you a great deal about the structure of your spine. What it cannot tell you is why you hurt, whether those findings are responsible for your symptoms, or what to do about it.
Understanding this distinction is one of the most important things a person with spine pain can do — and it’s central to how the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) approaches assessment and care.
The Research Is Clear: Imaging Findings Are Common — Even in People Without Pain
Landmark studies in spinal imaging have found that a significant proportion of people with no pain at all show “abnormalities” on MRI. Disc bulges, degeneration, and arthritis appear regularly in asymptomatic adults — and the prevalence increases with age. By the time most people reach their 50s, some degree of disc degeneration is essentially universal.
A widely cited systematic review published in the American Journal of Neuroradiology examined MRI findings in pain-free individuals and found that disc degeneration was present in 37% of 20-year-olds, rising to 96% in 80-year-olds. Disc bulges were found in roughly 30% of asymptomatic adults in their 20s.
If nearly everyone has imaging findings but not everyone has pain, the finding alone cannot explain the pain.
This doesn’t mean imaging is useless. It means it needs to be interpreted carefully, in context, and never in isolation.
What an MRI Can — and Cannot — Tell You
An MRI is excellent at ruling out serious pathology. It can identify fractures, tumors, infections, significant nerve compression, and other conditions that require immediate medical or surgical attention. For these purposes, imaging is essential and irreplaceable.
What imaging cannot do is tell you whether a structural finding is the actual source of your pain. A disc bulge at L4-L5 might be pressing on a nerve root — or it might have been there for years, completely asymptomatic, and your current pain is coming from somewhere else entirely. The image cannot make that distinction. Only a thorough mechanical assessment can.
This is one of the most common sources of confusion and frustration for patients. They receive an imaging report, see alarming-sounding language, and assume the findings explain everything. In some cases they do. In many cases, they don’t.
Common MRI Terms That Sound Worse Than They Are
“Disc bulge” — a very common finding, often asymptomatic. “Foraminal narrowing” — the opening where nerve roots exit; mild narrowing is nearly universal with age. “Facet arthropathy” — arthritis of the small joints of the spine; present in most adults over 40. “Degenerative disc disease” — a normal aging process, not a disease in the clinical sense.
What a Mechanical Exam Adds
The MDT assessment doesn’t replace imaging — it complements it. Where imaging shows structure, a mechanical exam evaluates function: how the spine moves, how symptoms behave in response to specific movements and positions, and whether there is a directional preference that can guide treatment.
During an MDT evaluation, a certified clinician systematically loads the spine in different directions — repeated flexion, extension, lateral movements — and observes what happens to symptoms. Do they centralize (move closer to the spine and away from the extremity)? Do they peripheralize (spread further down the arm or leg)? Do they abolish entirely with a specific movement?
These responses tell a trained clinician something an MRI fundamentally cannot: how the pain is behaving mechanically, and what direction of loading is therapeutic versus aggravating.
A patient can have a dramatic MRI report and a completely mechanical, self-treatable condition. Another patient can have a relatively unremarkable MRI and significant nerve involvement requiring careful management. The image alone does not determine the clinical picture.
When Imaging and Symptoms Don’t Match
One of the most valuable — and underappreciated — applications of MDT is in cases where imaging findings don’t match a patient’s symptom pattern. This mismatch is more common than most people realize.
A patient may have a disc herniation at L4-L5 on the right side, but their pain is primarily in the left leg. Or they may have multilevel “degeneration” on imaging but respond rapidly to a few sessions of directional loading — suggesting their condition is mechanical and reversible, not structural and fixed.
When an MDT clinician identifies a directional preference — a specific movement pattern that reliably reduces or centralizes symptoms — that finding has strong clinical meaning. Research consistently shows that patients with a directional preference have better outcomes with MDT than with general exercise, and that centralization of symptoms is a powerful predictor of recovery.
The Takeaway for Patients
If you’ve received an MRI report and feel confused, alarmed, or uncertain about what it means for your life and your pain — that’s an understandable response to a system that sometimes over-relies on imaging and under-invests in thorough clinical assessment.
Here’s what’s worth holding onto:
-
An imaging finding is not automatically a diagnosis of the cause of your pain.
-
Many findings that look alarming on paper are common, age-related, and not the driver of symptoms.
-
A mechanical assessment can determine whether your pain is driven by a mechanical problem that responds to specific movement — far more actionable than a structural label.
-
Centralization of symptoms during assessment is a strong, research-backed predictor of a good outcome with conservative care.