Beyond the MRI: Why Normal Imaging Doesn't Mean You're Making Up Pain

"Your MRI looks normal." For many people suffering from pain, hearing these words can be both relieving and frustrating. Relief because there’s no serious structural damage, but frustration because they’re still in pain. If this passage resonates, you are not alone — and more to the point, your pain is not a figment of your imagination.

We spoke to an expert Psychologist, Dr. Ali Navidi, who specializes in helping his patients escape chronic pain and GI disorders. Here are some highlights from our conversation.

The Imaging Paradox

Similar to how Dr. Navidi described GI disorders in his clinical practice, where patients may suffer significant symptoms despite being tested normal, the same occurs very frequently in musculoskeletal pain. This gives rise to this puzzling fact: extensive research has shown that many people WITHOUT pain have “abnormal” radiologic findings, while many people WITH horrible pain have “normal” tests.

Consider these findings:

• 60% of adults over 50 have disc bulges but no pain

• 80% of individuals over 65 have arthritis on X-ray but without symptoms

• 40% of individuals with knee pain have meniscus tears in their pain-free knee

This produces what we refer to as the imaging paradox: what your imaging shows frequently does not equal to how you feel.

Why Your Pain Is Real (Even With Normal Imaging)

Remind yourself of this important point: pain is always real. Just like we talked about with Dr. Navidi about GI issues, when we address the mind-body connection, we are not saying that the pain is “just in your head.” Every feeling you have — from stomach ache to headache to knee pain — has its workings in your nervous system and brain. That doesn’t make it less real.

One way to think of it: an MRI is a picture of your body structure. But pain is more than just the structure and anatomy — it involves how your nervous system is interpreting and responding to various factors.

An MRI can't show:

• Nervous system sensitivity

• Muscle tension

• Cellular level inflammation

• How your brain is processing pain signals

• The impact of stress, sleep, and other lifestyle factors

The Alarm System Example

So, I will refer to an analogy covered in our GI issues discussion. Your pain system is a complex alarm system:

• Sometimes, it’s perfectly calibrated, warning you of possible danger

• Other times, it gets overactive, like a car alarm that triggers as someone walks by

• Both alarms are valid — it's just that one is more useful than the other

So this is why you can have:

• Pain without tissue damage

• Tissue damage without pain

• Or both at the same time

When Tests Come Back Normal

If you've had normal imaging results but are still experiencing pain, here's what you should know:

1. This is Common

• Many people with chronic pain have normal imaging

• It doesn't mean you're making up the pain

• It doesn't mean you're "crazy" or "seeking attention"

2. It Can Be Good News

• No serious structural damage means more treatment options

• Many pain conditions respond well to active treatment

• You're not "destined" for surgery

3. Pain Is Complex

• Pain involves multiple body systems

• Imaging only show one piece of the puzzle

Moving Forward: What You Can Do

1. Work with Providers Who Are Familiar with Contemporary Pain Methods

• They need to explain things clearly

• They should validate your experience

• They must provide active treatment strategies

2. Focus on Function

• Instead of focusing on imaging instead

• Create goals according to the activities you want to return to

• Increase your physical activity level over time

3. Address Multiple Factors

• Your physical activity and exercise

• Sleep quality

• Stress management

• Overall health habits

Success Story

Take Sarah (name changed), who visited our clinic for chronic shoulder pain that had gone unfixed for a few years. Her MRI came back normal, and previous providers concluded that she was exaggerating her symptoms. She knew her pain was real, even when the imaging was normal, but she also learned how to manage that pain through education about pain science and a multidisciplinary approach to treatment. After two months, she resumed practicing her favorite yoga classes.

The Role of Physical Therapy

Physical therapists are uniquely positioned to help because we:

• Understand the complexity of pain

• Can assess movement and function, not just structure

• Provide hands-on treatment

• Teach self-management strategies

• Help you safely return to activitie

When to Seek Help

Consider physical therapy if:

• You are experiencing pain for longer than is normal

• You have symptoms but your imaging is normal

• You are avoiding activities you love

• You want to understand your pain more intimately

• You're preparing for an active recovery

Keep in mind: Just because your imaging is normal doesn’t mean your pain isn’t real. What it often means is that you have to have a different approach — one that looks at all the elements of pain, rather than just structural changes from the imaging.

Because we see patients like you at District Performance & Physio every day, we understand the frustration of pain with normal imaging results. We take the time to hear your story, complete a thorough exam, and create a multi-faceted treatment plan that treats all aspects of pain, not just what shows (or does not show) on an MRI.

Want to learn more about understanding and managing your pain? Call us now and book an appointment for an evaluation. Let’s work together to get you back to doing the things you love, no matter what your imaging reveals.