Why “mild changes” can still hurt — and frightening-looking scans don't always mean something is seriously wrong

One of the most common conversations I have in pain clinic starts with an MRI report.

Sometimes someone is living with severe pain that is affecting almost every part of their life, but their scan describes only “mild degenerative changes”.

They are understandably confused.

How can my pain be this bad if there is hardly anything wrong on the scan?

At other times, the opposite happens.

Someone has relatively manageable symptoms, but their report contains words such as degeneration, disc protrusion, stenosis, osteoarthritis or nerve compression.

Suddenly the scan sounds frightening.

They may start worrying about damaging their spine, stop exercising or become afraid of movements they previously performed without a second thought.

Neither situation is unusual.

The important thing to understand is this:

A scan is one piece of the puzzle. It isn't a measurement of how much pain you should be experiencing.

What does a scan actually show us?

MRI and other forms of imaging are extraordinarily useful.

They allow us to look at structures inside the body and can help identify important causes of symptoms.

In spinal pain, for example, an MRI can show discs, joints, nerves and the spinal canal. It can identify problems such as significant nerve compression, fractures, inflammation and other abnormalities.

But a scan is essentially a picture of anatomy.

Pain is not anatomy.

Pain is an experience produced by the nervous system in response to information coming from the body, interpreted alongside everything else the nervous system knows about what is happening.

That distinction matters.

A scan can show us what something looks like.

It cannot tell us exactly how it feels.

Lots of people have changes on scans without pain

Our bodies change as we get older.

Spinal discs lose some of their water content. Joints develop wear. Tendons change. Small disc bulges appear.

These findings become increasingly common with age and are frequently found in people who have no pain at all.

The same principle applies beyond the spine.

Changes can appear on scans of knees, hips, shoulders and other joints without necessarily causing significant symptoms.

This doesn't mean those findings are meaningless.

It means they need clinical context.

If we treated every abnormality visible on an MRI, we would end up treating an enormous number of people who weren't actually unwell.

Degeneration sounds worse than it often is

Medical language doesn't always help.

The word degenerative can sound as though something is crumbling or progressively failing.

Usually, it simply describes changes associated with ageing and use.

A useful comparison is grey hair or wrinkles.

They are genuine physical changes.

They don't mean the person is damaged.

Similarly, a phrase such as “multilevel degenerative disc disease” may sound alarming, but it doesn't automatically mean that a spine is fragile, unstable or destined to become increasingly painful.

The wording of a radiology report needs interpreting alongside the person sitting in front of us.

But what if my pain is severe and my MRI says “mild”?

This can be much harder.

You know how much pain you are experiencing.

You may be struggling to walk, work, sleep or look after yourself.

Then the scan report arrives and describes only minor abnormalities.

Sometimes people feel relieved.

Others feel completely invalidated.

They wonder whether anyone will believe them.

Perhaps someone has even said:

“There's nothing on your scan that explains your pain.”

That sentence can be devastating.

A more accurate interpretation is often:

“There isn't a clear structural abnormality on this scan that fully explains the symptoms you are experiencing.”

Those are not the same thing.

Mild findings can still be relevant

The severity of an imaging abnormality doesn't always correlate neatly with the severity of pain.

A relatively small disc protrusion in exactly the wrong place may irritate a nerve considerably.

A painful joint may not look dramatically abnormal.

Some structures that generate pain are simply not particularly well assessed by routine imaging.

And an MRI is usually performed while you are lying still.

It doesn't show us exactly what happens when you have been standing for an hour, climbing stairs, carrying shopping or walking several miles.

The clinical story still matters.

Where does it hurt?

What makes it worse?

What makes it better?

Is there weakness or altered sensation?

What happens when I examine you?

What happened after physiotherapy or a diagnostic injection?

These things can be just as important as the scan itself.

Sometimes the scan genuinely doesn't explain the pain

There are also times when imaging doesn't reveal a convincing physical explanation for the severity or distribution of someone's pain.

That doesn't mean the pain isn't real.

Persistent pain can become increasingly complex over time.

The nervous system can become more sensitive. Pain may spread beyond its original location. Sleep disruption, previous injuries, illness, stress and repeated episodes of pain can all influence how the nervous system processes information from the body.

Sometimes an original injury has healed, but the pain system has not returned to its previous state.

Sometimes there is an ongoing physical source of pain and increased sensitivity within the nervous system.

These possibilities are not mutually exclusive.

We don't have to choose between:

“There must be something damaged.”

and

“It's all coming from the nervous system.”

Often the reality sits somewhere in between.

The opposite problem: when the scan looks terrible

A dramatic MRI report can create problems of its own.

Imagine that you have been coping reasonably well with intermittent back pain.

Then an MRI describes:

• multilevel degenerative change

• disc desiccation

• facet joint osteoarthritis

• foraminal narrowing

• disc protrusions

Suddenly your spine sounds disastrous.

But you are the same person you were the day before you read the report.

Nothing happened to your spine when the radiologist wrote those words.

The scan has simply described what was already there.

This is why scans need careful explanation.

Scans can change how we move

Once someone believes their spine is damaged, it is very easy to start protecting it.

They stop bending.

They avoid lifting.

They give up exercise.

They brace whenever they move.

Perhaps they stop gardening, running or going to the gym because they are worried about making the scan findings worse.

Over time, they may become weaker and less physically confident.

Ironically, this can make the original problem harder to manage.

If imaging has ruled out anything requiring specific protection or treatment, one of the most useful things we can sometimes do is help someone understand that their body remains safe to use.

When imaging really does matter

None of this means that scans are unimportant.

Sometimes imaging identifies exactly the problem we were looking for.

A scan may reveal nerve compression that matches someone's symptoms and examination.

It may identify significant arthritis in a joint that is behaving exactly as we would expect clinically.

It may help plan an injection or surgical procedure.

And occasionally imaging identifies something unexpected that needs urgent or specialist treatment.

The point isn't to dismiss scans.

It is to use them properly.

Imaging is most useful when it answers a clinical question.

Why don't we just scan everyone?

When someone is in pain, having a scan can feel like the obvious next step.

Sometimes it is.

But more imaging isn't always better medicine.

If a scan is unlikely to change treatment, finding age-related abnormalities can occasionally create more anxiety than clarity.

This is particularly true with uncomplicated back pain, where imaging often shows changes that are extremely common in people without symptoms.

Before requesting a scan, a useful question is:

“What are we hoping this scan will tell us, and will the answer change what we do?”

If there is a good answer to that question, imaging may be very helpful.

If there isn't, the scan may not provide the certainty we are hoping for.

Diagnostic injections can sometimes add another piece of information

Occasionally the clinical picture and imaging suggest several possible sources of pain.

In these circumstances, a carefully selected diagnostic injection can sometimes help us understand which structure is important.

For example, medial branch blocks can help assess whether pain is likely to be arising from the facet joints of the spine.

Other targeted injections or nerve blocks may be useful in particular circumstances.

These procedures aren't simply attempts to make every abnormality on an MRI stop hurting.

They are sometimes a way of asking the body a more specific diagnostic question.

The response then needs interpreting alongside the history, examination and imaging.

Treat the person, not the picture

A scan should never be interpreted in isolation.

If someone has severe pain despite relatively modest imaging findings, I don't think the answer is to tell them that nothing is wrong.

We need to look more carefully.

Equally, if someone's scan looks alarming but they are functioning well, we shouldn't automatically turn them into a patient who is frightened of their own body.

Good pain assessment brings the pieces together:

the story,

the examination,

the pattern of symptoms,

the response to previous treatment,

and, where appropriate, the imaging.

Sometimes those pieces fit together beautifully.

Sometimes they don't.

And when they don't, that discrepancy is often where the most interesting clinical thinking begins.

Your MRI isn't your diagnosis

Perhaps the most important thing to remember is that you are not your scan report.

“Mild changes” don't mean your pain should be mild.

“Severe degeneration” doesn't mean your future will be severe.

And an MRI that doesn't provide a neat explanation doesn't make your symptoms any less real.

A scan can be extremely valuable.

But it is still only one source of information.

The scan matters. The body matters. The nervous system matters. And, most importantly, the person experiencing the pain matters.