“I’m hurt. I’ve been to the doctor and nothing shows up on an x-ray or MRI but I can’t do what I want to. No one can find anything wrong with me.”

Does the remark sounds familiar? It may feel like the pain isn’t real unless it shows up on the X-ray or magnetic resonance imaging (MRI) scan. But before you go for more tests, below are five common misconceptions about X-rays and MRIs that you should know:

1.  The MRI scan or X-ray will explain the cause of my pain

It is more common to have a pain or an injury, that doesn’t show up on an X-ray or a MRI scan than to have one that shows up on the scan. Don’t be surprised when the costly scan does not reflect your pain or injury, physical therapist Heather Moore wrote in a 2016 article for the American newspaper, the Philadelphia Inquirer.

Medical reports are too dependent on X-rays and MRI scans to make a diagnosis. The truth is most common pain won’t appear on imaging devices because most pain are caused by muscle imbalances in the body, she wrote. The symptoms won’t show up on the image unless there is a tear, or a lot of inflammation.

Muscle imbalances, where some muscles are weaker than others, are often cause by an injury like a fall or even a sprain, which may seem as minor as an ankle sprain. A painful ankle, for example, may cause a weight shift from the injured leg to the other leg to avoid the pain. Unequal leg strength and stresses can develop overtime when one leg bears more of the body weight than the other. A bad posture when sitting or standing, your occupation and lifestyle are other causes of muscle imbalances in the body.

2.   MRI scan or X-ray is a standard test for joint pain

Imaging tests are not necessary for all joint pain. Using an X-ray or a MRI scan to shed light on a pain is like taking a shot in the dark. Imaging and diagnostic tests are only useful when your doctor suspects the pain is a symptom of a specific disease, such as cancer, an infection, spinal stenosis where there is a severe impingement on the nerve roots, or cardiovascular disease.

Figure 1: Imaging tests are not useful for non-specific back pain, the type of back pain that most people have.

For example, only a fraction of people who have sought treatment for back pain in America have a pain that is associated with a specific disease. In fact, more than 85% of patients with low back pain have non-specific low back pain, statistics from the American Board of Physicians and the American Pain Society showed.

In 2007, both medical associations issued a guideline to doctors on the diagnosis and treatment of low back pain. In the joint guideline, they recommend clinicians not to make it a common practice to request for imaging or other diagnostic tests for nonspecific low back pain. Instead, doctors should look into the medical history of the patients and carry out their own physical examination for signs of a pathology or a neurological impairment before deciding whether imaging tests or other diagnostic tests are necessary.

3.   My scan shows no musculoskeletal abnormality. I should ignore the pain.

Pain is like an alarm bell from the body, that something isn’t right, so don’t ignore the pain. Rather than nothing is wrong, you should know that MRIs and X-ray are not good at revealing musculoskeletal pain.

Inflammation, where soft tissues in the body are hot and swollen, don’t often show up on imaging devices. Also the images would not reveal changes in soft-tissue density. Musculoskeletal pain often includes inflammation, where there is a build up of heat and tension. The soft tissues — which includes muscles and connective tissues — will be thicker. But on imaging tests, these changes may appear a mere blip or not appear at all.


An example is the case of a 35-year old woman with chronic non-specific calf pain. Her case was highlighted by researchers from the Indiana University, the U.S. who treated her. The 2011 study was published in the Journal for Manual and Manipulative Therapy.

Figure 2: The treatment diary of a 35-year old woman with chronic non-specific calf pain. When the images did not reveal the source of her pain, more diagnostic tests were given.

The woman suffered from frequent leg cramps for two years. The pain was on the right mid-calf. It first started during pregnancy but persisted after child-birth. The pain affected her daily life. She couldn’t carry her 35 lbs (15 kg)  child, cross her legs when she sits, climb up stairs or stand for long without leg cramps. Even at rest, there was a constant dull ache on the right calf.

She went through various scans to find the cause of her right leg cramps. She had an X-ray, a MRI and a Doppler ultrasound study. A Doppler study is commonly used to screen for deep venous thrombosis, a condition where there is a blood clot on the leg.

The X-ray and Doppler study revealed nothing, but the MRI scan showed a “small” network of superficial venous tissue on the right calf. It was missed by the radiologist who wrote the MRI report, who reported “no musculoskeletal abnormality.” Her physician spotted the small patch on the MRI scan, but it was not considered significant.


After more diagnostic tests, which did not reveal the source of her pain, she was eventually referred for manual therapy and exercise. During her evaluation session, nodules or knots were found on her mid-right calf on palpation, the researchers said in the study.

Muscle palpation is a stroking technique to evaluate muscle tone, and also to loosen tension in the muscle.

In a scale of 0 being no pain, and 10 being extremely painful, she reported the pain was 8 out of 10 when the right calf was palpated. She was diagnosed as having a soft-tissue dysfunction. Her right calf muscle was too tight and tense.

After nine sessions over eight weeks of manual therapy and exercises, her symptoms were gone, the study showed. She could carry her child, stand or cross her leg without pain. She also reported a pain rating of 0 of 10 when her right calf was palpated during the last assessment. She was re-assessed a month and 4 months later, and the pain did not re-occur.


Her case showed imaging devices are not effective in picking up musculoskeletal pain. When they do, it may appear a mere blip on the scan. When the images did not explain the pain, the common course of treatment is that more medical tests are needed. She also had an endocrine test and other diagnostic tests to screen for cardiovascular disease, gastrointestinal disorder and neurological deficit.

The researchers wrote manual therapy and exercises can bring real benefit to patients with non-specific pain, which is usually caused by a muscle imbalance. The treatment is viable, and is non-surgical and non-phramocological, the researchers wrote.

Although the study did not say whether any medication was given to the patient, but steroidal injections are often given for chronic pain.

4.  My scan shows arthritis, so arthritis must be the cause of the pain. Nothing can be done other than surgery to replace the joint.

Pre-mature arthritis, where certain bones and joints wear out faster than they should, is a red flag that there is a problem, Moore wrote. Particularly when the bone or spinal degeneration only occur on a certain joint or a certain segment of the spine. The questions we should ask are why do one joint feel more painful than the other? We walk with both legs, so why does the arthritis happen faster for example, on one knee than the other?

Figure 3: We walk with both legs, so why does the arthritis happen faster on one knee than the other? Pre-mature degeneration is a red flag there is a muscle imbalance.

Moore added: to understand why knee osteoarthritis occur, imagine the thigh muscle like a long string, that is attached from the hip to the knee. Take the string and tie a bunch of knots in it. The string will shorten and pull on the knee. As the shortened muscle draw the thigh and leg bones closer together, every time you walk, there will be some form of rubbing and grinding at the knee joint which hasten the rate of degeneration on the knee.

Manual therapy to loosen the knots, and exercises to try to bring balance to the muscle can prevent further arthritis on the affected knee. Pre-mature degeneration, particularly when it is asymmetrical, is often an indication of a muscle imbalance in the body. When left untreated, it would eventually result in an injury. You would need surgery to repair it.

5.   My scan shows my spine is crooked. I don’t want to move. It may aggravate the problem.

Critics of imaging devices said the scans often produce false alarms. Bone degeneration that shows up on imaging devices could be normal wear and tear, and may not be related to the patient’s current pain.

Being free to move increases the quality of a person’s life. To understand musculoskeletal pain, we have to first understand how muscles work. Muscles connect two bones together to create movement. They give purpose and life to the bones in the body.

Exercises when they are included with manual therapy re-train muscles in the body to work better in balance. Take the case of the woman with chronic calf pain, the researchers said the exercises which she performed after the manual therapy sessions contributed to her pain relief. They concluded that manual therapy alone may not produce the same success without the exercises.

The manual therapy she received was instrument-assisted soft tissue mobilization. The ISTM was followed by stretching and eccentric calf exercises to re-train and strengthen her leg muscles. After nine sessions over eight weeks, her pain was “abolished,” the researchers said. She had the pain for two years, and a medical care that would have been considered comprehensive.


What’s next when the MRI scan or X-ray doesn’t show your pain? It doesn’t mean your pain isn’t real. Having a non-specific pain is more common than having a pain, caused by a specific disease. You are in the majority when the images do no reveal your pain.

In Singapore, there is a high incidence of work-related musculoskeletal disorders. The good news is musculoskeletal pain is treatable with manual therapy and exercise. Although manual therapy — particularly with exercise — is still not part of mainstream healthcare or medical care, it has shown to be effective. Often, imaging tests, medication and surgery are the main treatment options for a patient with musculoskeletal pain.

Musculoskeletal pain can be debilitating. The pain can affect your work and daily activities, but medication or surgery is not always required. A few sessions of manual therapy and exercise may just be what you need.

Try a Move Therapy session today.

Medical Disclaimer: Always consult your physician if you have an existing pain or a pre-existing medical condition before beginning any exercise. The above information is not intended to diagnose any medical condition or replace your healthcare professional.

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