Shannon Clinic – Melbourne Chiropractic and Sports Care Blog

By Dr. Nicholas Shannon | Sports & Exercise Medicine Chiropractor (PGDipSEM, ICCSP, FAICE) | Shannon Clinic, Melbourne CBD

Your MRI report lands in your inbox. “Disc protrusion at L4/5.” “Complex medial meniscal tear.” “Supraspinatus tendinopathy.” Suddenly the mystery of your pain feels solved, there it is, in black and white. But here is the uncomfortable truth that decades of high-quality research keep confirming: the finding on your scan may have nothing to do with why you hurt.

At Shannon Clinic, a sports chiropractic and sports medicine practice in the heart of Melbourne CBD, we see this scenario play out every week with runners, tennis players, CrossFitters, and desk-bound professionals alike. A scan gets ordered early, an “abnormality” gets found, and a person who was simply sore walks away convinced their body is damaged. The worry itself can make the pain worse and recovery slower.

This blog explains, using high quality evidence, why MRI and other imaging modalities so often fail to explain musculoskeletal pain, and why a careful history and physical examination, not a scan, remains the foundation of an accurate diagnosis.

Key takeaways

• Imaging “abnormalities”; disc bulges, meniscal tears, rotator cuff tears, cartilage wear, are extremely common in people with no pain at all, and become more common with age.
• No imaging technique actually shows pain. Pain is produced by the nervous system, not by a picture of a structure.
• For most non-specific back, knee, and shoulder pain, early or routine imaging does not improve outcomes and can lead to unnecessary worry, injections, and surgery.
• MRI does not reliably predict return-to-play timelines after a hamstring strain, and the severity of osteoarthritis on X-ray correlates only weakly with how much pain a person feels.
• A thorough history and examination by an experienced clinician supported by selective imaging when it will genuinely change management produces the best results.

How imaging transformed healthcare and created a new problem

Diagnostic imaging is one of medicine’s genuine triumphs. X-ray, MRI, CT, and ultrasound let us see inside the body with a clarity that was unthinkable a few generations ago. They are indispensable for ruling out serious pathology such as fractures, tumours, infections and for guiding injection interventions and surgery when they are genuinely needed.

The problem is not the technology. The problem is what happens when we point powerful, exquisitely sensitive tools at ordinary aches. Because MRI in particular is so sensitive, it detects a great many incidental findings: changes that are simply part of a normally ageing, well-used body. When those findings are handed to a patient as “the cause” of their pain, they can trigger a nocebo effect, where the belief that something is broken amplifies the pain experience, and set off a cascade of further tests, injections, and procedures that never address the real driver.

Be Wary of The “Incidentaloma”

There is a well-described “incidentaloma cascade” at work. An early scan reveals a finding that was always there and was never the problem; that finding prompts a follow-up scan, then a specialist opinion, then perhaps an injection or an operation aimed at the picture rather than the person. Each step carries its own cost, risk, and anxiety, and none of it touches the actual reason the tissue became sensitive in the first place. Studies consistently show that patients who are imaged early for ordinary back pain tend to undergo more procedures and report no better recovery than those who are not. The imaging changes the journey without improving the destination.

This is why the American College of Physicians and the UK’s National Institute for Health and Care Excellence (NICE) both advise clinicians not to routinely image non-specific low back pain in the absence of red flags. A landmark systematic review and meta-analysis of randomised trials published in The Lancet found that immediate, routine lumbar imaging produced no better outcomes for pain or function than usual care without imaging, while increasing cost and intervention rates.

What Is Pain?

It helps to be precise about what pain actually is. Pain is not a faithful readout of tissue damage; it is a protective response generated by the nervous system, weighted by many inputs at once. The state of the tissue, yes, but also your training and load history, sleep, stress, mood, and what you believe is happening inside your body. This is the modern biopsychosocial understanding of pain, and it explains the everyday observations that pure structural models cannot: why a paper cut can throb while a footballer plays on through a fracture, and why two people with word-for-word identical scans can have wildly different symptoms.

Understanding pain this way changes what effective treatment looks like. Instead of chasing a structural finding on a scan, care should target the things that actually drive symptoms: load, capacity, movement, and confidence in the joint. That is the basis of how our Melbourne CBD chiropractors treat persistent pain.

What each imaging modality is actually good for

No scan is “better” than another in the abstract. Each answers a different question, and each has blind spots.

X-ray

Excellent for bone: fractures, alignment, advanced osteoarthritis (joint-space narrowing, osteophytes), and spondylolisthesis. It is fast, inexpensive, and low-radiation. But it is poor for soft tissue: discs, ligaments, tendons, and early cartilage change are largely invisible on plain film.. Crucially, the bony changes X-ray is good at detecting are frequently present in people with no symptoms.

MRI

The gold standard for soft tissue including discs, menisci, ligaments, tendons, muscle, and bone marrow coupled with no ionising radiation. Its great strength, high sensitivity, is also its great weakness: MRI picks up a large number of findings that are clinically irrelevant. A tear or bulge on MRI is a description of anatomy, not a diagnosis of your pain.

CT

Superior for complex bony detail like comminuted fractures, some cases of spinal stenosis and is useful when MRI is contraindicated (for example, certain implanted devices). The trade-off is a higher radiation dose, so it is reserved for questions that genuinely require it.

Ultrasound

Dynamic and real-time, ultrasound lets us watch tendons, ligaments, and muscles move under load, and it is outstanding for guiding injections. It uses no radiation, is cheap and is readily available in clinic. Its main limitation is that it is operator-dependent: the quality of the information depends heavily on the skill of the person holding the probe. Used well, point-of-care ultrasound is a powerful adjunct to a hands-on examination rather than a replacement for it, which is why we employ it at the Shannon Clinic.

The common thread though is none of these modalities images pain. Pain is a protective output of the nervous system, shaped by tissue state, load history, sleep, stress, beliefs, and prior experience. A scan shows structure. It does not show suffering.

When imaging does change management

Imaging is not the villain here, inappropriate imaging is. There are clear situations where a scan is essential: chiefly when the history and examination raise “red flags” for serious pathology, or when significant acute trauma suggests a structural injury that would change management.

• Progressive or significant neurological deficit (worsening weakness, numbness).
• Suspected cauda equina syndrome (saddle numbness, bladder or bowel changes).
• Features suggesting infection, cancer, or fracture (significant trauma, osteoporosis, long-term steroid use, unexplained weight loss, fever, night pain).
• Failure to improve after an appropriate course of conservative care around 6–12 weeks where the result would genuinely alter the plan, such as considering surgery.
• Following traumatic injury such as a shoulder dislocation or a torn ACL.

Outside these scenarios, guidelines are consistent: for non-specific spinal pain, imaging in the first six weeks rarely helps and often harms. The clinical question should always come first: will this scan change what we do next? If the honest answer is no, the scan is unlikely to help and may well hurt.

When imaging can actively mislead

Here is where the evidence becomes genuinely eye-opening. The “abnormalities” we find on scans are, to a large extent, the normal appearance of a lived-in body.

Low back pain

The most rigorous data come from a systematic review in the American Journal of Neuroradiology, which pooled imaging from 3,110 pain-free individuals. Among people with no back pain at all, disc degeneration was present in 37% of 20-year-olds and 96% of 80-year-olds; disc bulges in 30% of 20-year-olds rising to 84% by age 80; and disc protrusions in roughly 29–43% across the age range. In other words, a disc bulge in a 40-year-old is closer to a grey hair than a diagnosis.

It gets more pointed. A separate systematic review in the European Journal of Pain found that MRI findings do not reliably predict who will go on to develop future low back pain. When a scan cannot even forecast pain, we should be very cautious about assuming it explains present pain. This is exactly why a careful clinical assessment for back pain at our Melbourne CBD clinic starts with your story and your movement, not a referral slip.

Knee MRI and meniscal tears

A systematic review and meta-analysis in the British Journal of Sports Medicine examined the knees of asymptomatic, uninjured adults across 63 studies. The pooled prevalence of cartilage defects was 24% and of meniscal tears 10% overall, with both climbing steeply with age. In adults aged 40 and over with no knee symptoms whatsoever, meniscal tears were present in around 19% and cartilage defects in as many as 43%.

The clinical consequence of over-reading these findings is significant. A systematic review and meta-analysis in the British Journal of Sports Medicine on arthroscopic partial meniscectomy (surgery to trim a torn meniscus) found no clinically meaningful, lasting benefit over non-surgical care for degenerative tears. Multiple trials show structured exercise therapy performs just as well. When an incidental meniscal tear on MRI becomes the trigger for an operation that the evidence says will not help, the scan has done real harm.

Hip MRI

The hip tells the same story. A systematic review in Arthroscopy pooling 2,114 asymptomatic hips found cam-type morphology in 37% (over half of athletes), pincer morphology in 67%, and labral tears in around 68% of pain-free hips imaged on MRI. A separate comparison study in the Journal of Magnetic Resonance Imaging found cartilage or labral defects in 57% of asymptomatic volunteers. A labral “tear” on your hip MRI, on its own, tells us remarkably little about whether it is the source of your pain.

Shoulder MRI

Rotator cuff findings are perhaps the clearest example of imaging outpacing symptoms. A systematic review and pooled analysis in the Journal of Shoulder and Elbow Surgery of more than 6,000 shoulders found rotator cuff abnormalities rising from under 10% in people aged 20 or younger to over 60% in those aged 80 and above, with the same increase whether or not the shoulder hurt.

A more recent 2025 systematic review in the Journal of Orthopaedic & Sports Physical Therapy confirmed that tendinopathy, partial-thickness tears, and even full-thickness tears are common in shoulders that feel perfectly fine. For a large proportion of people over 50, a rotator cuff tear is simply a normal feature of an ageing shoulder, it is not automatically the reason it aches.

Hamstring injuries

This is a favourite talking point in elite sport, because the pressure to name an exact return date is intense and the evidence is humbling. A systematic review in Sports Medicine concluded there is no strong evidence for any single MRI finding that reliably predicts time to return to play after an acute hamstring strain. A study in the British Journal of Sports Medicine found that even intramuscular tendon involvement, often assumed to be a red flag for a long lay-off, has only limited value for predicting return-to-play time. And a further systematic review in the British Journal of Sports Medicine found no strong MRI predictor of re-injury risk either.

MRI still has a role in confirming a hamstring diagnosis and ruling out avulsion, but the timeline and the re-injury risk are best judged by clinical progress including pain, strength, and performance on functional testing, not by the appearance of the scan. This is where our background in sports and exercise medicine, including point-of-care diagnostic ultrasound and criteria-based return-to-run and return-to-play protocols, earns its keep.

Osteoarthritis

We are conditioned to equate “bone on bone” on an X-ray with severe pain and an inevitable joint replacement. The data disagree. A systematic review in BMC Musculoskeletal Disorders that summarised the literature on knee osteoarthritis found a striking mismatch between what X-rays show and what people feel: among those with knee pain, only 15–76% had radiographic osteoarthritis, and among those with clear radiographic osteoarthritis, only 15–81% reported pain. Joint-space narrowing and osteophytes are real, but they are a weak guide to symptom severity, and they do not, on their own, dictate who needs surgery.

This matters enormously for how we counsel patients. Many people with significant radiographic changes stay active and comfortable with the right loading and strengthening programme, while others with mild change report considerable pain driven by factors the scan never captures, deconditioning, sleep, stress, and central sensitisation.

Will loading a “damaged” joint wear it out?

This is the question that matters most once a finding turns up: if there’s a tear or some wear in there, won’t running, lifting, or playing simply grind it away? The best evidence points firmly the other way.

Start with the mechanism. In this marathon study, not only did most runners carry asymptomatic knee damage before training, after the marathon the subchondral bone of the main weight-bearing surfaces actually improved rather than deteriorated. Loading did not destroy the joint; it appeared to help it adapt.

At the population level, a systematic review and meta-analysis in JOSPT pooling over 114,000 people found hip or knee osteoarthritis in just 3.5% of recreational runners, versus 10.2% of sedentary controls, indicating recreational running was associated with better joint health, not worse. A separate meta-analysis in the American Journal of Sports Medicine found runners had roughly half the odds of eventually needing knee osteoarthritis surgery (pooled odds ratio 0.46).

The most striking evidence though, concerns people who already have osteoarthritis, precisely the patients usually told to give up impact and switch to “joint-friendly” low-impact exercise. A 2026 study in the British Journal of Sports Medicine followed 17,661 people with hip or knee OA in Denmark’s GLA:D registry. Those who took part in high-impact physical activity had 36–48% lower odds of needing a total hip replacement over the following year, and no increase in the risk of total knee replacement — with little sign that pain, function, or fear of “damaging” the joint explained the difference. Contrary to the standard advice, high-impact activity was not wearing these arthritic joints out.

Two honest caveats keep this rigorous: these are observational data, so we cannot fully separate cause from confounders such as body weight or prior injury; and the reassuring signals relate to recreational and moderate participation, with the picture for extreme, very high-volume loading less certain. But the practical message for a patient holding a scan report, even one showing established osteoarthritis is robust, an incidental or age-related finding is not, on its own, a reason to stop moving. Wrapping a joint in cotton wool is the wrong response to a frightening-sounding scan. Appropriately graded, progressive loading matched to your symptoms, capacity, and goals is one of the best things you can do for long-term joint health.

Why history and examination remain the gold standard

If scans over-call findings, what actually gets us to the right answer? The same thing it always has: a skilled clinical assessment.

A thorough history establishes the mechanism, the behaviour of the pain (what aggravates and eases it), the 24-hour pattern, the training and load history, previous episodes, and the psychosocial context, plus a deliberate screen for red flags. A targeted physical examination then localises and stress-tests the suspected structures: range of motion, strength, specific provocation tests, neurological screening, and, importantly, how the whole kinetic chain moves under load.

The reasoning behind this sequence is what separates a diagnosis from a label. A clinician builds a short list of plausible explanations from the history, then uses the examination to raise or lower the probability of each. Reproducing the pain with one test, clearing a structure with another, checking that the neurological system is intact. When a scan is finally ordered, it is asked a specific, pre-formed question (“is there a full-thickness supraspinatus tear that explains this weakness and night pain?”) rather than an open-ended one (“show me everything that might be wrong”).

An open-ended scan on a lived-in body will always find something; a targeted scan is there to rule in or rule out something that will change the patient’s management. This is what clinicians mean by clinical correlation and it is precisely the step that gets skipped when a scan is ordered before anyone has taken a proper history.

A Clinical Example of How Imaging Can Over Call An Injury

Consider a 45-year-old recreational runner with medial knee pain. An MRI will very likely show a degenerative meniscal tear and some cartilage wear, findings present in roughly one in five pain-free adults of the same age. Blame the tear, and the logical next step is arthroscopy, which the evidence says will not help. Take a history instead, and a different picture emerges: a 40% jump in weekly mileage three weeks ago, weak hip abductors, and worn-out shoes. The tear was an incidental passenger; the load error was the driver. Only one of these explanations leads to a treatment that works.

Done well, this process generates a working diagnosis and, just as importantly, a picture of why the problem developed. The training error, the strength deficit, the movement pattern, the equipment or technique fault. Imaging, when it is needed at all, is then used to confirm or refute a specific clinical hypothesis, not to go fishing for something to blame. That is the difference between imaging that helps and imaging that misleads.

The lazy alternative, scan first, think later, treats the picture instead of the person. It finds an incidental tear or bulge, attaches it to the pain by coincidence of timing, and sends everyone down a path that the best evidence says is often unnecessary. At Shannon Clinic we integrate clinical assessment with training-load monitoring and functional testing precisely because that combination, not a scan in isolation, is what reliably gets Melbourne’s athletes and professionals back to what they love. You can read more about how chiropractic and exercise-based care addresses pain and about Dr. Shannon’s sports medicine background.

What to ask before you request an MRI

If you are wondering whether you need a scan, these four questions cut through most of the noise:

1. Will the result actually change my treatment? If the plan is the same regardless of what the scan shows, the scan is unlikely to help.
2. Are there red flags, or have I failed a fair trial of conservative care? These are the situations where imaging genuinely earns its place.
3. What are the risks of finding an incidental “abnormality”? A finding unrelated to your pain can generate worry and unnecessary intervention.
4. Have we tried evidence-based rehabilitation first? For most musculoskeletal pain, load management and graded exercise are the front-line treatment.

Key take-home messages

• Imaging “abnormalities” are common in pain-free people and increase with age; often they are normal ageing, not damage.
• No scan directly shows pain; structure and symptoms are frequently mismatched.
• For most spinal, knee, shoulder, and hip pain, early or routine imaging does not improve outcomes and can lead to over-treatment.
• MRI does not reliably predict hamstring return-to-play time, and X-ray osteoarthritis severity correlates only weakly with pain.
• A careful history and examination by an experienced sports chiropractor or clinician with selective, question-driven imaging, is the foundation of accurate diagnosis and effective care.

Frequently asked questions

Does everyone with back pain need an MRI? No. Leading guidelines from the American College of Physicians and NICE recommend against routine imaging for non-specific low back pain when there are no red flags, because it does not improve outcomes and can lead to unnecessary treatment.

My MRI shows a tear, does that mean I need surgery? Not necessarily. Meniscal tears, rotator cuff tears, and hip labral tears are all common findings in people with no pain at all. High-quality trials show that surgery for degenerative tears often provides no lasting benefit over structured exercise. The decision depends on your clinical picture, not the scan alone.

Can a sports chiropractor help without a scan? Yes, and often more effectively. A thorough history and examination usually identifies the pain source and its underlying drivers (load, strength, movement, technique), allowing targeted rehabilitation to begin straight away. Imaging is used only when it will change the plan.

If the scan doesn’t explain my pain, what does? Pain is produced by your nervous system and influenced by tissue load, training history, sleep, stress, and prior experiences, not by a single structural finding. That is why two people with identical scans can have completely different symptoms.

Where can I see a trusted sports chiropractor in Melbourne CBD? Shannon Clinic, located at Suite 9.16, Level 9, 220 Collins Street, Melbourne, specialises in evidence-based sports and musculoskeletal care. The clinic is led by Dr. Nicholas Shannon, a sports and exercise medicine chiropractor with a 9+ year history as a provider at the Australian Open, an AICE Fellowship, and peer-reviewed sports medicine publications. The clinic prioritises accurate clinical diagnosis over reflexive scanning.

Concerned about pain, or unsure whether you really need a scan? Book an assessment with our Melbourne CBD sports chiropractic team and get a clear, evidence-based plan. Book now.

This article is for general education and is not a substitute for individual clinical assessment. If you have red-flag symptoms — significant trauma, progressive weakness or numbness, saddle numbness, or bladder or bowel changes — seek urgent medical care.