Why a Normal MRI Report May Be an Increasingly Dangerous Thing…

by Chris Centeno, MD /

what is nociplastic pain

We see patients every day who have normal MRI’s and pain and patients who have abnormal MRI’s and little pain. I’ve blogged about this extensively. Given that, for orthopedic imaging, a well-trained and observant physician can usually find more than the reading radiologist and also knows where to look, reading the MRI personally is a key part of establishing a diagnosis. Regrettably, most of my colleagues don’t read their own films and rely on the radiology report. This morning I’ll show you why this is a problem and also talk about how changes in pain nomenclature will make the lives of pain patients everywhere much worse. In essence, by trying to seek a simple label, one large organization is creating a way for armies of providers to misdiagnose patients.

First, an Example of Why Relying on the Radiology Report Can Be a Bad Idea…

The patient I’d like to introduce today has turned his left ankle a few times and has recently begun to get lateral ankle pain. He underwent an MRI, which was read out by the radiologist as normal, so based on the report, there’s nothing wrong with that ankle. Right? Wrong! In fact, actually performing an exam, looking at the images, and performing additional stress imaging shows that the radiologist completely missed the diagnosis.

First, the MRI image below is looking at the front of the ankle and shows a mix of the calcaneofibular and talofibular ligament. These are outside ankle ligaments that hold the joint together and are commonly sprained. These ligaments are outlined by the yellow arrowheads:

The blown-up area on the right defines those ligaments with the dashed yellow lines. They are further highlighted by the yellow arrowheads. A normal ligament should be uniformly dark. However, notice the white areas in the triangle-shaped ligament. These are not normal and suggest that there may be small tears in the ligament.

New Imaging Technologies Find the Problem

The ligaments that hold your joints together are like pieces of strong duct tape. The most accurate way to find out about if they’ve been damaged is simple and the same way you would test two blocks if you had taped them together. You would try to move one block on the other to determine if the duct tape was holding. While you could also inspect the duct tape by looking at it, the best test is always to stress the bond to see if it’s strong. The same holds true with the ligaments in your body.

Taking an MRI of a ligament gives you a picture, as above. By more carefully inspecting the ligament on the image, it looks like there may be a damaged ligament. However, if I really want to see if the ligament has an issue, I have to stress it. To do this, ultrasound works well. I can see the ligament and the bones while I try to pry them apart. This is what I did below:

Note that I have what looks like two mountains separated by a valley. Each mountain is actually a bone labeled with a letter (“F” for fibula and “C” for calcaneus). The ligament lives in the valley and is labeled “L” for ligament. On the left, the two mountains come apart as I try to pry the bones apart. This is NOT normal and represents a damaged ligament consistent with the MRI image. The two mountains on the right don’t come apart, so this is a normal ligament on his asymptomatic side.

In summary, this guy never really had a normal MRI. His ligaments are clearly damaged. In the past, this was just bad medicine and could be written off as problems with an imperfect care system. However, now one of the major pain-management organizations wants to rewrite the nomenclature that would describe what’s wrong with this guy. This will take his missed diagnosis from a nuisance to a big problem. Why? The new naming system will blame it all on his overactive nerves, giving him a new false diagnosis and ensuring that his ankle slowly deteriorates into severe arthritis over the next decade. Let me explain.

The New Nomenclature

The IASP is an international organization that is largely an academic group of pain researchers. As I have blogged, there’s a bizarre new twist on the 1980’s concept that chronic pain is “all in the head.” Due to new research confirming that some patients in chronic pain have overactive nerves and the fact that this can be treated with expensive drugs, pharma, coming off hits like the nerve-pain drug Lyrica, has been pushing for more patients to be classified as having overactive nerves. In addition, physical therapists who are profiting off the lucrative medical education market have begun to teach a generation of providers that if patients have overactive nerves, all they need is psychological counseling to solve their perceived disability. So we have a perfect storm setting up a change in how to diagnose pain.

The new term proposed by IASP is nociplastic pain. This is the definition:

“Nociplastic pain*
Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.”

Yikes, that’s some super-dense researcher speak, so let me translate. In patients who don’t have a clear diagnosis of why they hurt, the doctor can label them as having overactive nerves. I’m hoping that you can see how this impacts our patient with the normal ankle MRI whose ankle hurts when he walks. Given that few physicians would have ever known to perform a stress ultrasound exam of his ankle and almost all would have believed the radiology report that there was nothing wrong (and never looked at the images themselves), our poor patient would have eventually been labeled with nociplastic pain. He would have either been placed on nerve-pain medication or sent to a physical therapist to talk him out of pain. In the meantime, all he really needs is a precise guided injection of PRP to help heal the damaged ligament. In addition, if the ligament stays lax because of a missed diagnosis, his ankle joint will eventually get damaged and become arthritic. So you get the picture of how this new term is very dangerous for patients whose doctors will think that a normal MRI equals no problems and who never take the time to investigate further.

The upshot? We don’t need more terms for pain. We need to educate providers on how to diagnose what’s wrong with the musculoskeletal system. In the meantime, if your doctor can’t read an MRI in front of you or doesn’t know how to use ultrasound, you need to run!

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20 thoughts on “Why a Normal MRI Report May Be an Increasingly Dangerous Thing…

  1. DavePG

    Another interesting report, Dr. Centeno. Question: generally speaking, about how long do radiologists, and other physicians for that matter, review MRIs and other diagnostic tests for common injuries and conditions? The reason I ask is because I’ve visited doctors in my HMO network and get the sense that they spent at most around 30-60 seconds or so (with an office visit that lasts about 15 minutes).

    1. Regenexx Team Post author

      DavePG,

      Your experience is the norm in today’s medical system. Most physicians don’t read the MRI at all- just the report, and if they do just a cursory look looking for what the radiologist stated in the report. Please see: https://regenexx.com/blog/the-least-common-denominator-paradox/

  2. JJ

    Excellent explanation, including the use of video to help create a mental picture for the layperson. We need more real healers and healing information as presented here. Thank You!

    1. Regenexx Team Post author

      Thanks JJ!

  3. Sam

    Grateful for the warning regarding FAKE TERM “Nociastic pain”. Another repugnant attempt by pseudo-experts on big pharma / insurance industrial complex payola to conceal the truth and mislead for pursuit of profit. This is indeed an antisocial behaviour that must be neutralized to protect public’s safety. Nothing is more effective than educating the public. Thanks for being a teacher.

  4. Patty

    So physical therapists are now doubling as psychologists?
    “In addition, physical therapists who are profiting off the lucrative medical education market have begun to teach a generation of providers that if patients have overactive nerves, all they need is psychological counseling to solve their perceived disability”…
    … “sent to a physical therapist to talk him out of pain.”

  5. Iggy Gaurd

    Boy, you hit the nail on the head with this one. I’ve had multiple occurrences of sloppy diagnosis because, frankly, most doctors are poorly trained in the craft, and they just want to turn it over to someone else. They don’t dig any deeper than what can be gleaned from a cursory look. Thoughtful and careful diagnosis is almost non-extent. For many doctors, if the diagnosis is not a blaring horn, then there is nothing wrong- the patient is suffering from anxiety and/or depression, and now we have a new junk diagnosis- noviplastic pain. Who comes up with this garbage?

    I have always thought it was sheer stupidity to have a medical discipline like radiology where a diagnosis is made by someone with out ever examining the patient, and without a way for the diagnoser (radiologist) to find out whether his diagnosis is in fact accurate by seeing things through to the end. Medicine is a craft (I prefer that word over art), and all aspects of it must be practiced to be good at it. The way we practice these days is really a joke. I estimate that patients are accurately diagnosed less than 65% of the time. That is deplorable, and it is all due to fractitious affect of specialization – throw it over the wall to someone else and just assume they do a good job. It really is shameful because it reeks of the attitude than convenience and income trump perfect care. The patient comes last. I applaud your comprehensive and practical approach. I applaud your willingness to fight the tide and to put the patient first.

    I am glad there are still few intelligent doctors like you, Dr. Centsno, who are willing to dig deeper to get to the truth. Keep on blogging and writing papers. It’s the only hope we have of keeping the medical profession from going completely down the toilet.

    1. Regenexx Team Post author

      Thanks Iggy! Its frightening and frustrating for patients and Doctors alike. Please see: https://regenexx.com/blog/steady-decline-good-doctoring/ and https://regenexx.com/blog/the-least-common-denominator-paradox/

  6. Julie

    this makes me furious bc it is ABSOLUTELY TRUE!!!!! this just happened to me the other day!! a doctor read to me my MRI report, which was only what the radiologist said. and he scrolled through it scolding me saying “look, NO THIS, NO THAT, NO THIS, etc.” without even taking a breath! he just read what it said, like no slipped discs or no stenosis and basically he said no to everything. which is absurd bc i have previously diagnosed conditions for the last 10 years! by multiple other doctors! they have all seen my pain problems, but this idiot Dr. Lesneski from R A Pain Management in Mt Laurel NJ wasHORRIBLE!!!! i have been bed ridden for over 5 years now, in horrible pain, and he said there was absolutely nothing wrong with me except a bit of arthritis which none of my drs before ever said that to me! so thats a NEW condition!!! i moved here from out of state and found out that bc of previous governor Chris Christie, he put absolutely ridiculous laws in place in order to take everyone in NJ off of their pain medication!!!!! So I moved here from 18 hours away, unknowing to this problem, and had to stop all of my medications cold turkey and went into really bad withdrawal and cannot get the help I need anywhere here. These idiot doctors need to get their medical licenses revoked. I wish they felt the pain I feel and they were denied treatment. They have no idea what patients go thru on a daily basis!!! He didnt even examin me!!!! smh. just horrible.

  7. em

    Hi I am not too sure what to say , fell up a stair 4 years ago and have had x2 MRI scans + xrays on my ankle . No Arthritis detected , my ankle still in pain and has slowly inverted now slowly going flat footed . I have never before had so much pain and still think I do have a fracture BUT NOTHING SHOWS UP, my foot underneath is now aching , top of arch is now feeling compressed , second toe is feeling numb and getting spasms down/up my calf. Always been fit , Running/walking 10 miles a day have made professionally in soles but ankle does not connect to help from this still collapsing in while foot wants to be ok it seems they are fighting each other, in the morning can hardly walk and hobble during day and have to ask some one to pull my foot out from my ankle . When done ok to walk after large click sound used to last for a week or so but now gone down to a day or so, my knee is hurting too please help thanks for your time em

    1. Regenexx Team Post author

      em,

      We’d need to examine you. Where are you located?

  8. Tara

    How do you explain MRI’s with “positive” findings in people who are asymptomatic? I don’t believe we can really create a dichotomy between “patho”-anatomy and the nervous system, do you? I have never met a patient with an orthopedic complaint that didn’t have a complex nervous system. People are not machines. Please be careful in your interpretations and reporting of what other researchers are looking at.

    1. Regenexx Team Post author

      Tara,
      There are many things found on MRI that cause great pain in some patients, and no pain in others. Surgical decisions are all too often made based on MRI without determining the MRI finding is the source of the pain, and on the opposite end of the spectrum, patients with no MRI findings who have great pain are all too often told the pain is in their head, or prescribed opioids. This is simply because the structural paradigm of pain is flawed. Please see:https://regenexx.com/blog/the-orthopedic-structural-paradigm-is-dead/ and https://regenexx.com/blog/osteoarthritis-pain-not-related-to-structure-again/ and https://regenexx.com/blog/modern-orthopedic-surgery-for-pain/

  9. wes cormick

    As well as radiologist error, many radiologists buy into this idea of the inerrancy of imaging. However imaging is fallible and may get in wrong. Black and white images are not the same as pathology and do not necessarily represent pain. I am a retired sonologist and we implemented a technique of ‘pain-mapping’ for difficult cases where we would gently needle the structures to see which were painful and which were not and grade them on a scale of 1-10. It is very helpful in complex cases. See here halfway thru the article: http://www.aspetar.com/journal/viewarticle.aspx?id=130#.Wth5Zy5uapo

  10. Sofia Weisz

    I am in 7th grade. About 4 months ago, I went to the doctor for a left ankle fracture and 2 degree ligament sprain. They put me on crutches for 6 months and in an aircast boot. Then, I was still in a lot of pain so I got another MRI which only showed some bone bruising and contusions. My ankle is still swollen, tender, and I have sharp pain consistently in one area so the diagnosed me with crps. I have not improved with therapy exercises over the last month, and pain has gotten worse. Plus, all of my pain symptoms are of a badly torn ligament, says the physical therapist. What do I do? pls help.

    1. Chris Centeno Post author

      Sofia, in a patient like this, my first focus would be on making sure that there has been no nerve damage (CRPS type 2). Regrettably, tests like EMG are not sensitive in this regard, but sometimes an experienced physician who uses ultrasound can see issues in the nerve. Treatment for us is usually platelet lysate hydro dissection, see https://regenexx.com/blog/new-crps-treatments/ and https://youtu.be/TK757uOc0Js

  11. Jesse

    I just had 2 mri. One for cervical spine and one for my ankle. Both came back normal. I know I am not normal. I just want a proper diagnosis so I can be treated effectively and get on with my life. I am beyond the moon upset. I just paid for 2 mri. I could have went on a vacation for that price, still would be in pain not knowing but at least I would have had a sweet vacation.

    1. Regenexx Team Post author

      Jesse,
      Unfortunately, there is not a lot of thorough diagnosis that goes on today. But that’s actually a better outcome than if they had seen “the shiny object on the MRI”, that had nothing to do with your pain, and subjected you to unnecessary surgery which would have made your situation worse! What symptoms lead to the MRI’s?

  12. Lisa M.

    Hello and thank you so greatly for your wonderful blog article. I look forward to finding more of your writings online. I am an overly-educated patient with much medical training, having worked in aeromedical evacuation, but being born with Ehlers-Danlos (classical type), followed by a lifetime of both near-fatal traumatic injuries and numerous other medical diseases and conditions (many autoimmune, adrenal insufficiency, etc.). I landed here looking for more information on why I rarely MRI accurately, wondering if my genetic collagen and connective tissue defects could be affecting my results. Prior to the invention of MRIs, as a very young child I would have what I much later found out to be ligament tears where I would ben sent back to school, play and even sports on injuries such as ACL tears, badly sublexed joints and more. To this day I do not seem to “image well“ on MRI – – but I have learned that because I am always placed in a neutral position, my hypermobility is never accounted for, such as with my neck where only my body anatomy stops my neck ROM, for example. Open/weight-bearing MRI has been helpful to some degree for both spinal and lower extremity imaging, but significant injuries have been missed even in recent years. While I do have substantial hardware literally from head to toe that creates some artifact, I believe the greater issue is the neutral positioning, and will look to ultrasound and other techniques in the future, with great credit to your documentation here.

    In general, whether laboratory, MRI or other results – – my experience is that most physicians unfortunately do not take the time in today’s world of short insurance-regulated visits to dig for answers, relying on flags and concrete imaging findings. Having faced a lifetime of being questioned based on things like MRI findings that relied on a single radiologist’s report ( rarely even independently looking at the MRI disk itself) , resulting in lasting pain and injury that may have been to some degree preventable, your article shedding more light on this issue was very reassuring.

    On a brief sidenote to my reply, I was sent to a physical therapist who did PME (pain neuroscience education) which is the same basic theory and practice as the nociplastic thinking you mentioned. They were insistent I needed to only think about my pain differently to get rid of it, missing a serious problem at C2, causing what became a permanent nerve-related injury affecting the whole left side of my face. (This sadly was even with positive MRI findings.) While I agree that the nervous system and even brain functioning can be affected by a lifetime of chronic pain, this was truly not the right approach in this case.

    Many thanks for your helpful article!

    1. Regenexx Team

      Hi Lisa,
      Glad you found it helpful. Getting the right treatment, can unfortunately, be very challenging. For spinal issues, DMX, (Digital Motion X-ray) can be helpful. We are familiar with EDS, as many of our CCJ Instability patients have Ehlers Danlos Syndrome. Please see: https://regenexx.com/blog/new-ccj-instability-trial-begins/

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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