You Don't Need an MRI for Every Backache: What a Physiotherapist Looks For First

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An estimated 619 million people worldwide were living with low back pain in 2020, and it is the leading cause of disability worldwide, according to the Global Burden of Disease analysis published in The Lancet Rheumatology. When the pain is severe or keeps returning, many people ask the same question: should I get a scan?

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The instinct is understandable. An MRI feels like it should provide a clear answer. But a scan is not always the first thing needed to understand what is going on, and in many cases it is not the most useful one.

Dr Michael Manoj Chinnam PT, Consultant Physiotherapist and HOD - Physiotherapy and Rehabilitation at KIMS-Arete Hospital, explains what a physiotherapist looks for first, which warning signs need urgent attention, and when imaging genuinely helps.

Why Back Pain Doesn't Always Need An MRI

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"When someone walks into my clinic with back pain, one of the first things they sometimes tell me is, 'I think I need an MRI.'"

"I understand why. Back pain can be frightening, particularly when it is severe or keeps returning. An MRI feels like it should provide an answer. But a scan is not always the first thing I need to understand what is happening," said Dr Chinnam.

In many cases of uncomplicated back pain, the clinical examination tells me far more about what the person needs at that moment than a scan does.

Step One: How The Back Pain Behaves

"First, I want to know how the pain behaves. I will ask when the pain started, what brought it on, whether it is getting better or worse, and what makes it easier or more difficult," shared Dr Chinnam.

Is it worse after sitting for several hours? Does walking help? Does bending forward hurt? Does turning in bed trigger it? Did it begin after lifting something heavy, or did it appear without an obvious reason?

These details help distinguish different patterns of musculoskeletal pain and tell me how the problem is affecting movement.

Step Two: How You Move

"Then I look at how you move. This is a part of the assessment that an MRI cannot replace," added Dr Chinnam.

The expert watches you walk, bend, straighten up, squat or get up from a chair. They look at whether your movements are restricted, whether you are avoiding a particular direction because of pain and whether other parts of the body are compensating.

Sometimes the problem is not simply "the back". Reduced hip movement, poor trunk control, prolonged static postures or changes in the way someone moves can all contribute to back pain. Physiotherapy can play an important role in this process by assessing movement and function, guiding appropriate exercise and helping patients progressively return to their normal activities.

Step Three: Strength, Sensation And Reflexes

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"I check strength, sensation and reflexes when needed. If the pain is travelling down the leg, particularly with numbness, tingling or weakness, the examination becomes more detailed," said Dr Chinnam.

"I may assess muscle strength, sensation and reflexes to look for signs of nerve involvement. This helps determine whether what appears to be ordinary back pain could actually involve irritation or compression of a nerve," he added.

This is also where the decision about further medical evaluation or imaging becomes more important.

Back Pain Red Flags That Need Urgent Attention

Red flags should not be ignored. Not every backache is a mechanical problem, and this is where a good assessment matters. The following can require urgent medical assessment:

• A history of cancer
• Significant trauma
• Unexplained weight loss
• Fever or symptoms suggesting infection
• Severe or progressive neurological problems
• New problems with bladder or bowel control

In such situations, the answer is not to simply start physiotherapy and wait. The patient may need further investigation, including imaging, depending on the clinical findings.

What An MRI Can Show, And What It Cannot

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"An MRI can show a lot, sometimes more than we need to know. One reason I don't send every patient for an MRI is that scans can show changes that are not necessarily responsible for the pain," highlighted Dr Chinnam.

Disc bulges and degenerative changes, for example, can occur in people who have little or no back pain. Finding an abnormality on a scan does not automatically tell us that it is the cause of someone's symptoms.

This can sometimes make people more anxious about their back and lead them to believe that normal movement is dangerous when it may not be.

The purpose of an MRI should therefore be more than simply finding something abnormal. The question should be: will knowing this change what we do for the patient?

What the research says

A systematic review of 33 studies covering 3,110 people without back pain found that disc bulges were present in 30% of 20-year-olds and 84% of 80-year-olds, and disc degeneration in 37% and 96% respectively. Its authors concluded that many such findings are likely part of normal ageing and should be read alongside the patient's clinical condition.

The review, published in the American Journal of Neuroradiology, does not mean scan findings never matter. A separate meta-analysis found some disc changes are more common in adults aged 50 or younger who have back pain, though it stressed these findings do not prove they are the source of pain. This is why results have to be read together with the examination. American Journal of NeuroradiologyKaiser Permanente Division of Research

What Happens Instead Of An MRI?

"For many people, the first step is a proper clinical assessment followed by an appropriate management plan. This may involve advice on activity, exercises, improving movement, addressing contributing factors and gradually returning to normal function," explained Dr Chinnam.

If the pain is not improving as expected, is worsening, or the examination raises concerns, the treatment plan needs to be reassessed. At that point, further investigations or referral to a specialist may be appropriate.

An MRI is an extremely useful tool when it is needed. The point is not to avoid it. The point is to use it for the right patient, at the right time, for the right reason.

Bottomline

Dr Chinnam concluded, "Back pain deserves to be taken seriously. But serious attention does not always mean immediately getting a scan. Sometimes the most useful diagnostic tool is still a careful conversation, a clinical examination and watching how the person actually moves."

Disclaimer: The information provided in this article is for general informational and educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or a qualified healthcare provider with any questions you may have regarding a medical condition.