Most people who come to the office with a scan have already read the report, and the report usually lists several findings: a bulging disc, a degenerative tear, a labral abnormality, a partial-thickness tendon tear, cartilage thinning. Those words describe what the radiologist saw. They do not, on their own, say what is causing the pain, and they do not say whether anything needs to be done about it.
The reason is well documented. When researchers scan large groups of people who have no symptoms at all, they find the same list. The studies summarized on this page, drawn from peer-reviewed studies of people without symptoms, show that disc degeneration, meniscal tears, rotator cuff tears, hip labral tears and many other findings are present in a large share of pain-free adults, and that nearly all of them become more common with each decade of life. In many joints the finding is closer to a normal feature of an adult body than to an injury.
Dr. O'Donnell uses that literature every day, in two directions. It means an abnormal scan in a patient with no symptoms is usually left alone. It also means that in a patient who does have symptoms, the finding on the scan has to be matched against the history and the examination before it is blamed, and that surgery is recommended for the problem the patient actually has, not for the report. The sections below give the figures joint by joint. Each condition page on this site carries the same information in more detail.
Headline figures
A selection of the largest studies of people with no symptoms, showing how the prevalence of common findings changes with age. Study types and cohort sizes are given so the scale of the evidence is clear.
| Finding | People with no symptoms | Age trend | Source |
|---|---|---|---|
| Lumbar disc degeneration on MRI | 37% of 20-year-olds; 96% of 80-year-olds | Rises every decade | Systematic review of 33 studies, 3,110 people |
| Lumbar disc bulge on MRI | 30% at age 20; 84% at age 80 | Rises every decade | Same systematic review |
| Lumbar disc protrusion on MRI | 29% at age 20; 43% at age 80 | Rises with age | Same systematic review |
| Cervical disc bulging on MRI | 87.6% of 1,211 volunteers aged 20–70 | Rises with age | Prospective volunteer study, 1,211 people |
| Rotator cuff tear on MRI | 34% overall; 54% of those over 60 | Rises with age | MRI study of 96 volunteers |
| Full-thickness rotator cuff tear on ultrasound | 23% overall; 51% of those over 80 | 13% in the 50s to 51% in the 80s | Ultrasound study of 411 shoulders |
| Meniscal tear on knee MRI | 19% of women aged 50–59 to 56% of men aged 70–90; 61% of tears caused no symptoms | Rises with age | Community MRI study, 991 people |
| Any abnormality on knee MRI, age 50 and over | 89% of 710 people without radiographic arthritis | — | Community MRI study, 710 people |
| Hip labral tear on MRI | 69% of 45 volunteers (mean age 38) | Rises with age | Blinded MRI study, 45 volunteers |
| Cam morphology of the hip | 37% of asymptomatic hips; 55% in athletes | — | Systematic review, 2,114 hips |
| TFCC (wrist cartilage) perforation | 0% in the 20s to over 50% in the 60s | Rises every decade | Anatomic study of 180 wrists |
| Thumb base (CMC) arthritis on X-ray | 91% of people over 80 | Rises with age | Radiographic series of adult hands |
| Abnormal nerve conduction study, no symptoms | 18.4% of 125 symptom-free controls | — | Population study, 125 symptom-free controls |
Spine Joint overview →
Degenerative Disc Disease
Disc degeneration on MRI is the expected appearance of an aging spine, not a disease in itself. In a systematic review of 33 studies covering 3,110 people with no back pain, disc degeneration was present in 37% of 20-year-olds and 96% of 80-year-olds, disc bulges in 30% rising to 84%, facet joint degeneration in 4% rising to 83%, and spondylolisthesis in 3% rising to 50%. In 98 people who had never had back pain, only 36% had a normal disc at every lumbar level, and in 67 people who had never had back pain or sciatica, every subject but one aged 60 to 80 had disc degeneration or bulging at at least one lumbar level.
Full figures and references on the Degenerative Disc Disease page →
Disc Herniation
Disc bulges and protrusions are common in people with no back or leg pain at all. In 98 people who had never had back pain, 52% had a disc bulge at one or more levels, 27% had a protrusion and 1% an extrusion, and 38% had more than one abnormal disc. In 67 people with no history of back pain or sciatica, a herniated nucleus pulposus was found in 20% of those under 60 and 36% of those 60 and over.
Sciatica
Sciatica is a clinical diagnosis made from the pattern of leg pain and the examination, and the disc findings that are usually blamed for it are common in people who have never had leg or back pain. In 98 people with no history of back pain, 52% had a disc bulge, 27% a protrusion and 1% an extrusion, and in 67 people who had never had back pain, sciatica or claudication, a herniated nucleus pulposus was present in 20% of those under 60 and 36% of those 60 and over, with spinal stenosis in 21% of the older group. Across 33 studies of 3,110 asymptomatic people, disc protrusion was present in 29% at age 20 and 43% at age 80.
Stingers / Burners
A stinger (burner) is a transient traction or compression injury of the brachial plexus or cervical nerve root diagnosed from the story of a brief one-arm burning pain and weakness after a collision; it is not an imaging diagnosis, and there is no asymptomatic-prevalence literature for the stinger itself. Two kinds of imaging finding come up after a stinger and both are common in athletes and adults who have never had one. First, a 'narrow' cervical canal: in 224 professional and rookie football players, 32% of professionals and 34% of rookies had a Torg (canal-to-vertebral-body) ratio below 0.80 at one or more levels, in a group that was playing without symptoms; in 266 collegiate football players, a Torg ratio below 0.8 was present in 25.1% of players who never had a stinger, 32.3% of those with time-loss neck pain and 47.5% of those with a stinger, so a ratio below 0.8 roughly tripled the risk but most players with it never had a stinger; and in a prospective collegiate cohort the Torg ratio had no relationship to whether a player ever had a first stinger, only to recurrence (0.75 vs 0.87), leading the authors to propose 0.70 as a more meaningful threshold.
Full figures and references on the Stingers / Burners page →
Shoulder Joint overview →
Rotator Cuff Tear
Rotator cuff tears are extremely common in people who have no shoulder symptoms, and their frequency climbs steadily with age. In 96 asymptomatic volunteers who had shoulder MRI, 34% had a tear (15% full-thickness, 20% partial); among those over 60, 54% had a tear, versus a single partial tear among those aged 19 to 39. In 411 asymptomatic volunteers examined by ultrasound, a rotator cuff tear was found in 23% overall, rising from 13% in the 50s to 20% in the 60s, 31% in the 70s and 51% over 80.
Shoulder Impingement & Bursitis
The ultrasound and MRI findings usually attributed to 'impingement' or 'bursitis' - a thickened subacromial bursa, tendinosis of the supraspinatus, a curved or hooked acromion and subacromial spurs - are the norm in middle-aged and older people without any shoulder symptoms. In 51 men aged 40-70 with no symptoms in either shoulder, ultrasound was abnormal in 96%: subacromial-subdeltoid bursal thickening was present in 78%, supraspinatus tendinosis in 39%, subscapularis tendinosis in 25% and a bursal-sided partial-thickness supraspinatus tear in 22%. On MRI of 100 asymptomatic volunteers aged 19-88, one-third had subacromial spurs and joint fluid was seen in nearly all subjects.
Full figures and references on the Shoulder Impingement & Bursitis page →
AC Joint Injury
Degenerative change, joint-space narrowing, osteophytes and marrow or capsular signal change at the acromioclavicular (AC) joint are so common on MRI that they are essentially a normal finding in adults, and they cannot be used on their own to attribute pain or injury to the joint. In 50 shoulders (42 patients, average age 35, range 19-72) imaged for reasons unrelated to the AC joint and with no AC joint symptoms, 82% had MRI abnormalities consistent with AC arthritis - 68% of those aged 30 and under and 93% of those over 30. On MRI of 100 asymptomatic volunteers aged 19-88, changes characteristic of AC joint osteoarthrosis were present in three-quarters of shoulders, and the authors concluded that AC joint disease alone is not a reliable indicator of pain or tendon disease.
Labral / SLAP Tear
Labral 'tears', including superior labral (SLAP) findings, are reported on MRI in a large proportion of shoulders that have never hurt, especially after the mid-40s and in throwing athletes. In 53 asymptomatic adults aged 45-60 with no history of shoulder injury or surgery, two radiologists read the non-contrast MRI as showing a superior labral tear in 55% and 72% of shoulders respectively, and posterior labral tears in 15% and 55%, with only moderate agreement between readers. In 14 asymptomatic professional baseball pitchers (28 shoulders), the labrum was abnormal on MRI in 79%.
Full figures and references on the Labral / SLAP Tear page →
Shoulder Instability
Imaging findings that are often linked to instability - labral abnormalities, posterior labral (Bennett) lesions and capsulolabral signal change - are common in shoulders that are stable and pain-free, particularly in overhead and contact athletes. In 14 asymptomatic professional pitchers whose shoulders were clinically stable, the labrum was abnormal on MRI in 79% of 28 shoulders. In 20 asymptomatic elite overhead athletes, 25% of dominant shoulders had a Bennett's (posterior glenoid) lesion and 40% had MRI findings of a rotator cuff tear, yet at 5-year follow-up none had symptoms or needed treatment.
Full figures and references on the Shoulder Instability page →
Biceps Tendinitis / Tear
Abnormalities of the long head of biceps are found on ultrasound and MRI in a minority of people with no shoulder symptoms, and they occur alongside the far more common age-related cuff, bursal and AC joint changes. In 51 men aged 40-70 with no symptoms in either shoulder, ultrasound showed long-head-of-biceps tendinosis in 4% (2/51), fluid distending the biceps tendon sheath in 2% (1/51), medial subluxation of the tendon in 4% (2/51), medial dislocation with an empty groove in 2% (1/51) and a complete biceps tendon tear in 2% (1/51), against a background in which 96% of these asymptomatic men had at least one abnormal finding. In 53 asymptomatic adults aged 45-60, neither of two radiologists reported a biceps tendon abnormality on non-contrast MRI, even though they reported superior labral tears in 55-72% of the same shoulders.
Full figures and references on the Biceps Tendinitis / Tear page →
Shoulder Arthritis
Radiographic glenohumeral osteoarthritis becomes common with age and is frequently present without symptoms, so the degree of joint change on an X-ray or MRI does not by itself tell us whether the shoulder hurts. In a 2024 systematic review of imaging abnormalities in asymptomatic adult shoulders (SCRUTINY), 35 studies contributed prevalence data; the two population-based MRI studies (846 shoulders) reported glenohumeral osteoarthritis in between 15% and 75% of asymptomatic shoulders, and the authors concluded that the true prevalence in asymptomatic people is uncertain but may lie between 30% and 75%. In a general-population screening of 541 village residents aged 40-89, radiographic shoulder osteoarthritis was found in 17.4%, rising from 11.1% under 65 to 20.3% at 65 and older, with odds ratios of 5.59 at 60-69, 11.59 at 70-79 and 10.77 at 80 and over.
Full figures and references on the Shoulder Arthritis page →
Frozen Shoulder (Adhesive Capsulitis)
Frozen shoulder is a clinical diagnosis based on painful, global loss of both active and passive motion, and plain X-rays are typically normal; there is no imaging finding whose absence excludes it or whose presence proves it. MR arthrography in 22 patients with surgically confirmed frozen shoulder versus 22 matched controls showed a thicker coracohumeral ligament (4.1 mm vs 2.7 mm) and rotator-interval capsule (7.1 mm vs 4.5 mm), but a coracohumeral ligament of 4 mm or more identified only 59% of cases (specificity 95%) and interval-capsule thickening of 7 mm or more only 64% (specificity 86%), so a substantial share of frozen shoulders look normal even on advanced imaging. Conversely, the rotator cuff, labral and AC joint changes that are commonly reported in the same age group are found in 82-96% of asymptomatic people and do not explain a stiff shoulder.
Full figures and references on the Frozen Shoulder (Adhesive Capsulitis) page →
Elbow Joint overview →
Tennis / Golfer's Elbow
Tennis elbow (lateral epicondylitis) and golfer's elbow (medial epicondylitis) are clinical diagnoses; imaging is not required and its findings are common in people with no elbow pain. In 264 asymptomatic adults aged 20 to 96 who had both elbows scanned, positive color Doppler activity (the 'neovascularisation' often cited as a sign of tendinopathy) was present in 9% of common extensor tendons, and bony spurs at the tendon insertion rose from 23% of people in their 20s to 74% of those 70 and older. In 21 patients with chronic lateral epicondylitis, moderate or severe MRI signal change was present in 18, but the severity of the MRI change did not correlate positively with symptoms.
Full figures and references on the Tennis / Golfer's Elbow page →
UCL Injury
In throwing athletes the ulnar collateral ligament (UCL) adapts to load, and the imaging appearance of a pitcher's elbow is abnormal by ordinary standards even when the pitcher has no symptoms. In 26 asymptomatic major-league pitchers examined with ultrasound before spring training, the anterior band of the UCL was thicker in the pitching arm than the non-pitching arm (6.3 mm vs 5.3 mm at rest), hypoechoic foci were present in 18 of 26 (69%) pitching arms versus 3 of 26 (12%) non-pitching arms, and calcifications in 9 of 26 (35%) pitching arms versus none on the other side. In 368 asymptomatic professional pitchers scanned over ten years, the dominant UCL averaged 6.15 mm against 4.82 mm on the non-dominant side, hypoechoic foci were found in 28.0% versus 3.5% and calcifications in 24.9% versus 1.6%, and among the 12 pitchers who later sustained a UCL injury the baseline ligament thickness, joint gapping and rate of abnormalities did not differ significantly from those who stayed healthy.
Cubital Tunnel Syndrome
Cubital tunnel syndrome is a clinical diagnosis; ultrasound and nerve-conduction testing support it but do not make it. In 50 asymptomatic adults aged 19 to 67 (100 ulnar nerves), the mean ulnar nerve cross-sectional area at the elbow was about 7 mm2, yet 21%, 24% and 7% of nerves measured above 8 mm2 at the three standard measurement levels, and 4%, 7% and 0% measured above 10 mm2, the threshold the authors proposed as pathological; nerves were larger in men, in people 40 and older, and with higher body-mass index. On MR neurography, qualitative reading of ulnar nerve T2 signal had a sensitivity of 83% and a specificity of 85% when 20 patients with confirmed ulnar neuropathy were compared with 20 healthy controls, so a proportion of healthy nerves are read as abnormal.
Full figures and references on the Cubital Tunnel Syndrome page →
Elbow Arthritis
Primary elbow osteoarthritis is uncommon compared with arthritis of the hip, knee or hand, and no large cohort of asymptomatic people with elbow radiographs could be verified for this page, so no population prevalence figure is claimed. What the verified literature does show is that bony change around the elbow accumulates with age in people without symptoms: in 264 asymptomatic adults aged 20 to 96, bony spurs at the common extensor tendon insertion on the lateral epicondyle were present in 23% of people in their 20s and 74% of those 70 and older. In a case-control study of 50 patients with symptomatic primary elbow osteoarthritis compared with age- and sex-matched controls, osteophytes were seen at the olecranon in 96%, the coronoid in 90% and the radial head in 86%, with joint-space narrowing most often at the radiocapitellar joint (58%); the point of that comparison was to separate the changes of disease from those of normal aging.
Hand & Wrist Joint overview →
Carpal Tunnel Syndrome
Carpal tunnel syndrome is diagnosed from the pattern of symptoms and examination; nerve conduction studies support the diagnosis but an abnormal result on its own is not a diagnosis. In a general-population study in Sweden, 3,000 adults were surveyed and 2,466 responded: 14.4% reported pain, numbness or tingling in the median nerve distribution, 3.8% had clinically certain carpal tunnel syndrome on examination, 4.9% had median neuropathy at the wrist on nerve conduction testing, and 2.7% had both clinical and electrophysiological confirmation. In the same study, 125 people with no hand symptoms were examined as controls, and 23 of them (18.4%; 95% CI 12.0%-26.3%) had electrophysiological evidence of median neuropathy at the carpal tunnel.
Full figures and references on the Carpal Tunnel Syndrome page →
TFCC Tear
Tears and perforations of the triangular fibrocartilage complex (TFCC) are part of normal aging of the wrist and are very common in people with no wrist pain. In a cadaver study of 180 wrists from 100 fresh cadavers ranging from fetal age to 94 years, perforation of the TFCC disc was absent in the first two decades of life, then present in 7.6% in the third decade, 18.1% in the fourth, 40.0% in the fifth, 42.8% in the sixth and 53.1% over sixty; the author concluded that disc perforation is degenerative and age-related. In 103 asymptomatic volunteers who had wrist MRI, the TFCC was read as abnormal in 39 wrists, including every subject older than 60, with a complete tear diagnosed in 23 wrists, and abnormality correlated with age.
Thumb Arthritis
Arthritis at the base of the thumb (trapeziometacarpal or CMC joint) is one of the most common X-ray findings in the aging hand, and most people who have it on X-ray are not seeking treatment for it. In 615 consecutive patients whose wrist X-rays were taken for a distal radius fracture, the radiographic prevalence of trapeziometacarpal arthrosis increased steadily from age 41 onward and reached 91% in patients older than 80 (94% of women and 85% of men). In a larger series of 2,321 patients aged 31 and older X-rayed for the same reason, the prevalence reached 85% between ages 71 and 80, 100% in women aged 91 and older (half of them graded severe) and 93% in men aged 81 and older, yet only three patients had ever had surgery for it.
Hip Joint overview →
Hip Labral Tear
Labral tears are among the most common findings on hip MRI in people who have no hip pain. In a prospective blinded study of 45 asymptomatic volunteers (mean age 37.8, range 15 to 66), labral tears were identified in 69% of hips and labral or paralabral cysts in 13%. In 42 hips of asymptomatic volunteers aged 27 to 43 scanned with optimized non-contrast 1.5-T MRI, two radiologists identified labral tears in 85.7% and 80.9% of hips respectively.
Femoroacetabular Impingement
Cam and pincer morphology is common in people who have no hip pain. In a systematic review of 26 studies covering 2,114 asymptomatic hips (mean age 25.3 years), cam deformity was present in 37% overall, 54.8% of athletes and 23.1% of the general population, and pincer deformity was reported in 67% of asymptomatic hips. In a prospective blinded MRI study of 45 asymptomatic volunteers aged 15 to 66, osseous bumps at the femoral head-neck junction were seen in 20% and fibrocystic change at the head-neck junction in 22%.
Full figures and references on the Femoroacetabular Impingement page →
Hip Arthritis
Hip X-ray findings and hip pain match poorly in both directions. In the Framingham Osteoarthritis Study (946 community adults aged 50 and over, 1,850 hips), only 15.6% of hips with frequent hip pain showed radiographic osteoarthritis, and only 20.7% of hips with radiographic osteoarthritis were frequently painful; in the Osteoarthritis Initiative (4,366 people aged 45 to 79, 8,732 hips) the corresponding figures were 9.1% and 23.8%. In other words, roughly four out of five hips with arthritis on X-ray were not frequently painful, and most painful hips did not show arthritis on X-ray.
Greater Trochanteric Bursitis
MRI changes around the greater trochanter are very common in people who have no lateral hip pain. In an MRI study of 256 hips, peritrochanteric T2 abnormalities were present in 100% of the 16 hips with trochanteric pain syndrome but also in 88% (212 of 240) of hips without trochanteric pain, a difference that was not statistically significant (p = 0.15); gluteal tendinopathy was seen in 50% of the pain-free hips versus 88% of the painful hips. The authors concluded that detection of these abnormalities on MRI is a poor predictor of trochanteric pain because they are present in a high percentage of people without pain.
Full figures and references on the Greater Trochanteric Bursitis page →
Hamstring Strain / Tear
MRI abnormality does not equal a hamstring problem. In a retrospective review of 253 people with no hamstring symptoms (506 proximal hamstring tendons), only 35% were radiologically normal on both sides; 52% had bilateral pathology and 13% had unilateral pathology, including bilateral partial tears in 15% (median age 63) and bilateral complete ruptures in 2% (median age 68). In asymptomatic hockey players, 36% (14 of 39) had MRI findings of common adductor-abdominal rectus dysfunction and 77% had some hip or groin abnormality.
Full figures and references on the Hamstring Strain / Tear page →
Knee Joint overview →
Meniscus Tear
Meniscal tears on MRI are common in people with no knee symptoms, and become more common with age. In a Framingham community sample of 991 people aged 50 to 90, a meniscal tear or destruction was present in 19% of women aged 50-59 rising to 56% of men aged 70-90, and 61% of the people with a tear had no pain, aching or stiffness in the previous month. A meta-analysis of 63 studies of asymptomatic, uninjured knees found meniscal tears in 10% overall, 4% under age 40 and 19% at 40 and over.
Cartilage Injury
Cartilage defects are among the most common findings on knee MRI in people with no knee symptoms. In a meta-analysis of 63 studies covering 5,397 knees of 4,751 asymptomatic, uninjured adults, cartilage defects were present in 24% overall, 11% in people under 40 and 43% in people 40 and over. Among 710 Framingham residents over 50 whose knee X-rays were normal, 69% had cartilage damage on MRI and prevalence rose with age.
Knee Arthritis
X-ray and MRI signs of knee osteoarthritis are poorly matched to symptoms. In a national survey of 6,880 US adults aged 25-74, radiographic knee osteoarthritis (grade 2-4) was present in 3.7%, and only 47% of those people reported knee pain; conversely, of the 14.6% who reported knee pain, only 15% had radiographic osteoarthritis. A systematic review of the literature found that the proportion of people with radiographic knee osteoarthritis who had pain ranged from 15% to 81% across studies, and the proportion with knee pain who had radiographic osteoarthritis ranged from 15% to 76%; the authors concluded that knee X-rays should not be used in isolation to assess an individual with knee pain.
Patellofemoral Pain Syndrome
Anterior knee pain correlates poorly with what the scan shows, and 'chondromalacia' or patellar cartilage wear on MRI is common in people with no pain at all. In a 3T MRI case-control study of 64 patients with patellofemoral pain and 70 healthy controls aged 14-40, minor patellar cartilage defects (23% vs 21%), patellar bone marrow lesions (53% vs 51%) and high signal in Hoffa's fat pad (58% vs 51%) were equally common in both groups, and after adjustment none of the structural abnormalities was associated with pain. Patellar cartilage lesions were present in 35% of knees and trochlear lesions in 25% of knees of asymptomatic NBA players, and patellofemoral cartilage abnormality was the most common finding, in 57% of 230 knees, in asymptomatic sedentary adults.
Full figures and references on the Patellofemoral Pain Syndrome page →
MCL (Collateral Ligament) Injury
Fluid or high signal around the medial collateral ligament on MRI is a common finding that does not necessarily mean a ligament injury. In 60 people with no history of trauma, medial collateral ligament edema was present in 27 of 30 knees with medial compartment osteoarthritis (14 grade 1, 13 grade 2) and in 2 of 30 age-matched knees without osteoarthritis; the authors concluded that MCL edema is common in osteoarthritis in the absence of trauma and should not be attributed to injury. In 100 patients imaged for a suspected meniscal tear, collateral ligament abnormalities were reported in 53 of the symptomatic knees but also in 6 of the 100 asymptomatic opposite knees.
Full figures and references on the MCL (Collateral Ligament) Injury page →
Patellar Tendon Tear
A complete patellar tendon rupture is an acute, obvious injury; the imaging finding that causes confusion is 'tendinopathy' or 'partial tearing' reported in a tendon that has never hurt. In 134 elite junior basketball players (268 tendons, aged 14-18), 26% of patellar tendons contained an ultrasound hypoechoic region, while only 7% had patellar tendinopathy on clinical grounds, and 22% of tendons that had never been symptomatic still showed an abnormality; ultrasound change was three times as common as symptoms (Cook 2000, Scand J Med Sci Sports). In 54 elite Danish soccer players, 18% of asymptomatic patellar tendons (18 of 98) had ultrasound tendinosis at the start of the season.
Full figures and references on the Patellar Tendon Tear page →
Patellar Instability
Patellar dislocation is a clinical event, but the anatomical 'risk factors' reported on imaging (trochlear dysplasia, patella alta, a high tibial tubercle-trochlear groove distance, patellar tilt) are also found in people whose kneecaps have never dislocated. In the original anatomic study of 143 knees operated on for symptomatic instability, trochlear dysplasia was present in 85%, patellar tilt in 83%, a tibial tubercle-trochlear groove distance of 20 mm or more in 56% and patella alta in 24%, but these same features appeared in 3% to 6.5% of 190 control knee radiographs and 27 control CT scans. In a prospective ultrasound study of 102 skeletally mature people (203 knees) attending orthopaedic clinics for reasons other than knee pain, high-grade trochlear dysplasia was found in 5.4% by sulcus angle and 9.9% by trochlear depth, so that roughly one in ten knees in the general population has a dysplastic trochlea; knees with high-grade dysplasia were 11 times more likely to have a history of instability, but most did not.
Full figures and references on the Patellar Instability page →
Tibial Plateau Fracture
A tibial plateau fracture is diagnosed on the history and the X-ray or CT, and there is no meaningful 'asymptomatic prevalence' of a displaced fracture. The imaging findings that cause confusion around this injury are bone marrow edema ('bone bruise' or 'bone marrow lesion') and low-grade signal change on MRI, which are common in knees that have never been injured. In 710 Framingham adults over 50 with normal knee X-rays, bone marrow lesions were present on MRI in 52%; a meta-analysis of asymptomatic uninjured knees found bone marrow lesions in 18%; and in 230 knees of asymptomatic adults with a median age of 44, bone marrow edema was seen in 48%.
Full figures and references on the Tibial Plateau Fracture page →
Foot & Ankle Joint overview →
Achilles Injury
Achilles tendon changes on ultrasound and MRI are common in people who have no Achilles pain. A systematic review of 91 imaging studies (10,156 limbs, 5,841 asymptomatic participants) found that the prevalence of Achilles tendon abnormalities ranged from 0% to 80% per participant, with higher prevalence in people aged 40 or older, those with higher body mass index, and those who took part in physical activity. In a cross-sectional power Doppler study of 1,906 Achilles tendons in 953 long-distance runners, tendon thickness rose with age, height and weight, and intratendinous neovascularization was detected in 35% of healthy, symptom-free runners (Hirschmüller 2010).
Ankle Sprain / Instability
Ligament signal change and bone-marrow edema on ankle MRI are common in ankles that have never been symptomatic and in ankles that have long since recovered. In 113 amateur marathon runners with no ankle symptoms (183 ankles), MRI showed partial anterior talofibular ligament abnormality in 47.5% of ankles, calcaneofibular ligament abnormality in 39.3%, bone marrow edema-like signal in 41.5% and joint or tendon-sheath fluid in most ankles; the authors concluded that these MRI features are common in asymptomatic runners. After an acute inversion sprain with normal X-rays, 27% of 95 patients had a bone bruise on MRI, and its presence made no difference to return to work, walking, activity level or clinical outcome scores at three months.
Full figures and references on the Ankle Sprain / Instability page →
Osteochondral Lesion
Osteochondral lesions of the talus are found in people with no ankle symptoms, and many lesions cause no trouble for years. In 113 amateur marathon runners with no ankle symptoms (183 ankles), MRI showed osteochondral lesions in 3.3% of ankles and cyst-like lesions in 5.5%. In a consecutive series of 1,062 patients with a CT-confirmed talar osteochondral lesion who had both ankles scanned, 161 (15%) had a lesion in the other ankle as well, and only 53 of those 161 (33%) were symptomatic on both sides, so two out of three contralateral lesions were silent.
Full figures and references on the Osteochondral Lesion page →
Plantar Fasciitis
Heel spurs and plantar fascia thickening are both common in people who have never had heel pain. In 216 community-dwelling older people aged 62 to 94 (mean 75.9), 55% had at least one plantar calcaneal spur on X-ray, and 61% of those with spurs had no heel pain, current or previous. On 1,080 lateral ankle radiographs from a trauma clinic covering ages 2 to 96, 38% showed a plantar or Achilles calcaneal spur, with peak prevalence between ages 40 and 79.
How Dr. O'Donnell decides whether a finding is the cause of pain
The order of evidence is history, examination, imaging, and then, where the answer is still uncertain, a targeted test. The history has to fit: the mechanism, the onset, the activities that reproduce the pain and the ones that do not. The examination has to localize to the same structure the scan is describing, using the specific provocation and strength tests for that joint. The finding on the scan has to be on the correct side, at the correct level, and of a type that plausibly produces the symptom pattern; a small disc bulge on the left does not explain right-leg pain, and a partial-thickness cuff tear does not explain a shoulder that has lost passive motion.
When those three lines of evidence agree, the diagnosis is usually settled. When they do not, Dr. O'Donnell uses a diagnostic anesthetic injection under ultrasound or fluoroscopic guidance to test a single structure, compares the current scan with any earlier imaging to separate new findings from old ones, orders nerve conduction studies where a nerve is in question, and looks at the response to a proper course of therapy. A finding that is common in pain-free people, that does not match the examination, and that does not respond to an anesthetic block is treated as background.
Surgery is recommended when the symptoms, the examination and the imaging point to the same structure, when the natural history of that problem favors an operation, and when non-operative treatment has been tried where it is appropriate or is not a reasonable option. A finding on an MRI, X-ray, ultrasound or nerve study is not by itself a diagnosis, and it is not by itself a reason for surgery.
Frequently asked questions
My MRI report lists several abnormalities. Does that mean something is wrong?
Not necessarily. Studies of people with no symptoms show that most adults over 40 have at least one abnormality on a knee, shoulder, hip or spine MRI, and the number rises with age. What matters is whether a finding matches your symptoms and your examination. Many findings on a report are age-typical and need no treatment.
Do disc bulges and herniations need surgery?
Most do not. Disc bulges are present in about half of people who have never had back pain, and most symptomatic herniations improve without surgery over weeks to months, with many shrinking on follow-up imaging. Surgery is considered for persistent nerve compression with matching weakness or pain that has not responded to time, therapy and, where appropriate, injections, or for the rare emergency of bowel or bladder involvement.
If a tear shows on my scan and I have pain, is the tear the cause?
Often, but not always. The tear has to be on the correct side, in a structure that the examination also identifies as painful, and of a type that fits the symptoms. Where that is unclear, an anesthetic injection into the structure, comparison with older imaging or the response to therapy is used to confirm or exclude it before any operation is discussed.
Should I get an MRI before my first appointment?
Usually not. Dr. O'Donnell examines the joint and takes X-rays first and orders an MRI when the result would change treatment. If you already have imaging, bring it or upload it through mymedicalimages.com so it can be read alongside the examination rather than in isolation.
