Here’s the short answer: a scan that looks fine does not mean your pain isn’t real, and it does not mean nothing can be done. Pain and tissue damage are not the same thing. Scans show structure. Pain is produced by your nervous system, based on how much threat it believes your body is under. When back pain persists for months, the problem is often less about a damaged part and more about a protective system that has become overly sensitive. That is frustrating to hear, but it is also good news, because sensitivity can be turned down.

Why a normal scan and real pain can both be true

Most people expect a scan to work like a damage meter: more damage, more pain. The research says otherwise. Large imaging studies have found disc bulges, degeneration, and other “abnormal” findings in a high proportion of people who have no back pain at all, and the rate climbs steadily with age. A systematic review by Brinjikji and colleagues (American Journal of Neuroradiology, 2015) found disc degeneration in around a third of pain-free 20-year-olds and in more than 90 percent of pain-free people in their 80s.

So it works both ways. Plenty of people have scary-looking scans and no pain. Plenty of people have clear scans and significant, life-limiting pain. The scan tells us about the tissue. It does not tell us how much pain someone is in, or why.

Pain is a protective output, not a damage readout

A book I keep coming back to is Explain Pain by David Butler and Lorimer Moseley, two Australian researchers who have spent decades helping people understand persistent pain. Their central idea is simple to say and takes a while to sink in: pain is produced by the brain when it concludes your body needs protecting. It is an output, not an input.

Your tissues send signals about pressure, temperature, and chemistry. Your brain weighs those signals against everything else it knows: what happened last time you bent over, what the scan report said, how much sleep you’ve had, how stressed you are, whether you believe your back is fragile. Then it decides how much pain to produce. That decision is usually very sensible in the short term. After an injury, pain makes you rest and protect the area while it heals.

The trouble starts when the system stays switched on after healing has happened. Tissues typically recover within weeks to a few months, but a nervous system that has been on high alert for that long can become more efficient at producing pain. Smaller inputs trigger bigger responses. Movements that should be harmless start to hurt. The pain is completely real. It is just no longer a reliable signal of damage.

Why the way pain is explained matters so much

If pain is partly a judgement about threat, then the words used to describe your back can change how much it hurts. Someone told they have a “crumbling spine” or “the back of a 70-year-old” tends to move less, guard more, and worry more, and every one of those things turns the volume up. Someone who understands that their tissues are robust, that the scan findings are common, and that their sensitivity can be retrained tends to move more freely, and the volume comes down.

This isn’t just a nice idea. Pain neuroscience education has been studied as a treatment in its own right. A systematic review by Louw and colleagues (Physiotherapy Theory and Practice, 2016) found that helping people understand how pain works reduced pain, improved function, and lowered fear of movement in people with persistent musculoskeletal pain, particularly when combined with movement-based treatment. Understanding is part of the treatment, not a preamble to it.

What this changes about treatment

If persistent back pain were purely a tissue problem, the answer would be to find the damaged part and fix it. Because it is usually a sensitivity problem layered on top of a healed or ageing (and normal) spine, the approach is different:

• Understanding first. Knowing what your scan does and doesn’t mean, and why your back hurts despite it, takes a lot of threat out of the picture.
• Hands-on treatment to get things moving. Manual therapy helps ease stiffness and guarding, and gives the nervous system evidence that movement is safe again.
• Graded return to movement. Not resting until the pain goes, and not pushing through it either. Starting at a level your system tolerates and building steadily, so your back rebuilds capacity and your brain rebuilds confidence.
• Attention to the amplifiers. Poor sleep, high stress, and fear of certain movements all turn sensitivity up. They are part of the plan, not a side conversation.

This is why so much of the work I do with people who have had back pain for a long time is about exercise and confidence rather than chasing a structural culprit. The scan is one piece of information. How you move, what you believe about your back, and how your system responds to load matter at least as much.

So what should you do if your scan is clear but your back still hurts?

First, take the clear scan as good news. It means the structures are sound and there is nothing that needs surgical attention. Second, don’t accept “there’s nothing wrong, you’ll have to live with it.” A sensitised system is something that can be assessed and treated. Third, be wary of anyone who wants to pin your pain on a single finding and sell you a fix for it.

If you’ve had back pain for more than a few months and feel like you’ve been passed around without a clear explanation, that explanation is usually the place to start. You can read more about how I approach lower back pain, book online at chiropracticmoves.com.au, or call 0404 717 488.

References: Brinjikji W et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR 2015. Butler D, Moseley GL. Explain Pain, 2nd ed. Noigroup Publications, 2013. Louw A et al. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review. Physiotherapy Theory and Practice 2016.

Dr. Michael O'Doherty

Hi, I’m Michael; Chiropractor, Dad, science enthusiast, active weightlifter and keen sportsman. I work with busy and active people who are struggling with pain to find relief from their symptoms so that they can return to an active lifestyle, get through their work day and their workouts without having to pop a pill so that they can feel happier and healthier in their body.