Is It the Cause… or Just a Coincidence? Understanding Why Not Every Imaging Finding Explains Your Symptoms

David Stephen Klein, MD FACA FACPM
Mar 25
5 min read

Introduction

Modern medicine offers remarkable tools—X-rays, MRIs, and CT scans—that allow us to look inside the body with extraordinary detail. These technologies have improved diagnosis and treatment in countless ways.

However, there is a critical concept that is often misunderstood:

Not every abnormal finding on imaging is the cause of your symptoms.

In fact, many findings are simply coincidental—present on imaging but unrelated to the problem you are experiencing. Understanding this distinction can help prevent unnecessary procedures and guide more thoughtful, effective care.

What Is a “Finding”?

A finding refers to something seen on a diagnostic study. Common examples include:

Disc bulges or herniations in the spine
Arthritis in joints
Tendon tears
Degenerative changes in cartilage

These findings are extremely common, particularly with aging.

Causal vs. Coincidental: A Critical Distinction

When a finding is identified, it must be interpreted in context. There are two possibilities:

1. Causal (Responsible for Symptoms)

The finding directly explains the patient’s symptoms
Treatment targeting the finding is likely to provide relief

2. Coincidental (Incidental Finding)

The finding is present but unrelated to the symptoms
Treating it may not improve—and may even worsen—the condition

This distinction is one of the most important judgments in clinical medicine.

What the Evidence Shows

A substantial body of research demonstrates that many “abnormal” imaging findings are present in people with no symptoms at all.

For example:

Degenerative disc changes are seen in a large percentage of asymptomatic adults¹
Disc bulges and herniations frequently occur in individuals without back pain²
Meniscal tears are common on MRI in people with no knee symptoms³
Rotator cuff tears are often present in asymptomatic shoulders⁴

These findings increase with age and are often part of normal biological wear and adaptation.

A Common Example: The Spine

Learn the difference between causal and coincidental findings on imaging and why not all abnormalities are responsible for your pain or symptoms. — Causal vs Coincidental Findings: What Causes Your Symptoms

Low back pain is one of the most frequent reasons for imaging. When an MRI shows a disc bulge or degeneration, it is natural to assume:

“That must be the cause of my pain.”

However, studies show that:

Up to 50% or more of asymptomatic adults have disc bulges on MRI²
Degenerative changes are nearly universal with aging¹

This means the imaging finding may be coincidental rather than causal.

Why Coincidental Findings Are So Common

The human body changes over time:

Intervertebral discs lose hydration
Joints develop osteoarthritis
Tendons undergo microstructural changes

These are often normal aging processes, not necessarily sources of pain.

Much like wrinkles on the skin, these changes may be visible—but not symptomatic.

Flowchart showing how doctors determine if imaging findings are causing symptoms and when to consider conservative care versus surgery. — Clinical Decision Pathway: Do Imaging Findings Explain Pain?

The Risk of Treating the Wrong Target

When imaging findings are assumed to be causal without proper clinical correlation, several problems can arise:

Unnecessary surgery or procedures
Persistent symptoms despite treatment
Increased risk of complications
Patient frustration and loss of trust

Randomized trials have demonstrated that in some conditions—such as degenerative meniscal tears—surgical intervention may offer no better outcomes than conservative care⁵.

Similarly, spine interventions based solely on imaging findings may not improve outcomes if the structural abnormality is not the true pain generator⁶.

How Physicians Determine What Is Truly Causal

This is where clinical judgment becomes essential.

A thoughtful evaluation includes:

Detailed history: onset, location, and nature of symptoms
Physical examination: reproducible findings that match anatomy
Symptom patterns: consistency with known pain pathways
Imaging correlation: does the finding match the clinical picture?

When all of these align, the likelihood of a causal relationship increases.

When they do not, caution is warranted.

Spine imaging often shows disc bulges or degeneration that may not cause pain. Learn why MRI findings don’t always explain symptoms. — Spine MRI Findings: Why They May Not Cause Back Pain

A Pragmatic Approach to Care

Before proceeding with invasive treatments, a reasoned approach includes:

Confirming that the imaging finding explains the symptoms
Considering alternative diagnoses
Trial of conservative therapies (physical therapy, medications, lifestyle changes)
Reassessing response over time

Good medicine balances evidence, experience, and individual patient context.

The Role of Experience and Judgment

Medicine is not practiced by imaging alone.

While technology provides data, interpretation requires experience, pattern recognition, and clinical reasoning.

A pragmatic physician:

Avoids over-treatment
Recognizes uncertainty
Prioritizes patient-centered outcomes
Focuses on interventions most likely to help

Bottom Line

Not all abnormalities seen on imaging are the cause of symptoms
Many findings are coincidental and part of normal aging
Treating a coincidental finding may not improve outcomes
Careful clinical evaluation is essential before pursuing invasive treatment

The goal is not to treat what looks abnormal—but to treat what is truly causing your symptoms.

Call to Action

If you are dealing with persistent pain or have been advised to undergo a procedure based on imaging findings, a thoughtful, comprehensive evaluation can help clarify the best path forward.

At Stages of Life Medical Institute, we emphasize a careful, patient-centered approach—integrating clinical judgment, evidence-based medicine, and individualized care.

👉 Become a Patient: https://stagesoflifemedicalinstitute.com

References

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816.https://pubmed.ncbi.nlm.nih.gov/25430861/
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69–73.https://pubmed.ncbi.nlm.nih.gov/8208267/
Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108–1115.https://pubmed.ncbi.nlm.nih.gov/18784100/
Sher JS, Uribe JW, Posada A, et al. Abnormal findings on MRI of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–15.https://pubmed.ncbi.nlm.nih.gov/7822341/
Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369(26):2515–2524.https://pubmed.ncbi.nlm.nih.gov/24369076/
Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463–472.https://pubmed.ncbi.nlm.nih.gov/19200918/
Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am. 1990;72(3):403–408.https://pubmed.ncbi.nlm.nih.gov/2312537/
Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: systematic review with meta-analysis. Br J Sports Med. 2008;42(2):80–92.https://pubmed.ncbi.nlm.nih.gov/17720798/
Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22(1):62–68.https://pubmed.ncbi.nlm.nih.gov/19124635/
Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430–1434.https://pubmed.ncbi.nlm.nih.gov/16777886/

The medical references cited in this article are provided for educational purposes only and are intended to support general scientific discussion. They are not a substitute for individualized medical advice, diagnosis, or treatment. Clinical decisions should always be made in consultation with a qualified healthcare professional who can account for a patient’s unique medical history, medications, and circumstances.

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