Back injuries are the most common injury in construction with the highest rate occurring in tile and terrazzo contractors. Lower back pain is a leading cause of lost workdays and disability in the industry.1, 2

In fact, back injuries were 2.6 times more common in construction than all other industries combined, making up almost 42% of work-related musculoskeletal disorders. They were 3.5 times the number of shoulder injuries (the second most commonly injured body part in construction).3

In the United States, billions of dollars a year are spent on treating back pain, with money being spent on tests and treatments that are “the wrong ones,” in the sense of failing to provide the information and therapy that will be most effective in helping the patient reach functional restoration.

In The Economist in 2020, an article headlined, “Back pain is a massive problem which is badly treated,” highlighted the vast sums wasted on misleading diagnostic testing, stating, “In rich countries perhaps 80% of magnetic resonance imaging for back pain is unnecessary.” 4

MRIs have become a go-to diagnostic tool for back pain and are so common that it's easy to forget they are not a stand-alone diagnostic. To be meaningful, the findings on an MRI need to be correlated with the findings of a thorough physical exam; without this, an MRI and its results can be misleading and result in overly aggressive, expensive and ineffective treatment. Advanced imaging is of questionable benefit precisely because it often leads to unwarranted surgery.5

However, many (if not most) employees believe that imaging, such as MRIs, reveals the source of pain and gives physicians information needed to “fix it” and make it go away. That is simply not true. More than 85% of individuals have non-specific (or regional) low back pain, which is not mechanical in origin and cannot be attributed to a specific disease or pathology.6

What Appears on an MRI, Even When Pain is Not Present

No matter what a disc looks like on an MRI, a person can be asymptomatic or pain-free, and usually is. Such spinal abnormalities as bulging and herniated or degenerated discs are commonplace in asymptomatic individuals.

By age 50, 80% of adults without back pain have degenerative changes that will show up on an MRI; 60% of adults are likely to have bulging discs; and 36% may have disc protrusions.7 Someone who doesn’t understand that changes normally occur in the spine over the passage of time might be alarmed by what an MRI shows. In fact, one health expert says even just mentioning to an injured individual that an MRI is being ordered is enough to create alarm and the unfounded belief that he has a serious medical condition.8

Nortin Hadler, MD, in his book Stabbed in the Back, says, “Who among us can look at an image of our own spine and not feel disquiet as we come to realize how many discs have degenerated, how many facet joints have spurs, and how peculiar is the alignment.”9

Those images of “findings,” however common in people without back pain, become seared into the brain of a construction employee experiencing back pain attributed to overexertion. Given the way humans are wired, construction employees with back pain may catastrophize and, if they convince themselves they have a fragile back, they may avoid activity altogether.

When MRIs are Costly and Unnecessary

Scientific research now shows that, in cases without certain medical red flags, early imaging (sooner than six to eight weeks) is not recommended and is not associated with better outcomes—not even for older adults thought to have a higher prevalence of underlying conditions.10

It has been estimated that 30% or more of imaging may be unnecessary, costing approximately $30 billion annually in the United States.11 Compared with 10 other countries, the United States ranks among the highest in the number of imaging scans per 1,000 individuals.12

Most medical treatment guidelines generally ask physicians to wait at least six to eight weeks before ordering advanced imaging. In 2011, the American College of Physicians went further, stating that “routine spinal imaging should be eliminated from modern back pain treatments because the identification of asymptomatic spinal abnormalities led to unnecessary referrals, diagnostic interventions, interventional pain management procedures and surgery.”13

The Economist article hypothesized that healthcare systems “get it wrong” partly because people in pain want something done about it right away.

Frontline supervisors and workers’ compensation managers sometimes share this belief in the power of MRI scans to “show what’s wrong” with injured employees. They sometimes question if clinicians are “slowing progress” by not ordering an MRI sooner rather than later and urge them to do so as soon as possible.

Prevailing societal beliefs about the severity of pain being directly related to the severity of structural and tissue injury further muddy the waters. If there are no findings on the MRI pointing to a structural defect, it becomes tempting to dismiss an injured employee’s experience of pain and suspect that individual of exaggerating or malingering. In the workers’ compensation arena, this all too often leads to an adversarial situation and attorney involvement.

However, pain is complex and nuanced. The International Association for the Study of Pain currently defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” Emotional and physical pain activate the same neural pathways, and emotions that often accompany work injury, like anxiety, fear and anger, feed the experience of pain. It is entirely possible for an injured employee to still feel pain, even though injured tissues have healed.

What It All Means

Overuse and misuse of advanced imaging doesn’t benefit the injured employee. Furthermore, these practices can lead to misunderstanding, wasteful spending and distrust. It’s hard to convince a construction employee who has seen “findings” on a scan that they were not caused by work and are not the cause of his or her back pain. It’s hard to convince supervisors and workers’ compensation insurance adjusters that an injured employee’s pain is real when there are no findings on a scan.

It’s impossible to know exactly how many injured employees have been fast-tracked from an MRI into surgeries that have hurt more than they have helped, or how many employees experiencing pain have hired an attorney because their pain was discounted after a negative MRI.

Construction executives savvy to the dangers of diagnoses and treatment based on clinically uncorrelated MRI findings are more likely to seek experienced clinicians who will proceed in a manner that provides the greatest benefit for optimal clinical outcomes.