Introduction: Pain Is Real, But Damage Is Not Always the Cause
For decades, pain has been treated as a mechanical problem. Something hurts, so something must be broken. But neuroscience now tells a different story. Pain is not a direct readout of tissue damage. It is a protective output generated by the brain.
This shift is transforming how we understand chronic pain and anxiety. It also explains a confusing reality many people face. Their scans show damage, yet they feel fine. Or their scans look normal, yet the pain is severe.
This is not a failure of medicine. It is a misunderstanding of how pain works.
MRI Evidence: Structural “Abnormalities” Are Common Without Pain
Advanced imaging has revealed a striking truth. Many people with no symptoms show the same structural findings as those in pain.
Asymptomatic Findings Across the Body
Research consistently shows abnormalities in people who feel no pain at all:
- Shoulders: MRI findings such as rotator cuff changes appear in pain free individuals
https://doi.org/10.1016/j.jse.2018.10.030 - Spine degeneration: Disc bulges, herniations, and degeneration increase with age regardless of pain
https://pubmed.ncbi.nlm.nih.gov/25430861/ - Hips and labrum tears in athletes and non athletes without symptoms
https://www.jospt.org/doi/10.2519/jospt.2019.8779
https://pubmed.ncbi.nlm.nih.gov/25705927/ - Knees, ankles, Achilles tendons, plantar plates, and bursae frequently show MRI changes without pain
https://pubmed.ncbi.nlm.nih.gov/32519204/
https://pubmed.ncbi.nlm.nih.gov/24827167/
https://pubmed.ncbi.nlm.nih.gov/27364186/
What This Means
If damage automatically caused pain, these people would all hurt. They do not.
This tells us something critical. Pain is not a simple reflection of structure. The brain decides when pain is necessary.
The Brain Does Not Detect Pain. It Creates It
Pain is not received like a message. It is produced like an alarm.
The Neuromatrix Model of Pain
The brain integrates sensory input with emotion, memory, expectation, and context to determine whether pain is needed for protection.
This concept is known as the neuromatrix model of pain.
https://en.wikipedia.org/wiki/Neuromatrix
In this model, pain is a decision made by the brain, not a measurement of damage.
Why Pain and Anxiety Are Deeply Connected
Pain and anxiety share overlapping neural circuits. This explains why they so often appear together.
Shared Brain Regions
Pain and anxiety both involve:
- Amygdala, threat detection
- Anterior cingulate cortex, emotional pain processing
- Prefrontal cortex, meaning and expectation
When anxiety is high, the brain is already in threat mode. Pain thresholds drop. Sensations become amplified.
Fear Memory Amplifies Pain
Fear memories stored in the brain can intensify pain responses long after an injury has healed. The brain learns pain the same way it learns fear.
https://www.nature.com/articles/s41593-023-01291-x
This explains chronic pain that persists without ongoing injury.
Why Surgery and Structural Fixes Often Fail
If pain is primarily driven by brain circuits, fixing anatomy does not always resolve pain.
This helps explain failed back surgery syndrome, where pain persists or worsens after technically successful operations.
https://pubmed.ncbi.nlm.nih.gov/21412372/
The structure changes. The pain circuitry does not.
The New Treatment Paradigm: Treating the Brain, Not Just the Body
Modern pain science focuses on retraining neural circuits rather than chasing structural findings.
Neural Plasticity and Pain
Pain changes the brain, but the brain can also change pain.
Neural plasticity allows pain circuits to be recalibrated through:
- Education about pain mechanisms
- Emotional processing and fear reduction
- Nervous system regulation
- Gradual exposure to movement without threat
https://www.mdpi.com/2227-9059/9/6/624
Emotional Processing Reduces Pain
New clinical trials show that targeting emotional regulation can significantly reduce chronic pain, even without physical interventions.
https://www.sciencedaily.com/releases/2025/05/250506131322.htm
Why This Changes Everything
Pain is not imaginary. But it is interpretive.
Pain is the brain’s opinion about danger.
When the brain predicts threat, pain increases. When safety is restored, pain decreases, even if the body has not changed.
This is why understanding the neuroscience of pain and anxiety is essential for lasting recovery.
Final Thought: Pain Is Protection, Not Proof of Damage
The future of pain care is not about finding more damage. It is about understanding why the brain is protecting when protection is no longer needed.
When we stop treating pain as a broken part and start treating it as a protective process, healing becomes possible.
