It is at this point that the case can begin to drift into unhelpful territory. Some readers become suspicious, as though normal imaging proves the symptoms cannot be genuine. Others move too quickly in the opposite direction and treat the claimant’s account as sufficient. Neither approach is satisfactory. Normal imaging does not mean that pain is imaginary, but nor does persistent pain automatically prove that an accident or incident has caused an ongoing injury. The medico-legal task is to examine the space between those two positions.
A common difficulty in personal injury and clinical negligence work is the assumption that pain and tissue damage should correspond neatly. Sometimes they do. A fracture, dislocation, ligament rupture, or clear disc prolapse may provide a direct anatomical explanation for symptoms. In other cases, particularly those involving soft tissue injury, whiplash-associated symptoms, headache, spinal pain, or chronic pain presentations, imaging may be normal or may show findings that do not explain the severity or duration of the symptoms.
That does not make the symptoms false. Pain is a clinical experience, not simply an image on a screen. The difficulty, however, is that medico-legal reporting cannot rest on sympathy alone. The expert must consider whether the symptoms are medically plausible, consistent with the records, functionally significant, and causally related to the event under consideration. Imaging may assist with that assessment, but it rarely answers the whole question.
There are two recurring mistakes in the interpretation of scans. The first is to treat normal imaging as if it excludes injury. This is too simplistic. Painful conditions do not produce visible abnormalities on X-ray, CT, or MRI, and soft tissue or pain-processing problems may exist without a clear structural marker. The second mistake is to over-interpret minor abnormalities when imaging is not normal. Degenerative changes, disc bulges, and age-related findings are common and may have existed long before the accident. Their presence does not automatically explain symptoms, and it certainly does not prove that the accident caused them. Both errors come from the same desire and the wish for the scan to settle the argument. In practice, it often does not.
Where imaging is normal, the chronology becomes especially important. The expert needs to know when the pain began, whether it was immediate or delayed, whether treatment was sought, whether similar symptoms were present before the accident, and how the claimant’s function changed over time. It also matters whether symptoms improved and then worsened again, whether there were later events that may have contributed, and whether the account given at examination is consistent with earlier records. These are not background details.
They form the basis of the causation analysis. A claimant with no relevant prior symptoms, consistent reporting from the time of the accident, and a coherent pattern of treatment and limitation presents a different picture from a claimant whose first documented complaint appears months later against a background of similar pre-existing problems. The imaging may look the same in both cases, but the medico-legal significance may be quite different.
Function also requires careful assessment. Persistent pain is often evaluated by its effect on daily life, and that is reasonable. Pain that does not appear on imaging may still affect sleep, movement, mood, confidence, employment, driving, domestic tasks, and recreational activity. However, a report should not simply repeat that the claimant cannot lift, bend, sit, walk, drive, work, or exercise. It should consider whether those restrictions are consistent with the history, examination findings, treatment records, medication use, observed presentation, and wider evidence.
This is where a number of medico-legal reports become vulnerable. They record the claimant’s account but do not properly analyse it. The result is a report that reads more like a transcript than an expert opinion. In my own reports, I am cautious about firm conclusions based solely on what a claimant says they cannot do. That is different from disbelief. It is simply recognition that the court needs clinical judgement, not repetition. The issue becomes more difficult in chronic pain cases. Pain may persist after the original tissue injury has resolved, and in several cases a modest injury may be followed by prolonged and disabling symptoms. This is often uncomfortable territory for litigation, which tends to prefer cleaner categories: injured or not injured, recovered or not recovered, accident-related or unrelated. Clinical reality is rarely so tidy.
An accident may cause an initial injury that resolves structurally but leaves continuing symptoms. It may aggravate a pre-existing vulnerability. It may contribute for a limited period before other factors become more prominent. Alternatively, the ongoing symptoms may be better explained by unrelated pathology, psychological factors, deconditioning, occupational stress, or a combination of influences. The expert’s role is to distinguish between those possibilities as far as the evidence allows.
Normal imaging can also lead parties to focus too heavily on credibility. There will, of course, be cases where inconsistency, surveillance evidence, social media material, or the medical records raise legitimate concerns. Those matters should be addressed directly. But a medico-legal opinion should not assume that normal imaging makes the claimant unreliable. Equally, a sympathetic presentation should not lead the expert to overlook gaps, contradictions, or alternative explanations.
A better approach is to separate the questions. Are the symptoms medically plausible? Are they consistent over time? Is there evidence of similar pain before the accident? Is the reported level of disability supported by the records? Is the mechanism of injury capable of producing the symptoms described? What would have happened if the accident had not occurred? Those questions produce a more useful opinion than a simple statement that the scan is normal.
Where pain persists despite normal imaging, the expert’s reasoning becomes more important, not less. A good report should explain the significance of the imaging while also acknowledging its limits. It should analyse the chronology, pre-existing history, mechanism of injury, treatment record, examination findings, functional impact, and prognosis. If ongoing accident-related pain is accepted, the basis for that opinion should be clear. If it is not accepted, the alternative explanation should be identified as far as possible. The court is not assisted by artificial certainty. It is assisted by a careful explanation of what can and cannot be concluded from the evidence.
Normal imaging is often treated as though it ends the discussion. In medico-legal work, it usually begins the more difficult part of it. A scan may tell us that no structural abnormality has been identified. It does not, by itself, tell us whether the claimant is in pain, why that pain persists, or how far it can properly be attributed to the accident. That remains the expert’s task. It cannot be handed over to the radiology report.
