Clinical Conversations

What is the role of x-ray and MRI in physical therapy?

Nick Rinard MPT Cert MDT Owner of Nick Rinard Physical Therapy“Should I get an x-ray or MRI before physical therapy?” This is a common question, and the answer is – NO. Why not? I hope to clarify that in this article, and give you a convincing reason to try physical therapy first.

First, physical therapists can make an accurate clinical diagnosis that will most likely match the radiological diagnosis. A 2005 study published in the Journal of Orthopedic and Sports Physical Therapy compared the agreement between what the physical therapist thought the imaging would show, and what doctors thought the imaging would show. “Clinical Diagnostic Accuracy and Magnetic Resonance Imaging of Patients Referred by Physical Therapists, Orthopedic Surgeons, and Non-orthopedic providers.” Physical therapists could predict the correct imaging diagnosis 74.5% of the time! That’s almost as accurate as orthopedic surgeons, and over twice as good as general practitioners!

  • Physical Therapists = 74.5% (108/145)
  • Orthopedic Surgeons = 80.8% (139/172)
  • Non-orthopedic = 35.4% (86/243)

So, only in a small number of cases, will you need an x-ray or MRI to help determine your condition if it cannot be determined clinically.

False positives

Second, there are a lot of “false positive” findings associated with imaging. A false positive is when the test (radiologic image) shows you have the disease or condition, when you actually don’t. Some of you readers may know of people who were freaked out by a “finding” on their mammogram that turned out (luckily) to not be cancer. How often does this happen in the joints or spine that a physical therapist treats? If you are talking about the neck, quite a lot of people with NO NECK PAIN have a “major finding” on MRI. It is broken down below. (From The Journal of Bone and Joint Surgery 1990 “Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation”)

For people less than 40 years old:

  • Major abnormality in 14%
  • Herniated disc = 10% (of subjects)
  • Foraminal stenosis = 4%
  • No “major” bulging discs were seen
  • Narrowed disc space / degenerated discs = 25%
  • Cord abnormalities = 9%

For people older than 40 years:

  • Major abnormality in 28%
  • Herniated disc = 5%
  • Foraminal stenosis = 20%
  • Only 1 subject “major” bulging disc was seen
  • Narrowed disc space / degenerated discs = 57%
  • Cord abnormalities = 1%

Remember, these are findings in people with NO NECK PAIN. If you have neck pain, there is a good chance that you might have one of these findings, but it would not be the source of your pain. The study authors conclude: “The prevalence of cervical spine pathology in asymptomatic (pain free) individuals of a wide-range of ages, points out the danger in ordering surgery or invasive procedures, or even giving the patient an ominous-sounding diagnosis, without first correlating these MRI findings with clinical signs and symptoms.”

Imaging the lumbar spine can also lead to errors as there is even greater incidence of false positive MRI findings in asymptomatic subjects in the lower back as compared to the neck…

“Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.” J Bone Joint Surg Am. 1990

  • 33% had a “substantial” abnormality

60 years old:

  • 36% had a disc herniation
  • 21% had spinal stenosis

Accurate Diagnosis with your Physical Therapist

If you are still reading this article, then you must be interested in getting an accurate diagnosis of your problem, and you might think a physical therapist could be the one person who can do that. You would be right. Plus, a physical therapist will offer you treatment for your condition, not surgery or drugs. I have been convinced beyond a doubt in my 20 plus years of practice that one should start with a good physical therapy evaluation and possibly treatment before turning to x-ray or MRI. A good physical therapist knows when the clinical diagnosis is complete and correct and when imaging is needed to help fill in the blanks. Don’t get an x-ray or MRI first. It might point you in the wrong direction and bias the clinician trying to arrive at the correct diagnosis and treatment. If you truly need imaging, your physical therapist at Nick Rinard Physical Therapy can help guide you in that decision.


Is Your Work Out Wearing You Down?

Margo Burette, DPT, Physical Therapist at Nick Rinard Physical TherapyThe American Heart Association recommends at least 30 minutes of moderate-intensity aerobic activity at least 5 days/week. In the pursuit of good health and fitness, many people are using YouTube to access new workouts. Unfortunately, there is neither quality control nor an accreditation process to ensure that the workouts are sound. Further complicating things is the “no pain, no gain” exercise myth which leads people to expect suffering with exercise. If someone expects exercising to be painful, they may not heed the early warning signs of pain and become injured.

Recently, I treated a young woman who developed severe lower back pain after exercising with a popular fitness program online. She continued to push herself through the routines but after 2 weeks she quit exercising entirely. She was frustrated because her efforts to improve her health had actually worsened her condition. Her back pain was interrupting her sleep and limiting her ability to concentrate at work.

After just 4 sessions at Nick Rinard Physical Therapy she was pain free and equipped with an effective, individualized exercise program that supported her fitness goals without compromising her If your workout is wearing you down, we can help you get on the right track! Don’t settle for suffering through your exercise routine when you could be thriving.


The Power of Posture

ToyPoodle wearing Sunglasses Outdoor

What do a toy poodle and the human head have in common? They both share an average weight of 10-12 pounds. Your spine has three natural shock-absorbing curves which attenuate the stress of bearing that load above your shoulders while you move through your day. With good posture and frequent position changes, most of us can bear that weight without difficulty.

However, the moment you drop your chin to read the latest blog update on your cell phone the balance changes completely. When your head inclines forward 60 degrees the force your neck is bearing is equivalent to exchanging that toy poodle for a Labrador retriever – 60 pounds of force (Hansraj, 2014)! Consider that the average person sustains this position for 2-4 hours a day while using their smart phone and the load quickly becomes overwhelming. This chronic fatigue to the muscles and structure of the neck can lead to debilitating injury.

Your neck will thank you for contacting Nick Rinard Physical Therapy to address your posture.

Let us help you get that heavy Labrador off your shoulders!

Hansraj, KK. “Assessment of stresses in the cervical spine caused by posture and position of the head.” Surgical Technology International. 2014, November; 25:277-9


Miki’s Perspective: As a DPT Candidate and Patient

As a PT student exposed to the McKenzie Method for the first time, I observed therapeutic results that appeared miraculous in their efficiency and expediency. It was eye-opening to learn the principles of MDT and the systematic logical approach to classifying and treating notoriously difficult-to-treat conditions including chronic debilitating back pain. Many patients I observed confessed they had battled back pain for decades and tried everything, including pharmacology, chiropractic, acupuncture, massage, as well as craniosacral therapy.

When I was injured in a car accident, I received McKenzie treatment and felt better within the first 2 weeks. In this car accident, I had been rear-ended at high velocity on the freeway, and was recovering from a fracture. My treatment included rest (lying down for 10 minutes) to reduce inflammation and gentle range of motion exercises. This was doable despite a busy schedule and I was able to resume my regular workload sooner than anticipated.

Previously, I had been rear-ended twice at lower velocities, and pursued chiropractic and massage treatment both times. Chiropractic involved 3 visits per week initially, and went on for a year. This took a lot of precious time out of my schedule and came at a high financial expense. At the time, I noticed I felt better whenever I stayed active, but the sharp pain in my neck and back returned several times per week. I felt unable to manage my pain and thought I needed the chiropractor to “fix me.”

Nick Rinard Physical Therapy Portland Oregon Logo GreenAt Nick Rinard Physical Therapy I achieved a pain free full return to function in less than 2 months. Over the last 4 weeks, I only required 2-3 visits and was able to manage exacerbations of pain mostly on my own since I knew what exercises would provide relief. In addition to effective treatment, I was happy with the way Nick and his team treat everyone. I always felt welcome and appreciated, like a member of the family.

As both a student and patient of MDT, I am thrilled at the results it provides.

Patient perspective:

McKenzie is initially less hands-on compared to other PT approaches. The patient is an active participant in healing, and engages in a personalized home program from day one. Education is an integral aspect of treatment. This empowers the patient to understand the cause of their ailment, and provides the patient with tools to remedy recurrences or exacerbations. McKenzie treatment is a great investment of a patient’s time and funds, as it provides a toolkit to effectively self-manage pain.

Physical Therapist (PT) perspective:

McKenzie therapy is a disciplined classification system with a logical testing protocol that guides treatment. The classifications and associated interventions and progressions can be applied to many health conditions. Having a clear protocol helps the therapist stay focused and effective when the clinical presentation appears unclear. MDT includes the patient as an educated, active partner and decreases patient dependency on passive treatment mechanisms. Patients tend to obtain good results quicker and need fewer visits compared to other therapeutic approaches. MDT is based on understanding the mechanical and physiologic events of spinal derangements, altered tissue, and inflammation. It is logical and effective.

How MDT is different:

McKenzie therapy provides a clear, well-organized protocol to assess, classify, and treat health conditions appropriate for physical therapy. Treatment consists of limited, low-dosed and highly targeted exercises designed to provide clarity of diagnosis. This serves as the dependent variable whose effect is measured and helps clarify the clinical picture. Patient’s response to treatment is generally assessed within 48 hours, and fine-tuned/altered/progressed according to findings. Due to this disciplined and focused approach, MDT frequently resolves common conditions including back pain and neck pain in less visits, and therefore at substantial financial and time savings.


Balance and Aging

It is general knowledge that, as we age, our sensory systems start to decline. This includes sight, smell, temperature regulation and balance mechanisms.  It’s important to have good balance because if it declines, you are at a higher risk for falling.  And falling, results in injuries that can greatly affect your life.

Exercises that Challenge your Balance

What many people don’t know, is that you can work on making your balance stronger, just like you do a muscle: by exercising it!  What physical therapy aims to do, is find exercises that challenge your balance system, so that your body must learn to adapt to certain situations and re-train itself on what to do.

Static and Dynamic Exercises

Physical Therapists can provide both static and dynamic exercises for you, depending on what is most challenging.  Exercises can be very simple and integrated during daily routines- like balancing on one leg while brushing your teeth.

If you are having trouble with your balance, come in to Nick Rinard Physical Therapy and have an assessment by a physical therapist! 503-244-6232


One-on-one Appointment with PT Improves Satisfaction

Physical Therapy clinicians are not only therapists, they are educators. A big part of being a physical therapist is answering patient’s questions and educating them on anatomy, the proper way to perform an exercise, how to walk and transfer safely, and what to expect going into surgery.

One-on-one educational session with a physical therapist

A recent study looked at the benefit of having a one-on-one educational session with a physical therapist prior to having a total joint replacement surgery. A researcher split 126 patients into two groups: one group had a group class prior to having surgery, the second group had an additional one-on-one session with a physical therapist. “Significantly more patients who attended the extra one-on-one counseling session with the physical therapist before surgery indicated that they were better prepared to leave the hospital after surgery and were, overall, more satisfied with the preoperative education they received,” Dr. Joshi stated.

Additionally, the patients who received the one-on-one session had required fewer PT sessions in the hospital and met discharge criteria (walking up/down stairs and transferring out of bed) faster.

What this indicates is that patients benefit from a one-on-one educational session with a physical therapist prior to joint replacement.

Improve overall satisfaction

Patients, therefore, may consider having a pre-surgical appointment with a physical therapist to improve their overall satisfaction and outcomes following a total joint replacement




Physical Therapy decreases opioid use

Seeing a physical therapist first for low back pain decreases overall out of pocket costs, opioid use, and less ER visits.

Study from the University of Washington and George Washington University

A study split patients into three groups. The first group saw a physical therapist first “PT first” group. A second group was “PT later” group, as they saw another provider initially, but eventually had physical therapy.  The last group was “No PT” as they never had physical therapy.

This study found that the group that saw “PT first” for low back pain had lower costs for care vs the “PT later” and “No PT” groups (this includes what they are paying out of pocket). The “PT first” group also had lower costs with emergency room visits, imaging, and opioid use.

Physical Therapy reduces prescription medication use

What this means is that seeing a physical therapist can not only reduce your pain and use for prescription medication, it also costs you less! Since Oregon has direct access for physical therapists (by law, you do not need a physician referral to see a physical therapist), patients should be using this route directly for treatment of their low back pain. Call Nick Rinard Physical Therapy today and schedule your pain away! 503-244-6232





Total Knee Replacement (TKA) and Physical Therapy

At Nick Rinard Physical Therapy a lot of patients come to see us with knee pain and/or knee arthritis, both before and after various knee surgeries, including total knee replacement surgeries.

Since 2010, knee replacements have been the most performed surgery on people over 45 years of age. Knee replacements are performed at the rate of 700,000 per year. Because of this increasing rate, the efficacy of pain relief and improvement of function should be investigated.

100 patients with knee arthritis

A researcher, Soren Thorgaard Skou, has done just that. In his study, he looked at 100 patients with knee arthritis and assigned them to a surgical group or non-surgical group (which received physical therapy, medication and diet education). After one year, 85% percent of the surgical group had significant improvements in pain vs 68% of the physical therapy group. The surgical group and larger gains in their ability to climb stairs and walk. However, the study also showed that the surgical group is at greater risk for complications that the physical therapy group is not. The surgical group is more likely to have blood clots or a manipulation (another procedure performed by the surgeon to increase range of motion). The surgical group had more adverse side effects vs the physical therapy group (24 vs. 6).

Physical therapy is effective

Physical therapy is effective and should be considered a viable option before jumping to surgery. If the first knee replacement can be delayed, this can decrease the necessity for a second surgery (current replacements last 10-15 years).  We urge our patients to remember that we are always here for you before or after surgery.  Nick Rinard Physical Therapy is a phone call away 503-244-6232 !

1/3rd of knee replacements are unnecessary

This, taken into consideration with the study that came out last summer that found nearly 1/3rd of knee replacements are unnecessary, should be considered when deciding to have a knee replacement or a trial of physical therapy to determine effectiveness.

Dr. Skou’s report (N Engl J Med. 2015 373;17:1668-9)


Hiring: Physical Therapist Position Open



Physical therapist, 1 part-time and 1 full-time position available


Cert. MDT or seriously pursuing certification; valid or eligible for OR PT License. High level of professional and personal excellence is expected.
Our Clinics are MDT-based, outpatient physical and occupational therapy practice, 2 Portland locations (SW Portland and by Portland Airport)


Clinics are open 7-6 Monday –Fridays


• Compensation competitive for private practices in our area
• Incentive program based on productivity and leadership available
• 24 Paid Time Off days/year
• Excellent Health insurance
• Excellent Dental insurance
• 401K for individual contributions
• 3% 401K match by MDT
• 401K MDT Profit Sharing Plan
• License fee compensation
• Continuing Education allowance
• Sign-on Bonus for new grads or Relocation Assistance

Other Benefits:

• Exceptional work environment: collegial, esthetically pleasant, friendly, open, professional, conducive to learning
• This is a great opportunity for the right therapist looking for further training/mentoring in the McKenzie & MDT method
• Portland is a great place to live, offering year-round outdoor activity, coast and mountains, and a comfortable city scene


Please EMAIL resume and letter of interest.

Michelle Tillman, office manager
Nick Rinard Physical Therapy
9700 SW Capitol Hwy, Suite 140
Portland, OR 97219
Tel. 503-244-6232
Fax 503-296-2305

  • Principals only. Recruiters, please don’t contact us
  • do NOT contact us with unsolicited services or offers

Shoulder Pain

Nick came across this article about shoulder pain and MDT approach to treatment that we use at Nick Rinard Physical Therapy clinic.  He thought it would be informational for our audience.


Case Report

Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series Maria Corazon Aytona1 , Karlene Dudley2 1 Southeastern Regional Medical Center, Lumberton, NC, USA, McKenzie Institute, NY, USA, 2 Southeastern Regional Medical Center, Lumberton, NC, USA The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), is primarily recognized as an evaluation and treatment method for the spine. However, McKenzie suggested that this method could also be applied to the extremities. Derangement is an MDT classification defined as an anatomical disturbance in the normal resting position of the joint, and McKenzie proposed that repeated movements could be applied to reduce internal joint displacement and rapidly reduce derangement symptoms. However, the current literature on MDT application to shoulder disorders is limited. Here, we present a case series involving four patients with chronic shoulder pain from a duration of 2–18 months classified as derangement and treated using MDT principles. Each patient underwent mechanical assessment and was treated with repeated movements based on their directional preference. All patients demonstrated rapid and clinically significant improvement in baseline measures and the disabilities of the arm, shoulder, and hand (QuickDASH) scores from an average of 38% at initial evaluation to 5% at discharge within 3–5 visits. Our findings suggest that MDT may be an effective treatment approach for shoulder pain.