Clinical Conversations

Dealing with pain on a daily basis is fatiguing and frustrating. At Nick Rinard Physical Therapy, we empower our patients with individual, customized home exercise programs to help you gain control of your symptoms. We believe in education, and prioritize teaching our patients how to become effective in their daily routines.  If you are tired of being a victim to your out of control symptoms, contact us! Our team is dedicated to helping you chart a course to better health.

Many times we have patients who come for physical therapy treatment describing pain in their leg, but it turns out to be coming from their spine. This is often confusing for people, especially if they have been given a provisional medical diagnosis related to the area of pain, like “piriformis syndrome”, which is pain in one of your gluteal muscles. You may wonder how we determine where the pain is coming from and what to treat. Pain is produced by sensory nerves. Sensory nerves can be triggered locally at the spinally level, or peripherally either by muscle tension or injury. During the evaluation we always perform spine ROM to determine if the source could be coming from the spine. The screen must begin from the center outward. In some cases, knee/hip/ankle pain will decrease or increase during the lumbar spine screen, and then we know it is coming from the spine. This can be hard to understand for some patients because the pain they are experiencing feels like it is coming from that very spot, whether it is a joint or muscle, that is painful. For example, I recently evaluated a patient with ankle pain. She had even fallen, which made it possible she could have some trauma to her ankle from the fall. However, during the lumbar spine screen, her ankle pain decreased while performing a back bend. She was in disbelief that her ankle pain went away. After only a few visits her ankle pain was gone and it did not return. One of her lumbar discs was pressing on a nerve root and causing her ankle pain, and the back bending pushed the disc away from the nerve and abolished the pain. The moral of the story is, we can never assume a diagnosis until a thorough examination is performed.

“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.