One of the primary things I like about being a manual therapist is that I get to be a detective and gather information, which allows me to solve a problem. A new patient presents with an issue and you listen to their medical history, find out what activities cause the problem, and then perform a thorough evaluation.  These steps  provide a roadmap to which tissues are producing the symptoms. By strictly following these principles, you can often figure out how to help someone — even if problem seems complex.

Unfortunately, too many times health care providers take shortcuts and make false assumptions leading to treatment failure.  By making these assumptions, they skip parts of the information-gathering process that could reveal the true cause.  It seems like patients are being told is all shoulder pain is a rotator cuff problem. All hip pain is from trochanteric bursitis or from a degenerative hip that needs to be replaced. All heel pain is from plantar fasciitis. And one of my favorites, all lower back pain is coming from bad discs.  And the best way to determine the source is through diagnostic imaging, such as x-rays, MRIs, CT scans, or ultrasound.

Well, in practice I have found these assumptions are often not true leading to poor progress with treatment. What is being missed is that diagnostic testing provides  pieces of information, but you need to put all the pieces together to see the true picture.  What is often forgotten are 2 key concepts — differential diagnosis and clinical correlation.

Differential diagnosis involves the process of examining various possibilities, ruling out those that are not the source of the problem in this situation, and then seeing what diagnosis seems the most likely.  Next comes the process of clinical correlation.  Does the diagnosis make sense based on what the patient is telling you is wrong and what you are finding in your clinical exam.

A good example of this situation is a call I got this week from a patient saying they have been having lower back pain for the past month that is coming from bad  discs and that weeks of treatment has not helped.  These types of calls are all too frequent.  A common occurrence with treatment failures relate to the lack of differential diagnosis and lack of clinical correlation.

I have found that lower back pain may be from multiple possible sources that include:

  1. Biomechanical malalignments that may be in the pelvis, lumbar spine, and/or hips.
  2. Muscle strain in the lower back, trunk, or thighs.
  3. Fascial strain into the lower back that originates from joint dysfunctions in the feet and ankles.
  4. Fascial strain into the lower back that originates in the organs in front of the spine.
  5. Poor nerve gliding resulting from inflammation and/or infection in the area that may or may not be current.
  6. Primary somatic dysfunctions in the cranial base and cranium that are causing pulling at the other end on the spine from tension on the dural layer of the spinal cord.
  7. Sympathetic nervous system facilitation, perhaps from stress, that results in increased tissue tension and decreased blood flow leading to lower oxygen levels.
  8. Intervertebral discs.
There is a reason I listed intervertebral discs last.  Lower back pain from true discal sources must present will ALL of the following: sensory changes (pain, numbness, burning), motor weakness (often an inability to walk on the heels and toes or weakness found in muscle testing), and changes in deep tendon reflexes in the patellar and/or Achilles tendons.  In addition, true discal patients usually present with increased neural tension that causes pain immediately with straight leg raise or Slump nerve gliding tests.   Unless someone presents with all of these factors, the source of their back pain is usually coming from one or more of the other sources listed above.  In my 30+ years of practice, I have found had ONLY a handful of lower back pain patients that I thought were truly discal in nature and that surgery was the appropriate choice.
Why all of the emphasis on discs?  Medical opinions seemed to change in the 1930s.  In the 1920s, German pathologist Christian Georg Schmorl  discovered disc herniations during autopsy of 10,000 spines.  By 1934, neurosurgeon William Mixter, M.D. and orthopedic surgeon Joseph Barr, M.D. presented a study of 19 cases that revealed a correlation between disc prolapse and the clinical syndromes associated with the resulting nerve and cord compression. They advocated a surgical approach and the diagnosis of a “ruptured” disc gained traction in the medical community.  This theory remains the prevailing source of lower back pain today — despite evidence to the contrary.

In 1994, a study by Maureen C. Jensen et. al. published in the New England Journal of Medicine found that only 36% of asymptomatic subjects had normal disks at all levels. 52% had a bulge at least one level and 38% had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The findings were similar in men and women.

The primary reason that a diagnosis of a lower back pain from a discal source may be a poor choice is the total reliance on diagnostic imaging without clinical correlation. Many of the other sources listed above cause pain as a result of movement disorders. Pain is produced when there is inappropriate motion in a joint or a fascial restriction in a muscle or deeper layers or around an organ that produce a tissue pulling in lower back when the person moves in certain directions.  These restrictions often also cause decreased blood flow to the area that delays healing. However, diagnostic images are just still pictures that are incapable of considering movement disorders.

So to avoid these issues in your clinic, always perform a thorough exam in order to produce a good differential diagnosis and always do a clinical correlation of any diagnostic imaging findings to determine if the findings match what you find on your table. And if not, treating what you find often gives you much better results.