Thursday Thoughts: What is Wrong with This Patient Vs What Can I Do For This Patient? | Modern Manual Therapy Blog

Thursday Thoughts: What is Wrong with This Patient Vs What Can I Do For This Patient?

This edition of Thursday Thoughts is something I have wrote about before, It's a question I see often asked on social media PT circles.

Traditionally, much of our entry level, and indeed continuing education is focused on evaluation. This is a good thing that separates our profession from others who would perform a la carte based services. However, too much emphasis is often placed on diagnoses, which includes both ruling out and ruling in.

Ruling out is a good thing, you still want to screen for red flags, even if a recent systematic review found most of our traditional ones are not significant.

Ruling in is where I find most clinicians get stuck in analysis paralysis. If finding out whether or not someone has an internal shoulder vs external shoulder impingement, rotator cuff tendinitis, or subacromial bursitis affects your treatment and patient education, and you can come to that conclusion efficiently, then stop reading and continue treating. If you do provocation tests, manual muscle testing of each muscle around the patient's complained area, and in general spend 20 minutes on minutiae only to use the same old IASTM, joint mobs, and patient education/exercises, then why did you want the diagnosis in the first place? That diagnosis, especially if using negative terminology like "rotated sacrum," "out of place," "herniated disc," can lead to nocebo, and adversely affect your outcomes.

The diagnosis should be de-emphasized, and your clinical decision making should be based on what you can do for them, and how you can educate them, versus finding out "what is wrong" in terms of pathoanatomy.

I give my patients this choice: "Would you rather....

  • have simple self assessment and treatment homework that addresses your condition or....
  • have an educated guess on your diagnosis that involves a lot of extra testing that may or not be relevant?
What would you opt for?

Keeping it Eclectic...


  1. How about both? You want to give your patient confidence you know what their problem/pain generator is instead of throwing darts. This oversimplification of our profession is a joke. This is the information age and patients know more than you think or they will go to the all powerful Google and ask you questions. It's less of an educated guess if you have some level of confidence you know what is really going on.

  2. I'm not quite certain how you reached this conclusion from this post. Do you have any data that demonstrate your point of, "...some level of confidence you know what is really going on"? It appears you are making an assumption that the assessment model proposed above is not sufficient to do so.

    Do you feel that, "...provocation tests, manual muscle testing of each muscle around the patient's complained area, and in general spend 20 minutes on minutiae..." has a place for every patient that you see, with demonstrably good literature to back up what you do?

  3. I have found that my patients cannot get over the fact that they do not have a SPECIFIC diagnosis that they can hold on to, post on facebook, look up on webMD, ask for advice on Twitter.
    Internal, external, biceps impingement, I don't care, all shoulders get 90% of the same exercise. If they don't have a Dx by 6 weeks, off to the tube, which gives us a snapshot it time.

  4. Quicker diagnostics leading to using more appropriate tools for better outcomes. Is that over simplified?

  5. I cite research to patients that getting a "diagnosis" or groups who received an MRI had worse outcomes than those who did not. It's all in how you present it, sure some really want a Dx, and I give them one to keep the interaction positive, but make sure not to focus on it at all.

  6. Contrary to popular belief, simplification is not a negative thing. Research support classfication versus diagnosis, enhancing clinical decision making and dictating treatment, thus improving outcomes. Focusing on the diagnosis or pathoanatomical dysfunction may lead to nocebo effect, and increase fear avoidance. You've never taken one of my courses, and if you would have, you would know i highly stress the positive interaction, with a great emphasis on Pain Science, which very strong evidence behind it. It has nothing to do with a lack of confidence, but doing what is best for the patient and getting them away from things that cannot be changed, like bone spurs, degeneration, asymptomatic disc bulges, etc.