The report that becomes a life sentence
What your scan does not say
A scan describes a structure at a moment. It does not describe your pain, and the gap between those two things is where a great deal of unnecessary fear and unnecessary surgery lives.
A scan describes a structure; it does not describe your pain. A scan describes a structure at a moment; it does not describe your pain. Disc bulges, degeneration and rotator cuff tears turn up in large numbers of people who have no symptoms at all, and their prevalence rises steadily with age in people who feel completely well. So a report can be entirely accurate and still not be the reason your back hurts. We read your imaging, we take it seriously when it changes the plan, and we will not let a phrase from a radiology report become the story you tell yourself about your spine.
Somebody hands you a radiology report. It contains the words degeneration, bulge, tear, or the particularly unfortunate phrase “wear and tear”. You read it as a description of damage, because that is what it sounds like, and from that afternoon onwards you have a story about your back.
The trouble is that these findings are extremely common in people who have no symptoms whatsoever, and they become more common with every decade of age in people who feel completely well. Disc degeneration, disc bulges and rotator cuff tears all appear in large proportions of pain-free populations. Which means a report can be entirely accurate and still not be the reason you hurt.
What the imaging is genuinely good for
Ruling things in and out that would change what we do. A fracture. A tumour. A nerve root under genuine compression with weakness to match. Surgical planning, when surgery is on the table. These are real and important and we take them seriously.
What imaging is poor at is explaining ordinary musculoskeletal pain. The correlation between what a scan shows and what a person feels is much weaker than everybody assumes, in both directions: people with dramatic scans who feel fine, and people in a great deal of pain whose scans are unremarkable.
The words that do the damage
“Degenerative disc disease” is not a disease. It is the radiological description of a disc that has aged, which every disc does, and by sixty most people have it whether or not their back has ever hurt.
“Bulging disc” describes a shape. Bulges are present in a large share of pain-free adults and the proportion climbs steadily with age.
“Tear” in a rotator cuff sounds acute and frequently is not. Degenerative cuff tears are common with age and many are entirely symptomless; a shoulder can have a full-thickness tear and full function. Finding one on a scan does not establish that it is the cause of the pain that prompted the scan.
None of this means your pain is imaginary. It means the picture is not the explanation, and being handed the picture as though it were is how somebody ends up protecting a back that would be better off being loaded.
What we do with your imaging
Read it, properly, and take it seriously. Then examine you, and see whether the findings and the examination tell the same story. Sometimes they do — a nerve root compression with matching weakness and matching distribution is a coherent picture and it changes the plan.
Frequently they do not, and then we will say so, and explain why the report is not the thing that should govern what you do next. That conversation is one of the more useful hours in this building and it happens several times a week.
We do not order imaging. Physical therapists in New York do not, and it is rarely the missing piece in a first presentation anyway. What we do is recognise the presentations that need it and send you to somebody who can order it, same day where the picture warrants it.
When a scan genuinely does change the answer
Progressive weakness. A sudden change in bladder or bowel control. Unexplained weight loss, night pain that does not vary with position, fever with back pain, or new bone pain in somebody with a history of cancer. Trauma with a suspected fracture.
Those are the things we screen for at every first appointment, and any of them means we stop and refer you the same day. The whole argument on this page is about ordinary musculoskeletal pain; it is not an argument for ignoring the presentations that need a physician.
In order
How this works in practice
Bring the report, not the disc
The written report is what we need. We are not going to page through images we are not licensed to interpret formally.
We read it before we examine you
Then we examine you without letting it decide the answer in advance.
We compare the two stories
Does the examination reproduce a picture consistent with the finding? Frequently it does not.
We tell you which one we are treating
And why. If the finding is incidental we will say so plainly, and explain what that does and does not mean.
We escalate if the picture warrants it
Progressive weakness, a change in bladder or bowel control, or any red flag means a physician the same day.
Questions we are actually asked
What your scan does not say — frequently asked
My MRI shows a herniated disc. Do I need surgery?
Usually not on the strength of the scan alone. Most herniations reduce over months and most people with them do well without surgery. What changes the answer is progressive weakness, loss of bladder or bowel control, or a genuinely unmanageable course that has not responded — and those we escalate immediately rather than treat around.
If the scan finding isn't causing my pain, what is?
Frequently a combination that is less photogenic: a tissue that has been asked to do more than it currently can, movement patterns that have adapted around a past episode, deconditioning, and a nervous system that has become efficient at producing pain. None of that images well and all of it responds to loading and to time.
Are you saying my pain is in my head?
No, and we would ask you to hold us to that. Pain is real, it is produced by a real nervous system, and telling somebody their pain is imaginary is both cruel and clinically useless. What we are saying is narrower: the picture is not automatically the explanation.
Should I get a scan before starting physical therapy?
Usually not. For ordinary back, neck and joint pain a scan rarely changes what the first six weeks of treatment should be, and it carries a real cost in the form of findings that frighten people out of moving. Where a presentation genuinely warrants imaging we will recognise it and send you to somebody who can order it.
Can a physical therapist order an MRI in New York?
No. We do not order imaging and we do not formally interpret it. What we do is read your report, examine you, and recognise the presentations that need a physician — which is the part of this job the direct access law's three-year experience requirement exists to protect.
Sixty minutes, one to one, with the therapist you chose
Book an appointment
The booking page shows each therapist's own diary rather than a generic grid, so a slot you can see is a slot that is genuinely free. Most people do not need a doctor's referral to start — New York's direct access law runs to ten visits or thirty days — though Workers' Compensation, No-Fault and Medicare each need one from the first visit. If you are not sure which of those you are, telephone and we will work it out before you book.