Do Physical Therapists diagnose? What's really in a name?

So, you’ve been having some shoulder pain for a few weeks that just isn’t going away.  What do you do next? … go see your primary care doctor, of course!  Common sense says you need to get it checked out to make sure nothing serious is going on, an

d you need something stronger than Tylenol to kick it so you can go about your business. After all, a doctor knows all about the body…they kind of went to school for it, right? 

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. But just how accurate is their assessment and diagnosis for these types of conditions? 

In a study published in the Journal of Orthopaedic & Sports Physical Therapy, PTs demonstrated 75% diagnostic accuracy — nearly identical to orthopedic surgeons at 80%. However, data showed only 35% accuracy for non-ortho providers.  That means nearly 2 out of 3 people may not be receiving the most accurate musculoskeletal diagnosis on the first visit. One has to wonder how accurate an assessment can be when  it’s not their specialty, and they have very little time to assess and address it in a single appointment. 

Another study (1) showed a 90% concordance in the diagnosis of orthopedic conditions between PTs and orthopedic surgeons. The same study reported:

There was an 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.

“I don’t understand. Why would there be such a difference between PTs and non-orthopedic providers?  They are experts on the body.”

That’s kind of like saying I know a good amount about cars, because I’ve studied them, owned them, and done some of my own work on them. But I’m not a mechanic, and I’m not going to try to tell someone what’s wrong with their vehicle or how to take it apart and fix it. 

Yes, doctors receive extensive education in anatomy and the function of the body. However, providers who do not specialize specifically in orthopedics aren’t experts in orthopedic conditions and movement dysfunction. This is all I do every single day as a PT.  

In my career, I have had numerous physicians, surgeons, specialists, and medical providers from a range of specialties, whom I still have to educate on their pain, injuries, movement dysfunction, and help to correct misconstrued ideas. Often, non-ortho providers still operate under the outdated education they received years ago. Commonly, I will assess a patient and come to a different conclusion or diagnosis than the one the prior provider gave them before they saw me.  I’m then put in a position of providing some education on what’s going on without throwing their doc under the bus!

Let’s break this down in an example: The dreaded IT Band Syndrome.  

If you have exercised and / or played sports for any extended length of time or if you are a runner or cyclist, you have probably experienced this to some degree.  

Now, the prevailing education you will receive from your doctor is to “stretch” or “roll out” your IT band.  (By the way, IT stands for “Iliotibial” which are the attachment sites of it).  This may feel good temporarily (or at least hurt then feel good after), but it doesn’t last.  The reason for this is that your IT band isn’t tight.  It can’t be tight, because it’s not a muscle. It’s not an elastic tissue. The IT band is a tensile fascia that provides stability between your hip and knee.  If it was truly “tight” or “shortened”  you would be walking around with your leg out to the side and rotated outwards like an exaggerated impersonation of a cowboy or sumo wrestler, because this is how the IT band pulls on those joints. 

What do I do as a PT when I see someone from their doctor with a referring diagnosis of “IT Band Syndrome”? 

First, there are a couple of tests to look at the mobility of the IT band, so I perform those. 9 times out of 10 those tests are negative. I look at motion at your hip and your knee. I look at the strength of your entire leg. I look at how you walk, how you squat, how you stand on one leg, how you run. I do tests to rule out other possible conditions. I spend upwards of an hour with you on this one issue. Not 7 minutes. Not 12 minutes. An hour. 

My findings?  I saw that your hip muscles on the outside were weak. I saw that your hip drops and your pelvis doesn’t stay level when you stand on one leg. I noticed that your leg often crosses over the midline of your body while walking and running. I observed less control of your knee on that side when you would squat.  

My conclusion, which is a common one for IT band issues, is that your hip muscles are weak and you lack pelvic control in weight-bearing which leads to movement compensations and overloading of your IT band to make up for the lack of control and strength you don’t have at the hip. So your brain tells you the IT band is under excess strain.  My eyes tell me it’s not your IT band that’s the issue at all. 

This is the difference in a PT who is trained to observe, assess, diagnose, and treat musculoskeletal and movement dysfunction compared to a provider who pokes on your leg, maybe moves it a little bit, gives you a diagnosis and a prescription and sends you on your way. 

Identifying and addressing this pattern of pain and dysfunction is the basis of my job. The body is going to be as efficient as it can be to complete whatever tasks you place on it.  This means your body can deceive you, cut corners, steal movement from somewhere else, and take the easy path of least resistance if it means taking strain off an area where there is something that’s not quite right going on. 

Your shoulder blade can hurt, but it’s coming from your neck. Your leg can hurt, but it’s coming from your back.  The front of your shoulder can hurt, but it’s because the muscles of your shoulder blade in the back aren’t working right.  Your elbow can hurt, but it can be coming from your neck or your shoulder not moving right.  Most non-orthopedic providers aren’t able to properly assess and diagnose this.  

An orthopedic surgeon can absolutely diagnose it. But their primary expertise is surgical management. A PT’s expertise is conservative, movement-based treatment — and often that’s exactly what’s needed.

In most states, you don’t need a physician referral to see a physical therapist.

That means you can go directly to a musculoskeletal movement specialist first.

With this knowledge in mind, the next time you have been having some kind of joint or muscle pain or movement issue going on, who are you going to call? 

(Hint: not the Ghostbusters… and not necessarily your PCP either.)