Every veteran manual therapist knows this scene: the door opens, and a patient enters, usually hunched and walking cautiously. He sits down, sighs, and places a large envelope (or a USB drive) on the table. His eyes reflect a mix of pain and deep anxiety. "The doctor said I have an L4-L5 disc herniation with pressure on the thecal sac," he says, voice trembling. "He told me I have the spine of an 80-year-old. I’m afraid any wrong move will paralyze me. Can you even touch me?"

 

In this article, based on the principles of our "Imaging Interpretation for Therapists" course at Manual IL, we dive into this paradox. We will understand when imaging findings are critical and require caution or referral, and when they are merely anatomical "background noise" that causes unnecessary stress and hinders recovery.

 

Chapter 1: VOMIT – Victims of Modern Imaging Technology

The term VOMIT (Victims of Modern Imaging Technology) highlights a modern challenge: our imaging resolution is so high that we see every minor tissue change, but the technology cannot distinguish between a change that causes pain and one that is a natural part of aging—essentially "internal wrinkles."

The Groundbreaking Evidence: Massive systematic reviews (e.g., Brinjikji et al., 2015) examined thousands of asymptomatic individuals (people without back pain) and found:

• Among 40-year-olds: ~50% have a disc bulge or herniation, and ~68% show signs of disc degeneration.
• Among 60-year-olds: The numbers jump to over 80% for degeneration and over 60% for bulges.

Clinical Insight: If you take a random person off the street, they likely have "pathologies" on an MRI. As Giveon Peled (STB) suggests, a structural finding often becomes symptomatic only when the surrounding muscular and fascial environment loses balance.

 

Chapter 2: Clinical Correlation – When Does Imaging Matter?

At Manual IL, we view imaging as a critical tool, but only when it matches a meticulous clinical examination. Eyal Feigin emphasizes: "We don’t treat the picture; we treat the person. The picture must match the clinical presentation."

When is an MRI finding relevant?

1. Dermatomal Correlation: If an L5 root compression on MRI matches pain or numbness along the L5 dermatome (lateral thigh, anterior shin, and big toe).

2. Myotomal Correlation: Weakness in a specific muscle innervated by that root (e.g., weakness in lifting the big toe).

3. Reflex Changes: A diminished or absent tendon reflex (e.g., the Achilles reflex in L5-S1 herniation).

The Common Trap: Many patients diagnosed with "Sciatica" actually suffer from Somatic Referred Pain. The source is often trigger points in the gluteal muscles or Piriformis Syndrome. In these cases, STB and joint mobilizations will solve the problem despite the "finding" on the MRI.

 

Chapter 3: The Danger Zone – Red Flags for the Manual Therapist

Distinguishing when to treat and when to refer to the ER is the mark of a professional.

Cauda Equina Syndrome (CES): A medical emergency where a massive herniation compresses the lower spinal nerve bundle.

Clinical Signs: "Saddle Anesthesia" (numbness in the groin/genitals), loss of bladder/bowel control, and bilateral leg weakness.

Action: Immediate ER referral.

Fractures: Suspected in cases of trauma or osteoporosis.

Action: Avoid HVLA or heavy pressure; refer to an orthopedist.

Malignancies or Infections: Non-mechanical pain (night pain that prevents sleep, unexplained weight loss, fever).

Action: Immediate medical investigation.

 

Chapter 4: The Psychology of Imaging – The Nocebo Effect

Giveon Peled emphasizes the impact of words. Terms like "bone on bone" or "severe degeneration" act as a Nocebo, creating Kinesiophobia (fear of movement). Our job is to "normalize" these findings, explaining that many MRI results are part of life and that one can live a full, active life even with a disc bulge.

 

Summary: Seeing the Bigger Picture

Imaging is a support tool, not a replacement for clinical reasoning. The Manual IL integrative approach maintains that:

• You must rule out Red Flags first.
• You must seek correlation between the image and the neurological signs.
• Most back pain is a response of soft tissues and fascia to structural changes, not direct nerve damage.
• You treat the person and their fears, not just their L5 vertebra.

 

Do you feel uncertain when a patient brings in an MRI? Want to learn how to identify Red Flags yourself and understand what is truly relevant to treatment? Join our unique course: "Imaging Interpretation for Therapists" at Manual IL.