Have you ever wondered what goes through your doctor’s head when treating your back pain?
Gerard Malanga, MD, is a physiatrist that is board certified in physical medicine and rehabilitation, sports medicine, and pain medicine. Using a patient example, Dr. Malanga shares his thought process through the patient care lifecycle—from the first appointment through recovery.
Larry is a 56-year-old computer programmer who plays golf at every opportunity—even when the greens are covered in snow. But low back pain has set Larry’s game back, and he’s not able to manage the pain with his trusty heating pad and occasional over-the-counter pain reliever. His primary care physician referred him to Dr. Malanga.
Q: Why did Larry’s primary care physician refer him to you?
Dr. Malanga: Larry’s primary care physician referred him to me as opposed to a spine surgeon because my specialty in pain and sports medicine approaches care by maximizing conservative, non-operative techniques. The United States has 4 to 6 times the surgical rate of most other countries, so referring to a non-operative spine specialist is the best initial approach for Larry.
Dr. Malanga: After learning about Larry’s medical history, I would dig deeper into other areas of Larry’s health status. I asked about his diet, physical activity level, current psychosocial status, and smoking status. These things can have a great impact on how Larry feels, how he functions, and they helped me craft his treatment plan.
In learning more about Larry, I discovered that his occupation was likely contributing to his pain. He’s a computer programmer, so he spends a lot of time sitting. Sitting is one of the worst things you can do for your spine—some even consider sitting a disease. When you sit for a long time, your hip muscles get tight, and your glutes and spinal muscles get weak. Larry sits most of his day and then spends the weekend golfing, so suddenly using those weakened muscles can cause pain.
Larry also said his pain worsened when he swings his golf club and bends to pick up a ball or tee. However, his pain eased during resting and sleep.
Q: Tell us about Larry’s physical and neurological examination. What did you discover?
Dr. Malanga: During Larry’s physical examination, I looked at alignment, motion, inflexibilities (not only of the spine but other areas like the hips and lower extremities), and muscular imbalances and weaknesses.
I noted that Larry had a flattening of lumbar lordosis, so the nice gentle curve in his low back had flattened out. He had restricted motion in one direction—flexion. I also found that he had weakness in his buttock muscles and hips, and he had tightness in his lower extremity muscle groups.
His neurological exam was normal. When I pushed on certain areas along his spine, he had tenderness in his mid to lower lumbar spine and areas where joints are found. Initial treatment for Larry’s mechanical low back pain would include: anti-inflammatories and physical therapy. While there are injection techniques we could use, the best initial treatment is work on the muscular imbalances of his spine and lower extremities that are affecting his biomechanics in daily living and his sport.
Q: Are there any other exams you might consider for Larry?
Dr. Malanga: I might consider giving Larry a functional movement screening. This test is often used in sports medicine to check for imbalances from the feet all the way up to neck. After this evaluation, Larry would receive specially designed exercises from a physical therapist to address the muscular imbalances that are found.
Q: Did Larry need radiographic, CT, or MRI imaging?
Dr. Malanga: Many people believe that imaging tests are essential to the diagnostic process, but I disagree. In some cases, imaging tests do more harm than good. In Larry’s case, I don’t believe his pain and symptoms warrant imaging tests. He has mechanical symptoms with a normal neurologic examination. Imaging at this point, would not affect the treatment plan.
The problem with indiscriminately ordering an imaging test is that we might find a lot of things in his age group or older that have nothing to do with his complaints. If you ordered an imaging test for a 56-year-old man with no pain, you will likely find abnormalities. This often leads to unnecessary treatment.
My goal for Larry is to get him pain free and functional—I would not want him to worry about what an imaging test might show.
Q: Why are imaging tests important? Do the results confirm your diagnosis?
Dr. Malanga: Imaging tests are important when someone has neurologic findings or complaints, such as muscle weakness or sensory loss, because this may indicate the potential need surgical treatment. Imaging tests are also helpful when guiding targeted treatments, such as epidural steroid injections. Also, if your doctor has concerns there may be something serious involved, such as a spinal tumor or infection, you should receive an imaging test right away.
Q: What was Larry’s diagnosis?
Dr. Malanga: Because Larry’s pain worsened during golf and eased during sleep, I diagnosed him with mechanical low back pain. This type of back pain is affected by various mechanical activities or loading, whereas non-mechanical low back pain is pain that exists all the time.
Q: Please describe your thought process as you developed Larry’s treatment plan.
Dr. Malanga: My treatment plan is initially focused on controlling pain and inflammation. I first recommended judicious use of anti-inflammatory medication and heat compresses. I prescribed a short course of anti-inflammatory medication for Larry, as using these drugs for too long increases the risk for cardiovascular problems. After completing the course of medication therapy, I suggested Larry take naturally derived supplements, such as turmeric, bromelain, and high-dose omega 3s, to reduce inflammation. These have been proven to be effective without the potential serious side effects from both over-the-counter and prescription medications, such as non-steroidal anti-inflammatory medications.
Larry and I also discussed his diet. I recommended reducing his carbohydrate and processed sugar intake to curb inflammation, while upping his consumption of healthy fats and sugars like those found in nuts and berries.
I would teach Larry some simple movement strategies, including how to position himself at work and stretches he can do throughout the day. While those small adjustments can reduce pain in the short term, I suggested that Larry work with a physical therapist to build sustained strength and flexibility, which should start taking shape in 4 to 6 weeks. After a few sessions with a physical therapist, the goal is for Larry to be able to do those exercises on his own.
Q: How soon until Larry’s low back pain allowed him to return to golf?
Dr. Malanga: Rather quickly, if he safely uses his natural anti-inflammatory supplements and follows through with a few weeks of physical therapy. The key is that Larry start slowly—jumping into a round of 18 before finishing your course of physical therapy would set him back. I recommended he start by playing 9 holes after completing physical therapy, and then take a day or 2 to see how he feels. If he takes it slow, he should be back to full strength on the course within 2 months after his initial visit with me.
I also shared these preventive tips with Larry to help keep him on the course and pain at bay:
Visit the SpineUniverse Golf and Back Pain Slideshow for some inside tips on simple exercises and stretches for golfers.