In the primary care setting, one of the most common reasons for somebody to visit a physician or a health practitioner will be low back pain. It’s also very common to have neck pain, to have shoulder pain, knee pain, ankle pain, etc. Unfortunately, medical education has lagged quite a bit in terms of preparing primary care practitioners for this type of complaint. the amount of training that they receive in medical school and then in residency regarding the evaluation of some of these very common musculoskeletal conditions is very minimal. One very important point that I want to make is that imaging studies should not be the first thing that you order. If you start with the imaging studies, there’s going to be a lot of red herrings, a lot of pathology that will send you down the wrong path when, in fact, the pain generator or the pain condition may have absolutely nothing to do with that. The first thing that you should do is try to get a thorough history, do a basic physical examination, and with that, you probably have 85 or 90% of your diagnosis. Don’t get me wrong; some of these imaging studies are very important, but they are to be used in conjunction with your thorough physical evaluation, including the history of the patient.
Many conditions in the musculoskeletal system except for significant trauma with derangement of joints, etc., are actually self-limiting. It’s a matter of reassurance; it’s a matter of using some rest, maybe some anti-inflammatory medications, then getting into some stretching and physical therapy. We’re just too quick to try to medicate people when we probably want to stay away from that because that really takes us down the wrong pathway. That being said, it’s always important to look for what we call “red flags” or things that should alarm you as a provider that there could be something very wrong here. For instance, in low back pain, we could be looking at infection, at malignancy, at invasion of the vertebral bodies, etc. Whenever you explore for some of those in the history, there’ll be some key historical findings, neurological evaluation, that should prompt you to say, ‘there could be something very serious here, and we really need to move on this faster.’ When it becomes something that continues to progress or doesn’t get better after initial management, it’s time to enlist a specialist.