LAS VEGAS — Clinicians involved in the treatment of musculoskeletal pain pathologies are frequently looking for tools that can change the way tests are ordered, interpreted, and used to improve the care of their patients. Understanding when a test is necessary not only assists with determining a diagnosis, but it also improves patient satisfaction. 

“Not only are many procedures unnecessary, some are actually harmful and can lead to mistaken diagnosis or endless rounds of follow-up testing when nothing is wrong,” said David M. Glick, DC, DAAPM, CPE.

He told attendees at PAINWeek that the medical community can enhance the use of common studies for pain diagnosis by the “better understanding of the clinical limitations as well as the significance of the results of such studies.”

Dr. Glick spoke of Choosing Wisely, an initiative launched by the ABIM Foundation that aims to identify unnecessary medical treatments, during his presentation. To date, the initiative has identified hundreds of potentially unnecessary medical tests and treatments.

The most important tools for differential diagnosis include history, clinical examination, and clinician experience, he said. There are adverse factors affecting physical diagnosis: limitations of time, reliance upon technology, and lack of clinical experience.

The reliability or the clinical relevance of any diagnostic procedure is never 100%, he said. The studies themselves could be deficient in a particular clinical situation. 

During his presentation, Dr. Glick reviewed shortcomings of common studies and identified ways to address them in a clinical setting. For instance, research shows that approximately 50% of asymptomatic patients have pathologies present on magnetic resonance imaging (MRI).1 

“The reverse is also true. So just because a study is negative for pathology, does not mean that a patient’s pain should go untreated,” he cautioned. “On the other hand, that same information when combined with clinical examination findings can be quite defining of the underlying pathology, even when the MRI is negative. Being able to understand how to use this information in the clinical decision-making process can completely alter the potential clinical course, resulting in improved clinical outcomes.”

It is important to note that there are various assessment measures tied to outcomes and patient satisfaction, he mentioned during his presentation. 

“Being able to explain what these tests are to a patient in simple terms they can understand goes a long way to address such measures,” Dr. Glick explained. “With even more patients having to deal with larger deductibles and out-of-pocket expenses, I would expect there are and will be thousands of discussions occurring daily as healthcare providers are attempting to explain the importance of the patients undergoing these tests.”

“Objective clinical examination findings should not be dismissed based solely upon negative test results,” he said. 


  1. Moosmayer S, Tariq R, Stiris MG, Smith HJ. MRI of symptomatic and asymptomatic full-thickness rotator cuff tears.  A comparison of findings in 100 subjects. Acta Orthop. 2010;81(3):361-366. doi: 10.3109/17453674.2010.483993.