Somebody walks into my clinic with six months of back pain. They have already had an MRI, two rounds of anti-inflammatories, one injection, and a conversation about whether surgery is next. Then they get sent to physical therapy.
By the time I meet them, we have spent thousands of dollars and half a year to arrive at the intervention that had the best odds of working on day one.
This is not a rare story. It is the normal path. And it is backwards.
The order of operations is wrong
For most musculoskeletal problems — low back pain, neck pain, shoulder impingement, knee pain, the everyday complaints that fill primary care schedules — conservative care is the safest and cheapest place to start. It carries no surgical risk, no medication dependency, and no recovery window. When it works, the patient learns how their own body failed them and how to keep it from happening again. When it does not work, you have lost weeks, not years, and you have gathered real information about what the problem is not.
Yet physical therapy is routinely treated as what you try after everything else has disappointed you. Not because clinicians believe that — most of the physicians I work with do not — but because the system is built that way. Imaging is easy to order. A prescription takes thirty seconds. A referral to therapy takes a conversation, a network check, and a patient who is willing to show up eight times.
What that costs, specifically
I run a clinic in Flint. I see what the delay does.
A shoulder that would have taken six visits at week two takes sixteen at month eight, because the patient has spent half a year compensating and now has a stiff joint, a deconditioned rotator cuff, and a nervous system that has learned to guard. The tissue problem became a movement problem became a fear problem. Every month of waiting adds work.
And the people who get hurt most by the delay are the ones with the least margin. If you are hourly, uninsured, or driving forty minutes to the nearest clinic, an eight-month path to the right treatment is not an inconvenience. It is the reason you stop coming.
What I would change
Refer earlier, not louder. If a musculoskeletal complaint has no red flags, therapy first is not a compromise. It is the evidence-based option. The referral does not have to wait for imaging to come back clean.
Measure something. Ask your therapy partners for outcomes, not visit counts. We track function — what the patient can do this week that they could not do last week — and we report it. If a clinic cannot tell you that, ask why.
Treat access as a clinical variable. Where the clinic is, whether it takes the patient’s plan, whether it can see them this week — those factors change outcomes as much as technique does. A perfect plan of care at a clinic the patient cannot reach is worth nothing.
Put hands on people. Manual therapy, spinal manipulation, dry needling — these are not add-ons. Used well, they change what a patient can tolerate in the same session, which changes what they believe is possible, which changes whether they come back.
The part nobody puts in a guideline
Most of my patients do not remember which technique I used. They remember that somebody spent forty minutes with them and explained what was happening in words they understood. That is not soft. That is the mechanism. A patient who understands their problem participates in solving it; a patient who does not, quits.
Movement is the most underused intervention in medicine. It does not get a sales rep, a launch, or a conference booth. It just works, and it works earlier than we usually let it.
Dr. Jerome Adams Jr., DPT, OCS, is a board-certified clinical specialist in orthopaedic physical therapy and the founder of Horizon Physical Therapy & Rehabilitation in Flint, Michigan. He speaks to health systems, payers and community organizations about conservative care and access.
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