Therapists can’t pinpoint where low back pain is coming from

PainSci » bibliography » Hancock et al 2007
updated May 6, 2025

Tags: diagnosis, back pain, spine, intervertebral disc, special tests, study_review, pain problems, anatomy, spine pain

Three pages on PainSci cite Hancock 2007: 1. The Complete Guide to Low Back Pain 2. The Complete Guide to Neck Pain & Cricks 3. Diagnose, schmiagnose! Physical exam accuracy for back pain is poor (Member Post)

PainSci notes on Hancock 2007:

This is an older review of the ability of professionals to suss out the specific causes of spinal pain using a variety of diagnostic tests, mostly physical exam stuff. The Hancock et al. review of about 40 studies that tested such tests. (An updated version of this review was published in 2023, see Han, but it mostly ignored the physical exam tests, so this older paper is still distinct and useful.)

Could the pros pinpoint where back pain is coming from? Sometimes, but mostly not:

“Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain.” (“Centralization” is the tendency of pain distribution to shrink in response to specific repeated movements or sustained postures.)
“None of the tests for facet joint pain were found to be informative.” And that result really made me cringe, because I “tested” for facet joint involvement frequently during my clinical career. That was a couple minutes of my patients’ time and money wasted every time I did it (to say nothing of the misleading results). And the evidence that such testing is largely futile had already existed for years even back then, but had not trickled down to me through my texts, instructors, or continuing education. Yet another great example of how important it is for clinicians to keep up with their journal reading.
“Single manual tests of the sacroiliac joint were uninformative,” but perhaps slightly more helpful in combination. Unfortunately, an effective combo is much harder to confirm, and much less likely to be used in practice.
Conclusions about MRI were too all over the map to make much of. An absence of degeneration was “the only test found to reduce the likelihood of the disc as the source of pain.”

So there was some good news, but overall the diagnostic power of the tests was “usually small and at best moderate” and their value was “unclear.” This theme of mediocre reliability and dubious validity will be continued in similar reviews like van der Windt and Nezari.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR)> 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR > 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4-5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: -LR = 0.21 (95%CI 0.12-0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3-4.4) and -LR of 0.29 (95%CI 0.12-0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

related content