If you’re suffering from neck, back or knee pain, physical therapy is one of the most commonly recommended treatments. But often, it just doesn’t work. There’s a good reason for that, though very few people understand what goes wrong. 

Typically, when pain is severe and/or chronic, doctors order an MRI, which often identifies a structural abnormality (such as a herniated disk, pinched nerve, arthritis or torn cartilage)—and that structural deviation is usually assumed to be causing the pain.

Here’s where things get tricky: Most people—in pain or not—have these sorts of structural variations within their bodies. In fact, research shows that the overwhelming majority of people age 65 and older who are not in pain have some disk degeneration

Based on my 25 years of treating thousands of patients with neck, back or knee pain, I have found that in more than 95% of the cases, the cause of pain was muscular—and not due to a disk, nerve or some other structural abnormality. Muscular problems often go undetected because they are not visible on an MRI or other diagnostic scans, and there are no medical specialists trained to diagnose and treat them.

Once you’re in a physical therapist’s (PT) office, he/she is not required to confirm or refute your doctor’s diagnosis. If you’re diagnosed with a pinched nerve or arthritis when you enter physical therapy, you’ll be treated for that condition—even if that’s not the real cause of your symptoms. 

A complete physical evaluation can identify whether the cause of the pain is structural or muscular. When muscular, the simple tests below will reveal telltale clues to the underlying problem, which often can be corrected with the exercises that follow (typically performed in three sets of 10 reps each, three times a week, resting one minute between sets…until you are pain free).* Give this information to your PT, who can use it to identify the true cause of your pain and help you perform the exercises…

Neck and Upper-Back Pain

The likely culprit: Muscle weakness and/or imbalance of the neck and upper-torso muscles will lead to poor posture. Most neck and upper-back pain is felt a few inches away from one or both sides of the spine. However, a structural variation (such as a bulging disk or pinched nerve) would typically lead to a major loss of range of motion (ROM) and cause pain along the spine.

One common offender: The levator scapulae muscle, which attaches from the inside upper corner of each shoulder blade to the upper neck, supporting the head and stabilizing the shoulders. Because of rampant computer and smartphone use, hunched, rounded posture shortens and pulls the chest muscles forward, weakening and overstretching the levator scapulae muscle, causing neck and/or upper-back pain.

Ask your practitioner to…

• Press on the spot where you typically experience pain. For many patients, this will be at the top inner corner of one or both shoulder blades, where the levator scapulae originates. If pressing here triggers or intensifies your pain, this strongly suggests a muscular problem.  

• Evaluate your posture. If your head and shoulders lean in front of your hips when standing, that’s another indicator of weak muscles.

• Check your ROM. Tight, weak muscles can restrict motion and/or cause pain as you move your head side to side, touch your chin to your chest or lean your head back. 

Try this test:Lie on your back on the exam table with your head hanging off the end but supported by the PT. As you completely relax your neck, ask the PT to gently move your head side to side…and up and down. 

If your head can be easily and painlessly moved back and forth and up and down, the tight muscle theory is confirmed. If the PT has difficulty moving your head, and it feels like a bone is hitting another bone, this is a sign that a structural variation is limiting ROM and contributing to neck pain.

Exercises to perform to correct the muscular imbalance causing neck pain and poor posture: Lat pulldowns with a neutral grip and a lower trap exercise to strengthen the lower trapezius muscle, which extends from your neck and across your shoulder blade to the middle of your back. (Ask your PT to demonstrate.)

Low-Back Pain

The likely culprit: Tight quads and hip flexors. Hip flexors are workhorse muscles that originate on either side of the lower spine and travel down the front of the pelvis, attaching at the hip joints. Sitting for hours at a time, day after day—at a desk, in a car or in front of a TV, for instance—weakens the hamstrings and shortens and strains the hip flexors. Tight hip flexors, along with weak hamstrings, cause the pelvis to tip forward, creating an excessive arch and back pain…none of which show up on an MRI.

Hint: If you typically need to push on your thighs with your hands to stand fully upright after sitting, you likely have tight hip flexors—your hands are helping to manually lengthen your hip flexors.

Ask your practitioner to…

• Press on your hip flexors.Tender? That’s one sign they may be causing your low-back pain.

• Evaluate your posture. You want just a very mild curve in your lower spine, with the front and back of the pelvis at equal height. 

• Check for dominant quad muscles.Again, lie on your back on the exam table, this time with your butt at the edge of the table and your legs hanging off. Pull one knee toward your chest as the other leg dangles. If the foot of the dangling leg is not perpendicular to the knee (less than a 90-degree angle with the foot pointing away from the table), the quad is dominant and overly tight, contributing to low-back pain.  

Exercises to resolve the muscle imbalance leading to low-back pain: Hamstring curls, hip extensions and hip abductions. (Ask your PT to demonstrate.) Note: Perform the exercises only on the painful side—or on both sides if pain affects both sides.

Knee Pain

The likely culprit: People with pain around the kneecap are frequently told they have meniscal tears or “bone-on-bone arthritis,” which indicates a complete loss of cartilage in the joint between the base of the thighbone and the top of the shinbone. Both of these conditions limit ROM and can be treated only with surgery. Furthermore, neither of these conditions causes pain around the kneecap. If the real cause of your pain is muscle imbalance (with your quads being far stronger than your hamstrings)—and it likely is—surgery isn’t necessary and won’t even help.  

Ask your practitioner to…

• Check your ROM when you bend your knee if you’ve been told you have bone-on-bone arthritis or a meniscal tear. If either condition is causing your pain, you will have a significant loss of ROM, and the end point of movement will feel like a bone is hitting another bone, preventing further motion. If pain occurs around the kneecap and you have full ROM, this rules out either bone-on-bone arthritis or a meniscal tear as the cause of pain.

• Watch you negotiate stairs.A muscular problem causes pain as the knee joint struggles to maintain alignment as you walk up or down stairs—as well as with standing and sometimes with sitting.

• Check for dominant quad muscles. (See earlier description.)

Exercises to resolve muscular imbalance and pain around the kneecap: Hamstring curls, hip extensions, knee extensions and quad stretches. (Ask your PT to demonstrate.) Do these exercises only on the side where the knee is painful. If you have pain in both knees, do the exercises on both sides.

*Ask your PT for guidance on any exercise regimen you take.