The Smarter Way to Diagnosis and Treat Low Back Pain: Exam, Hands-On Care, and Targeted Injections
By Dr. John Mishock, PT, DPT, DC
Low back pain is one of the most common health problems in America. Nearly 80% of adults will experience significant back pain at some point, and up to 30% of those cases come from the sacroiliac joint (SI joint)—the small but essential joint connecting the spine to the pelvis. Unfortunately, SI joint pain is often overlooked or mistaken for disc or muscle problems.
Research now shows that the most effective way to treat SI joint–related pain is through a stepwise, team approach: start with a skilled physical therapy or chiropractic exam and gentle manipulation, add a core-strengthening program for long-term stability, and use image-guided injections when needed for pain that doesn’t settle quickly.
Step 1: A Skilled Exam and Hands-On Treatment
The first step is always a comprehensive exam by a physical therapist or chiropractor. This isn’t just about finding where it hurts; it’s about using specific movement and stress tests to confirm whether the SI joint is likely the pain generator. Studies show that when at least 3 out of 5 SI joint “provocation tests” are positive, the accuracy for diagnosis is about 85-90% (American Academy of Family Physicians, 2022).
Once the SI joint is identified as the problem, the next move is often gentle manipulation or mobilization. These hands-on techniques restore normal motion and relieve muscle guarding. Research in the Pain Physician Journal found that manipulation provided rapid improvements in pain and function, especially in the first 6 weeks of care.
Step 2: Spinal Stabilization and Core Strength
Pain relief is just the beginning; lasting results come from building stability around the spine and pelvis. Spinal stabilization programs target the deep abdominal and back muscles, along with the glutes and hips. These muscles act as a natural “belt” to support the SI joint and protect it during lifting, walking, and sports.
A 2019 clinical trial compared exercise therapy, manipulation, and the combination. All groups improved, but those who did both exercise and manipulation had the most lasting benefits at 12-24 weeks. In simple terms, once the joint is moving better, strengthening keeps it that way.
Step 3: Injections When Needed
For some people, even after therapy and adjustments, pain remains stubborn. That’s where a multidisciplinary step comes in: referral to a pain management specialist for an image-guided injection.
These injections serve two purposes:
- Diagnostic: If pain eases immediately after the numbing medicine, it confirms the SI joint is the pain source.
- Therapeutic: Adding lidocaine and corticosteroid can calm inflammation. Studies show that about two-thirds of patients feel meaningful relief for at least six weeks, with some carrying on improvement for several months.
This approach isn’t about masking pain; it’s about breaking the cycle of inflammation, allowing the patient to continue progressing with exercise and stabilization.
Why the Combination Works
Each step has its role:
- Exam + Manipulation – confirms the problem and restores motion.
- Stabilization – builds long-term strength and prevents recurrence.
- Injections (when needed) – provide diagnostic certainty and pain relief to support therapy.
This stepwise approach avoids rushing into unnecessary procedures, while still offering powerful tools if pain doesn’t improve quickly. It’s true multidisciplinary care; the physical therapist, chiropractor, and pain management physician working together with the patient at the center.
Final Thoughts
Low back pain can be frustrating and confusing, especially when it lingers. But if the SI joint is the culprit, the best plan isn’t a single “magic bullet”. It’s a team approach that starts with careful hands-on care, adds targeted strengthening, and only brings in injections if pain doesn’t settle.
This is more than just good medicine. It’s a roadmap that combines science, common sense, and cooperation across specialties, helping patients not just get out of pain, but stay out of pain.
We can help!
If pain is limiting you from doing the activities you enjoy, give Mishock Physical Therapy a call: locations in Gilbertsville (610-327-2600), Skippack (610-584-1400), Phoenixville (610-933-3371), Boyertown (610- 845-5000), Limerick (484-948-2800) at www.mishockpt.com or request your appointment by clicking here.
Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has also authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon or train2playsports.com.
