How is lumbar spinal stenosis diagnosed?

The diagnosis is made by combining the clinical history of neurogenic claudication, physical examination, and MRI. Your physical therapist or doctor will look for symptoms when extending the back (leaning backward) and relief when flexing (leaning forward). The MRI reveals the narrowing of the canal. However, your functional symptoms are more important than the severity visible on imaging.

The diagnosis is mainly based on the history of symptoms and clinical examination.¹ The physical therapist or doctor will look for the typical profile: symptoms in the legs caused by walking and relieved by sitting. The physical examination includes tests where leaning backward reproduces the symptoms.⁵ Leaning forward relieves them.

Clinical tests to identify spinal stenosis

• Standing extension test: You lean backward while standing. This reproduces or worsens the symptoms in your legs.
• Walking test: We assess the distance you can walk before symptoms appear. Some patients can walk 50-100 meters, others several hundred meters.
• Mobility assessment: We examine the movement of your lumbar spine and nerve gliding.
• Strength tests: Muscle strength and stability are assessed to identify specific deficits.

The physical therapy assessment also examines your joint mobility and the quality of your movements.¹ These elements help identify problems that contribute to your limitations. They guide the treatment plan.

Imaging and severity grade on MRI

In some cases, you will need to undergo radiological examinations.¹ X-rays or MRIs can reveal the severity of the stenosis. Magnetic resonance imaging (MRI) allows the canal to be seen directly. It measures its diameter. Radiologists often classify stenosis as mild, moderate, or severe.²

It is important to know that what is seen on imaging is not always relevant.¹ The correlation between the severity of narrowing and your symptoms is modest.² Some patients with severe stenosis on MRI have very few symptoms. Others with moderate stenosis are significantly limited. If your MRI shows significant stenosis, don't be discouraged: it's not a death sentence. This difference means that treatment decisions should be based on your symptoms and actual limitations.²

Imaging becomes important when considering surgery. It helps identify the levels that need to be decompressed. However, for physical therapy, functional assessment is more useful than the exact MRI grade.²

How does physical therapy treat lumbar stenosis?

Physical therapy focuses on flexion exercises, manual therapy, postural training, and cardiovascular conditioning. The goal is to maximize the space available for the nerves and improve your function. The emphasis is on active strategies that help you maintain your mobility and quality of life despite the narrowing.

Your physical therapist will conduct a comprehensive assessment. They will evaluate your joint mobility, nerve glide, and strength.¹ This thorough assessment helps identify specific deficits and tailor a treatment plan. Physical therapy offers several effective approaches to managing lower back pain and improving your function.

Treatment is based on several pillars. First, flexion exercises aim to increase the space in the canal.⁵ These exercises include stretches such as knee to chest and pelvic tilts. Stationary cycling is particularly good. It provides cardiovascular conditioning while keeping the spine bent forward.⁵

Second, muscle strengthening plays a central role in managing stenosis. Strengthening and endurance exercises improve your control of movement and protect the spine.¹ Targeted work on the deep stabilizing muscles of the core is particularly important. These muscles reduce the load on arthritic structures and improve your overall posture.

Third, manual therapy offers significant relief. Joint mobilizations and manipulations restore spinal mobility and reduce mechanical stress.¹ Nerve treatment techniques improve neural gliding, which is the ability of nerves to move freely within the canal. This combined approach maximizes the space available for nerve structures.

The physical therapist will teach you how to pace your daily activities.¹ You will be given advice on your posture and movements. Understanding your condition allows you to make informed choices. You will know which activities and positions aggravate or relieve your symptoms.⁵

It is important to note that stenosis cannot be cured. It is a degenerative process that cannot be reversed. However, symptoms can be completely eliminated with treatment, even if the stenosis is still visible on imaging. This reality underscores the importance of focusing on your function and quality of life.

What is the prognosis for lumbar stenosis?

Rest assured: lumbar stenosis typically progresses slowly. Many patients maintain good function with conservative management. The anatomical narrowing cannot be reversed. However, symptoms can be effectively managed with physical therapy. Only 10 to 15% of patients require surgery over a 5-year follow-up period.

The natural history of stenosis is generally benign. It progresses slowly over several years.² Contrary to some beliefs, stenosis does not always lead to worsening symptoms. Follow-up studies show that many patients remain stable. Some even improve over time. This is particularly true when they participate in a physical therapy program.²

The success rates of conservative treatment are encouraging. Between 85 and 90% of patients can be managed without surgery.² By combining activity modifications, postural strategies, and physical conditioning, they are able to continue their important activities despite the narrowing of the canal.

It is important to know that 90% of episodes of lower back pain resolve within 6 to 12 weeks.¹ And 50% resolve within 1 to 2 weeks. Although stenosis is a chronic condition, periods of aggravation often follow this pattern of natural resolution.¹ Especially when combined with appropriate management.

Several factors influence the prognosis. Patients who maintain regular physical activity have better outcomes.² Those who apply the strategies learned in physical therapy also do better. It is important to avoid fear of movement. The presence of worsening muscle weakness may indicate a more guarded prognosis. In this case, surgery may be necessary.²

Quality of life can remain high for most patients.² The goal is not to eliminate all symptoms. Rather, it is to manage them at a level that allows you to continue your meaningful activities and maintain your independence.

When is surgery recommended for spinal stenosis?

Decompression surgery (laminectomy—removal of part of the bone) is considered for severe neurogenic claudication that limits walking to less than 200 meters. It is also considered for progressive neurological deficits, or if conservative treatment has failed after 3 to 6 months of structured physical therapy. Surgery offers good results for appropriate patients.

The indications for surgery are well defined. The presence of cauda equina syndrome (compression of the nerves at the bottom of the spine) is a surgical emergency.² This syndrome includes loss of bladder or bowel control. It causes numbness in the genital and anal areas. It causes severe weakness in both legs. It is important to be aware of these warning signs, but rest assured: this syndrome is extremely rare. It occurs in less than 1% of cases.¹

Serious symptoms to watch for include:¹

• Severe weakness or paralysis of one or both legs
• Significant loss of sensation in one or both legs
• Recent loss of balance when walking
• Significant and new incoordination
• New difficulties in controlling your urine or stool
• Loss of sensation in the genital areas

For non-urgent cases, surgery is typically considered when the claudication is so severe that it significantly limits your quality of life.² This is despite having tried conservative treatment. An adequate trial is generally 3 to 6 months of physical therapy with activity modifications.If after this period you can only walk 50 to 100 meters, a surgical consultation is appropriate. This is also true if your muscle weakness is progressing.

The most common type of surgery is decompressive laminectomy.² The surgeon removes part of the vertebra. Structures that compress the canal are also removed. This includes osteophytes and thickened ligaments. This decompression creates more space for the nerves. In some cases, spinal fusion (welding two vertebrae together) is added if instability is present.²

Surgical outcomes are generally good for appropriate patients. Approximately 70 to 80% report significant improvement in their leg symptoms.² However, surgery does carry risks. These include infection, bleeding, and cerebrospinal fluid leakage. In rare cases, neurological complications may occur.² Even after successful surgery, physical therapy rehabilitation is essential. It helps restore strength, mobility, and optimal function.²

How can daily activities be modified for stenosis?

Modifications include using grocery baskets or walkers for support, taking frequent seated breaks during walks, sleeping with your knees elevated, and using good ergonomics at work. These strategies help you manage symptoms while maintaining your independence and activity levels.

Several practical strategies can be implemented immediately:

• When grocery shopping: Use the shopping cart for support and lean forward slightly.
• Walking: Take short breaks to sit down regularly (every 100-200 meters depending on your tolerance).
• Standing: Limit the amount of time you spend standing still; sit down every 20 minutes.
• Prolonged standing: Place one foot in front of the other and shift your weight slightly from one foot to the other.
• Kitchen: Place one foot inside the cabinet in front of you to bend your back slightly.
• Sleeping: Lie on your side with a pillow between your knees, or on your back with pillows under your knees.

When walking, adopt a strategy of taking breaks. Rather than walking a long distance in one go, plan your route with places to sit down.¹ This approach often allows you to cover a much greater total distance.

If you have to stand, micro-movement helps. Making small weight shifts changes the pressure on the spine. This can delay the onset of symptoms.¹

The use of assistive devices can be very beneficial. A walker or cane allows you to walk further.⁵ They provide support and encourage a slightly forward-leaning posture. If you are hesitant to use these aids, remember that they are a tool for freedom, not a sign of weakness. They allow you to maintain your independence and participate in meaningful activities.

Stop movements that cause too much pain temporarily. Gradually resume them afterwards.¹ However, do not remain completely immobile for long periods of time. You will be stiffer and in more pain afterwards.¹ The balance between respecting the pain and maintaining movement is crucial.

What exercises help manage the symptoms of stenosis?

Flexion exercises such as knee-to-chest stretches, pelvic tilts, and stationary cycling help open the spinal canal. We combine this with core strengthening and hip flexibility exercises to support spinal stability. The selection of exercises is individualized based on your symptomatic response and goals.

Repeatedly bending your back can relieve symptoms.¹ These movements temporarily increase the space in the canal. For example, gently bend forward to touch your toes. Hold this position for 10 to 30 seconds.⁵ You can do this several times a day.

Stationary bikes are an excellent option for cardiovascular exercise.⁵ The forward-leaning position on the bike keeps the spine flexed. This allows for aerobic conditioning. Many patients who can only walk for a few minutes can ride a bike for 20 to 30 minutes. Recumbent bikes are often even more comfortable. They eliminate the load on the spine.

Water exercises also offer excellent benefits.⁵ Buoyancy in water reduces the load on the spine. It allows for movements that would be difficult on land. Water walking, water aerobics, and swimming are all suitable options. Swimming on your stomach with your head above water should be avoided. It forces lumbar extension.

Strengthening the core muscles helps support the spine.⁵ It reduces stress on arthritic structures. Stabilization exercises such as modified planks (on the knees if necessary) strengthen the deep muscles. These exercises do not create excessive lumbar extension. They should be taught by a physical therapist to ensure proper technique.

Hip flexibility exercises are important. Stiff hip flexors pull on the pelvis. This increases lumbar lordosis (the curve in the lower back). This can aggravate stenosis.⁵ Gentle stretching of the psoas and piriformis muscles helps. Hip mobilization helps maintain mobility, which allows the spine to remain in a neutral position.

A gradual conditioning approach is essential.⁵ Start with gentle, short exercises. Gradually increase the intensity and duration according to your tolerance. Some days will be better than others. It is important to adjust the program according to your current symptoms. Do not push through significant pain.

If you see no improvement after 10 days, you should consult a physical therapist.¹ A personalized and supervised program is generally more effective. It can be tailored to your specific deficits and individual response.

Stenosis is a classic example of a condition that responds well to flexion exercises. To better understand why and discover other exercises suited to your pain pattern, check out our comprehensive guide to directional preferences.

How does stenosis differ from other back conditions?

Unlike a herniated disc, which causes sciatica on one side, stenosis typically causes symptoms on both sides. These symptoms worsen when standing and improve when sitting. Vascular claudication, on the other hand, simply improves when you stop walking and remain standing. These distinctions guide the appropriate diagnosis and treatment.

The distinction between stenosis and herniated disc is clinically important. A herniated disc usually occurs suddenly, often after a bending-rotation movement with weight bearing. It typically compresses a single nerve root on one side.⁶ This creates classic sciatica: pain that travels down one leg along a specific path, with numbness and sometimes weakness. To better understand this radiating pain, see our comprehensive guide to lumbosciatica.

In contrast, stenosis develops gradually over many years. It often affects several vertebral levels. It causes symptoms on both sides that are more vague.² The pain of stenosis is aggravated by extension (bending backward) and standing. Herniated discs are often aggravated by flexion (bending forward) and sitting.²

The distinction between neurogenic and vascular claudication is also crucial.² In vascular claudication, symptoms improve when you stop standing: muscles at rest require less oxygen. In neurogenic claudication, you need to sit down or lean forward. It is the change in position of the spine that decompresses the nerves, not muscle rest. This positional distinction is often the simplest test to differentiate between the two conditions.²

Hip osteoarthritis can also cause pain in the buttocks and thighs.⁴ This pain can be confused with stenosis. However, hip osteoarthritis typically causes pain in the groin, which is aggravated by walking and hip movements. This pain is not affected by the position of the spine, which distinguishes it from neurogenic claudication.⁴

These distinctions highlight the importance of a thorough clinical evaluation. Although imaging can confirm the presence of stenosis, herniation, or osteoarthritis, it is your medical history and physical examination that will determine which structure is causing your symptoms.² And therefore, which treatment will be most appropriate.

When should you consult a physiotherapist for spinal stenosis?

You should consult a physical therapist if you have one or more of the symptoms described. Especially the characteristic neurogenic claudication: pain in the legs that is aggravated by walking and relieved by sitting or bending. You can consult a physical therapist even if your doctor has not yet ruled out all other causes.¹

You don't need to see a doctor before consulting a physical therapist.¹ In Quebec, physical therapists are front-line professionals. They can assess and treat musculoskeletal conditions independently. If your condition requires you to see a doctor, your physical therapist will let you know.¹ This allows for faster access to treatment.

However, certain warning signs require urgent medical attention. These serious symptoms include:¹

• Severe weakness or paralysis of one or both legs
• Significant loss of sensation in one or both legs
• Recent loss of balance when walking
• Significant and new incoordination
• New difficulties in controlling your urine or stool
• Loss of sensation in the genital areas

These symptoms may indicate cauda equina syndrome. This syndrome requires emergency surgery.² Fortunately, severe symptoms are present in less than 1% of cases of lower back pain.¹ In most cases, although the pain can be unpleasant, the condition responds well to conservative management.

Early consultation with a physical therapist allows for an accurate diagnosis. It helps rule out any warning signs. It allows you to quickly begin an appropriate treatment program. This can prevent worsening of the condition and improve your function.

Ready to effectively manage your spinal stenosis?

Our physical therapists at Physioactif specialize in the conservative management of stenosis. We develop personalized programs to maximize your function and mobility. We help you understand your condition, improve your movement strategies, and maintain your quality of life despite the narrowing of the spinal canal.

Lumbar spinal stenosis does not mean a life of pain and limitations. With a good understanding of your condition, appropriate strategies, and a suitable exercise program, the vast majority of patients maintain excellent function and continue their valued activities.²

The goal is not to "cure" degenerative changes. These changes are often permanent. Rather, it is to manage symptoms and improve your functional ability despite these changes.

Don't wait until your symptoms become severe before seeking treatment. Early intervention can often prevent worsening symptoms. It allows you to establish management habits that will serve you throughout your life. Our physical therapists will work with you to develop an individualized plan. This plan respects your personal goals, your current limitations, and your ability to commit to rehabilitation.

To schedule an appointment with one of our physical therapists specializing in lumbar conditions, contact the Physioactif clinic nearest you. Together, we can help you regain control of your spinal health and live life to the fullest despite lumbar spinal stenosis.

References

1. Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal. 2013 Jul 1;13(7):734-43.

1. Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234.

1. Wu L, Cruz R. Lumbar spinal stenosis [Internet]. StatPearls Publishing; 2020 Sep 3 [cited 2025 Oct 11]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563269/

1. Quebec Professional Order of Physiotherapy. Osteoarthritis and physiotherapy [Internet]. Montreal: OPPQ; 2024 [cited 2025 Oct 11]. Available: https://oppq.qc.ca/

1. Ammendolia C, Stuber KJ, Rok E, Rampersaud R, Kennedy CA, Pennick V, Steenstra IA, de Bruin LK, Furlan AD. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013 Aug 30;(8):CD010712.

1. Alexander CE, Varacallo M. Lumbosacral radiculopathy [Internet]. StatPearls Publishing; 2019 Mar 23 [cited 2025 Oct 11]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430837/