If you are not well-versed in ruling out the spine as the source of an extremity symptom, you are missing roughly half of the sources of patients’ problems. This issue can be mitigated if the patient has been referred from someone whom you trust has already effectively clinically cleared the spine. Often, however, people with knee pain go directly to a “knee doctor” or those with numb hands visit a “hand doctor” who, in my experience, only examine that specific body part.
A system, an algorithm, is needed to ensure success in any paradigm. In my practice, experience and pattern recognition factor in, but a structured process directs my evaluation and treatment. Most importantly, a patient’s spine is investigated before moving on to an extremity. I’ll say we need to ensure the problem is not coming from a faulty fuse box (since so often it is). How long I spend on this inquiry can be minutes, it can be days - it depends on the individual case.
There is certainly a role for these professionals, but our current utilization methods need revamping. Let’s use extremity specialists only when it’s clear-cut that that intervention would be most effective for helping patients. --Laura
Try to know the source of your orthopedic information the best you can. There is a huge amount of incorrect information out there and, as this phenomenon illustrates, people who know very little yet think they know a lot. I am happy to share my education and my experience with people and can easily admit when I don't know something. (This definition and graph courtesy of Wikipedia.)-- Laura
I recently spoke with Jason Ward, host of the podcast Mechanical Care Forum, about my trajectory in the field of physical therapy and what drove me to start my own practice. Episodes #243 and #244 are linked below but can also be found via the Mechanical Care Forum Podcast on iPhones. --Laura
This is a lateral shift. A lateral shift of the low back (lumbar spine) joints. It's not a hip, pelvis, SI, or IT band issue. They're not always as obvious as this, so orthopedic clinicians must remove the patient's shirt to see it. It is not observable in lying; the patient must be standing. It is corrected (often painfully) by moving the low back joints in the opposite direction first. Usually that entails side glides against the wall or in free standing, and sometimes I need to assist as the clinician. Once the patient has free movement in both directions side to side, we restore extension and flexion of the low back. These are not that common, but I will typically see a few patients a month with a lateral shift.
If a patient has knee complaints - and I rule out the spine as the source - I treat the knee with repeated movements. Usually the movement is to address the joint position itself, though sometimes the movement addresses a tendon or muscle. Here McKenzie diplomat Joel Laing demonstrates the movement: knee extension with overpressure in partial weightbearing. I used this with a patient last week in fact! There are many ways to move a knee, but this is one of the most commonly used movements. Please remember, even in the presence of arthritis, meniscus, ligament, tendon, or cartilage damage, in most cases joints can be rapidly fixed with repeated movements. The typical exercise prescription for home for the knee is 10 repetitions every 3-4 hours. McKenzie clinicians are trained to examine whether your problem falls into the 80% of cases which will respond to repeated movements, and to find which movement is best for you. --Laura
I recommend checking the spine first in nearly all patients, but if your symptoms are not improving (even symptoms like sinus congestion!) with whatever treatment, repeated movements are worth a try. The McKenzie method typically uses repeated movements to address patients' symptoms as movement is frequently the best medicine - and carries little to no risk as we use the least force necessary. While my role is to investigate exactly how you need to move, it's true that most therapeutic movements are those opposite our normal joint position. In this patient's case, that means neck retraction (moving the neck back). --Laura
The technology we have to see what is going on inside our bodies is tremendous. However, it is not always helpful. Just like many of us develop wrinkles and gray hair, orthopedic changes in our body are normal. Since we know that many people have these changes (eg disc bulges or cartilage defects or neuromas) WITHOUT symptoms, we should realize that if a person has complaints we cannot automatically blame these changes. A thorough clinical exam with repeated movement testing is necessary for diagnosis. We find that the bulk of patients just have a joint that's not sitting quite right which can be resolved with movement.
If the patient's complaint is not resolving within several visits using the McKenzie method, then an image may be warranted to see if there is a structural finding that is consistent with the patient's complaint. This is rare, however - the percentage of times I request a patient get an image is under 5%. -- Laura
If you lie propped up on your elbow for some time, it’s likely when you go to first move it, it’s stiff. Same with sitting on a crossed hip or ankle. As you start to move, the joint rapidly loosens and there’s no lasting impact. Do this enough, though, and it can become harder for a joint to consistently rebound to its correct alignment. And as the joint further deforms, this stiffness may become pain.
While this applies to extremity joints, these days it seems more prevalent in the spine. If your day entails primarily kneeling, it can become increasingly stiff and painful to straighten your knee(s). More commonly, though, if your day is spent protruding your neck looking at a computer or rounding your back driving in a car’s bucket seat, your spine may enter the stiffness-pain paradigm.
For many joints, it can be hard to notice stiffness/motion loss. Detecting stiffness, however, is often important in the prevention of pain, especially with previously painful joints. I therefore teach my patients how to self-test their affected joint each day. If stiffness is spotted, their corrective exercise should be performed to restore full joint motion and prevent unwanted escalation into pain. --Laura
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