​How do I increase a person's ankle dorsiflexion range of motion? There is no one way to fix a sign/symptom. I can name ten possible things I would do to increase a person's dorsiflexion depending on the source of the deficit. A sign or symptom is not a diagnosis. You diagnose the problem that causes the sign/symptom and provide the appropriate treatment for that diagnosis. It’s the same as with other medical problems. There’s not one way to relieve head pain nor one way to increase low blood pressure. You figure out the reason (the diagnosis) and address that.

I know I sound like a broken record, but people want to oversimplify orthopedics when it actually takes solid diagnostic skills to achieve effective care. If a patient of mine has decreased dorsiflexion, that is just one piece of data in isolation. Combined with the other data I obtain (verbally and physically) and combined with the response to repeated dynamic testing, that piece becomes more intelligible. I use the treatments mentioned here but others as well if needed. If you think you simply need to stretch your Achilles to gain more dorsiflexion, by all means, go ahead. It will help sometimes, but it’s not high on my list of treatments I use to gain dorsiflexion. So the answer to how I increase dorsiflexion is: “It depends.” -- Laura

Joint mobility is an extremely important piece of data when diagnosing and treating orthopedic disorders. Even though testing a joint’s mobility is easy, it is rarely done well. While the length of a muscle may matter, the strength very rarely does. A tight muscle (which is rare) may reduce a joint’s range of motion in a specific direction (the direction in which the tight muscle is put on stretch), but weakness is rarely a factor.

A muscle would have to be significantly inhibited and/or significantly weak for the patient not to be able to achieve full active range of motion, especially with gravity eliminated or gravity assisted procedures. (Remember: muscle inhibition usually comes from a nearby joint or spinal joints.) Muscle weakness does not impact passive range of motion, which is when the joint is moved by something external (not internal muscle strength). If a joint doesn’t move well - passively and/or actively - my investigation starts with joints themselves (local and spinal). If that proves fruitless, only then will I consider that muscles are causing reduced joint range of motion. -- Laura

Clinicians should base diagnosis and treatment on tests that are reliable and valid. I have attended courses that taught me how to determine sacral and facet positioning with my fingers. Only later did I realize that stuff was ridiculous. When you palpate (touch) a structure at rest, for starters, you’re touching many structures. In addition, it doesn’t consider referred pain. For instance, if I touch your Achilles tendon and it feels thickened or it feels painful to the patient, I can't make strong inferences from that other than it feels thickened or it feels painful to the patient. It doesn't help with diagnosing what is causing those phenomena. If you want to use that as a baseline test and see if it changes with the intervention, that is fine; but that is not the original intent of these palpation tests that are commonly taught, which are geared more to defining (diagnosing) a problem. Palpation during movement tests are similarly flawed - most notably because they purport that clincians can reliably detect small amounts of movement. Reliablitiy is not only in question when the same clinician performs the test on different occassions, but is clearly questionable when it comes to comparing several clinicians. We’re better than saying we know the diagnosis by eliciting pain when we touch something (which is below skin and everything else). And we’re better than saying we know the diagnosis based on (allegedly) feeling a 5-degree rotation in a joint. ​-- Laura

When clinicians think of joint mobilizations, they think of clinicians moving joints at the level of the joint with their hands, which is true. This applies to the spine as well as the extremities. However, joints can be less-precisely mobilized - or moved - without that specific technique. In fact, if my goal for a movement is to move a joint versus, say, stretch something or strengthen something, I call it a joint mobilization. More loosely, we can just call it a movement or an exercise, but the intent is what matters - and the intent is to move the joint in a specific direction (its directional preference).
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Sometimes the technique or the force applied by a clinician via mobilization or manipulation is necessary temporarily. But in the large majority of cases diagnosed as joint derangement, patients can learn how to mobilize themselves. In the trickier cases, we might have to figure out how to get assistance from some equipment at their home or from another person. When mobilizations (with or without a lot of force) are necessary as treatment, the results will be better the more often you do them. That said, in order to get those reps, it’s imperative we teach patients how to self-mobilize the best we can. The McKenzie method is predicated on teaching people how to self-treat in order to improve outcomes. My hands aren’t magic and I’m here to teach. -- Laura

Perhaps if people consider common “medical” problems, they can better understand musculoskeletal problems. While a cough may feel like it’s coming from the throat, plenty of things can cause a cough. It can be due to a problem in the stomach, lungs, sinuses, nose, mouth, or throat. A quality verbal history and evaluation will steer the clinician’s investigation into the cause (diagnosis).

While your knee may hurt, plenty of things other than your knee can cause your knee pain. While your hands may be tingling, plenty of problems other than hand problems can cause that tingly sensation. While your shoulder may not rotate, there may be a cause other than your shoulder. While your calf muscle may be weak, there could be a cause other than your calf muscle.
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Signs and symptoms such as a cough, pain, paresthesia, decreased mobility, and weakness are pieces of data which help us understand the problem. The location of signs and symptoms is not necessarily the location of the diagnosis. -- Laura

If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.

With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.

There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura

There are diverse opinions when it comes to orthopedics. And you should feel free to explore the myriad thought processes, approaches, opinions, techniques, etc. But when your goal is to fix something, you need to focus on one approach. Let one chef take over, even if just for the time being. Not only does that allow you to focus all your time and energy on the game plan in front of you, but it, most significantly, gives it the greatest odds of success.

If I want someone to repeatedly flex his spine, but another clinician wants him to repeatedly extend it - well, those are obvious contradictions. Doing both at the same time in this example would make zero sense and would preclude either approach from working. Outside of obvious examples, though, there are more subtle ways that things get derailed. For instance, if I tell someone she has a terrific prognosis if we follow these four steps, but her primary care physician keeps telling her therapy won’t help because the x-ray looks bad, then things often stall.

Research all the different options first if you really want to, but give just one approach, just one clinician, the title of head chef at a time. If it’s concluded that another perspective is needed, then you can move on. As the saying goes: we can't have too many cooks in the kitchen. -- Laura

It’s not uncommon that sleeping makes problems worse. That is, symptoms become exacerbated and/or movement becomes limited. Morning stiffness to a small extent is allowable when it comes to spinal flexion, but, otherwise, after being up and about for a few minutes, you should have the same amount of mobility you went to bed with.

During sleep, we often spend considerable time in one position without moving - whether we want to or not. It is my opinion that most orthopedic problems are related to movements and postures, so it makes sense that, just like with sitting or walking, sleeping postures can easily make people worse (or better).

If the thought process is that people need muscular strength to “hold” or “stabilize” joints in the right position, then there must be profound weakness if the simple act of sleeping causes joints to destabilize. Similarly, sleeping should not be aggressive enough to strain/pull muscles.

My thought process is this: I agree healthy joints should be able to withstand prolonged positions while sleeping, but I don’t think the answer is muscle-driven stability. And I don’t think muscles get pulled in our sleep. Benign positions like sitting or lying can indeed move joints - regardless of how much muscle is nearby. And these subtle changes can commonly cause symptoms. On the whole, strength is wonderful, but I believe we need to get the joint better first by moving the joint itself.

It’s true that spinal discs enlarge when we lie down to sleep, and that may be the sole factor why someone has more pain and/or less motion upon waking (vs related to any certain position). But even if that is the causative factor, then, again, I want to primarily address the disc (part of the joint) versus address the musculature around it. It’s also true that not all orthopedic problems are joint problems. Sleeping on a painful tendon can worsen symptoms, too. But most problems do have to do with joints - and addressing them effectively is important. -- Laura