Try to get to, and understand, the “why.” Why is my leg restless? Why is my patellofemoral joint hurting? Why is my bowel irritable? Why is my head aching? Why is my nerve pathological? Why is my IT band painful?
We unfortunately do not have an answer 100% of the time, but it’s close. And there is usually at least a strong hypothesis. It may take more than one clinician. If you strike out with one, try another. Once you uncover the “why,” you can treat that. -- Laura
We wash our hands to prevent infections, wear helmets to minimize head injury, and brush our teeth to reduce disease and decay. There are tips to preventing musculoskeletal problems as well. I put it succinctly recently: Move your joints. In all directions. Quite often.
Learning the basic tenets of prevention goes a long way. My goal is to help patients with their current problem and, just as importantly, to teach them what is occurring so that they can minimize or prevent recurrence. Advice to stay active, flexible, and strong to prevent injury is valid. What is lacking in my experience, however, is nuanced advice on maintaining joint balance and health. If people had a basic understanding of how joints worked, and some daily or weekly prevention strategies, a lot of aches, pains, and “injuries” that come on for no reason could be avoided. (Most musculoskeletal complaints, after all, cannot be blamed on major, or even minor, trauma.) -- Laura
Rolling an ankle impacts more than ligaments and tendons. The ankle joints (there are several) are obviously involved - and possibly the structures that get injured. Before I jump to the conclusion that pain and tenderness on the lateral (outer) aspect of the ankle is coming from the lateral ligaments, I move the joints to assess the effect. The joints of the ankle can create pain anywhere near the joints. If a joint is indeed the culprit, most will resolve rapidly with directional preference exercises. If a ligament is to blame, then traditional treatment of a ligament sprain is indicated. Looking for the problem that usually gets better the fastest not only makes diagnostic sense, but also benefits the patient. Who doesn’t want to get better as fast as possible? -- Laura
You need to investigate the source of your complaint - and not make assumptions. A spinal curve, flat foot, bowed leg, askew elbow, elevated shoulder, etc. may or may not be related to your current complaint. If your abnormality, or deformity (we all have them to some extent), has been around for years and your complaint is new, the odds that they are related decreases. If you noticed they occurred at the same time, the odds increase. Too often people make assumptions without understanding how to repeatedly move the body to test for any relationship. -- Laura
When reaching hard enough, will you feel pulling in your hamstrings? It’s likely. Tendons and muscles (unlike other structures) will usually allow you to eek out another centimeter in pursuit of your toes, which you’ll feel. But “feeling it there” does NOT mean that is necessarily the limiting factor. To touch your toes you’ll need sufficient hip mobility, low back mobility, and sciatic nerve length for starters, not to mention mid back mobility and even arm length! Whereas so many (I want to say most) fitness professionals and medical clinicians alike make assumptions such as this, I critically assess why someone cannot do something. We move your body in various ways repeatedly to understand the source of a complaint or functional deficit. And by the way: it’s usually not your hamstrings.
In general, those who strength train work opposing muscles - quads/hamstrings at the knee and biceps/triceps at the elbow, for example. Notwithstanding specific athletic performance needs (a very small population), it’s generally a good idea to balance muscle groups so that innate human biomechanics are not significantly thrown off.
In the same vein, joints should be worked in opposing directions. Knee extension/flexion and elbow extension/flexion, for example. In my book, the most important manifestation of this credo is with spine flexion/extension. While people perform many activities of spine flexion (forward bending), they rarely move into spine extension (backward bending). Considering only the gym, you see squats, burpees, deadlifts, sit ups, hamstring stretching (and more!) involving spine flexion. Only on rare occasions will you see a standing back bend or “cobra” or “upward dog” stretch on the floor. I have no problem with flexion; I just want balance. Public gyms provide a glaring example that people will attend to muscle balance but rarely joint - specifically spinal joint - balance, but this applies to everyday life as well. --Laura
The large majority of patients I see have problems that can be resolved with physical therapy. However, when evaluating a patient - or over several visits - it sometimes becomes clear that a different intervention is needed. For example, oral medication, injection, surgery, cognitive therapy, and so on. My first question to myself as a clinician is always, “Is this person in the right place?”
Physical therapy is a great place to start for most people complaining of orthopedic problems, though, given it is indeed where most people need to be and given it’s non-invasive and carries little to no risk. I say that at least 80% of people I see benefit from what we can do together. That is partly due to the fact that I briefly speak with patients first before seeing them. But I still see patients that do not respond and therefore make an appropriate referral/recommendation. No intervention treats everything. The objective is to get a quality diagnosis and choose the best intervention based on the diagnosis. I diagnose based on repeatedly moving the body, which I find to be most effective.
Can we at least agree that a muscle spasm creates a shortening of the muscle as it performs its action? When you have a true calf cramp your foot starts to plantar flex (point down). When your hamstring spasms, your knee bends. When your toe flexors cramp, your toes curl. And so on. (There can be many causes of these muscle spasms including musculoskeletal, nutritional, and others.)
So, if your low back muscles were in true spasm, they (primarily extensors which extend - or backward bend - your low back) should pull you into backward bend. Why don’t they? Because while you feel muscular symptoms, it’s rarely (I want to say never) a true muscle spasm. Instead, it’s pain referred from the nearby low back joints. These muscular symptoms can be horrendous, but they are driven by the joint; and once you start to get the joint moving correctly again, the muscular symptoms calm down.
Many patients with low back problems actually lean forward or are stuck forward due to the joint derangement, which further disproves the common theory that muscle spasm is the problem and is what needs to be treated. -- Laura
Inflammation is rarely the main cause of complaints. And before any symptoms are addressed with pharmaceutical anti-inflammatories or injections, a quality clinical exam must be performed. Typically a mechanical problem will be found - which is treated with targeted movement. While inflammation may indeed be present, it almost always resolves once the real mechanical cause is resolved. Inflammation is usually therefore a symptom (not a cause).
If a patient does not respond to mechanical care, chemical (anti-inflammatory) care may be indicated. I have suggested anti-inflammatory measures in just 4-5 patients in the past couple years. So if your knee keeps swelling, for example, the question is why. A joint disturbance (derangement) can easily cause consistent inflammation. So can any number of problems.
I clearly remember one patient years ago who had years of knee pain with episodes of swelling that got so bad she had it drained many times. An avid runner, she was sidelined. The issue was coming from her low back and after 5 visits of different movements, her knee was good to go. Once her muscles had their electricity restored in the spine they could control to the knee so it didn’t reactively hurt and swell. -- Laura
Regularly sitting for prolonged periods, especially slouched, can lead to orthopedic problems. But the problems arise almost always from joints, not muscles. I continually hear people (health professionals, notably) declare that sitting’s “shortened” position of the hip flexors can cause painful, tight hip flexors. Granted this doesn’t affect all sitters (nothing does), but if large amounts of time in shortened states can lead to painfully tight muscles, then where is the observable pattern? Why aren’t more biceps affected secondary to prolonged elbow bending? Where’s the complaint of painful anterior neck muscles as our heads are so often forward?
Though I make my case verbally, people won’t budge. It’s likely the only way to prove my point would be to demonstrate an evaluation and treatment of someone with this given “diagnosis.” In the absence of that, I put forth that, one, we have ways of clinically determining if this is occurring, which, importantly, involves ruling out joints and nerves. Two, if we consider joint mechanics, deranged upper-mid lumbar segments and hip joints can send referred/radicular pain to the hip flexor area. Deranged elbows usually refer pain to the medial, lateral, or posterior elbow. And neck derangements typically send pain posteriorly and laterally – rarely anteriorly. The deranged joint pattern is observable. --Laura
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