Ever wonder why, with all the technological medical advances in orthopedics, our population doesn’t seem better? In conservative care, there’s been electric stimulation, ultrasound, laser, and less techy modalities such as tape and soft tissue tools. Outside conservative care, we’ve gone so far as to make injecting steroids, fusing spines, electrifying nerves, and removing and replacing whole joints commonplace!
Perhaps the worst offender is the MRI. Imaging is certainly warranted in a few situations (as is surgery), but it’s current widespread use isn’t. Not only is this expensive for society, but overreliance is bad medicine: MRIs cannot reliably demonstrate cause and effect regarding symptoms and they often create needless fear in patients’ minds that they’re degenerating.
The human body has an amazing capacity to heal itself; orthopedic issues such as fractures, tears, disc herniations, sprains, etc. are regularly alleviated with time, not medical intervention. However, when a body’s independent healing falters, learning the right movement (and learning which to temporarily avoid) is key. Immobilization is rarely necessary. A clinician who uses her ears and brain to thoughtfully understand a patient’s problem should realize that a self-management protocol based on movement – nature’s best remedy – is almost always the best medicine. -- Laura
Check out this short article at Time.com. It emphasizes the point of seeking opinions from several medical professionals if you are not improving.
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A mechanical examination begins with a methodical verbal history, typically producing one or two diagnoses to prove or disprove during the examination. Key information I elicit includes location of all/any symptoms, mechanism of injury, injury duration and trend, and activities that worsen/improve symptoms.
In the mechanical exam, I care precisely about tests’ effects. I examine the effect of upright posture. I check active and passive movement at the affected joint(s). If the patient has an extremity complaint, I always look at spine motion too. I often check nerve tension (arm or leg). The patient performs something that generates symptoms, such as squatting or lifting a bag - a “functional baseline.” Strength is also tested: for all upper body complaints I test roughly 8 arm muscles. With all lower body complaints, I test 6 leg muscles. With distinct extremity problems, I additionally strength test the specific muscles at those joints.
Next, most importantly, the patient performs repeated movements in the direction I have determined and we reassess relevant findings (symptom behavior, motion, nerve tension, strength, and/or functional baseline). Based on cause/effect, other directions may be tested. Before leaving, one specific movement is chosen for the patient to perform frequently at home. --Laura
In orthopedics, the core comprises a specific group of muscles in the trunk/pelvis. (Others use core generally to mean trunk.) Core muscle strength is beneficial. Just as arm, chest, and foot strength are beneficial! Core muscles are not exemplary. They’re no more our “foundation” than our foot muscles or those running the length of our spine.
Many erroneously treat orthopedic low back pathology by strengthening the core. Assuming core muscle strength can be accurately assessed, if one or more of them is weak, the question is why. Muscles become weak (and painful) from pulls/tears. However, these are very rare when it comes to the large muscles of the core. (Tears follow a consistent, predictable pattern, too, which should make them obvious to an attentive clinician.) Pain can create weakness, but absent a clear tear, the pain usually originates from something other than the muscle.
The number one reason any muscle is weak (the large majority of cases) is because its electricity from nerves has been inhibited – either at the spine or extremity joints. It’s a joint problem. Therefore, in most cases strengthening a weak muscle (or entire group!) is simply attacking a symptom, which won’t fully resolve the problem.
Treating symptoms (and signs) alone will not fix a problem. Yet I consistently see people consistently attacking their symptoms. In many cases this has even been advised by a healthcare professional. Examples of signs and symptoms include: pain, tightness, achiness, weakness, clicking, locking, numbness, stiffness, buckling or giving way, tingling, and imbalance.
The question is always: what is causing this/what is the diagnosis? Why does your back hurt? Why is your foot numb? Why is your knee giving out? Why is your calf tight? Why does your shoulder ache? Why is your quadriceps or grip weak? Why can’t you balance on your left? Why is your pelvis rotated? Why is your neck stiff?
There are many diagnoses that create each of these symptoms, such as nerve impingement (at the spine or in the extremities), misaligned joints, torn structures such as muscles, and dysfunctional tendons. Very often the cause is located away from the symptoms. And even these causes have causes - which need to be addressed, like changing sitting posture to prevent nerves from being pinched in the spine. An expert diagnosis from a professional who understands all the possible diagnoses and then finds and treats the cause is warranted. -- Laura
Joint derangements are about 80% of all orthopedic problems. Derangements are when a joint isn't sitting properly, leading to pain, stiffness, tightness, and so on. They are usually rapidly reversible! Unfortunately, people are often given structural diagnoses instead (here, it's an AC sprain) or told they have a muscle or tendon problem.
Since joint derangements comprise the LARGE majority of orthopedic problems, McKenzie experts are trained to look for them first. If a joint derangement is found, we use repeated movements to restore joint alignment. This patient had shoulder pain and limited movement following a car accident. One movement fixes her symptoms (bringing her arm across her body) - and one movement worsens her symptoms (bringing her arm back away from her body). McKenzie experts are trained to find WHICH movement is best for you and use that one movement as the treatment approach. -- Laura
Mechanical pain isn’t a new concept - it’s the most common kind of pain. Besides pain, tightness, numbness, clicking/locking, and tingling are also possible symptoms. The bad news is usually mechanical problems are diagnosed incorrectly as structural problems (eg torn meniscus). The good news is almost all are fixable - if you find a clinician who can diagnose and treat them, like a McKenzie expert.
Mechanical problems are those that, simply, can be fixed with movement. Examples include pinched nerves, dysfunctional tendons, pulled muscles, and frozen shoulders. However, the biggest subset of mechanical problems is joint derangements. Derangements (misalignments) are when something (somehow!) obstructs the joint, such as a fat pad; a herniated/bulging disc; a bone fragment; or a piece of meniscus, labrum, or cartilage. Treatment for muscles/tendons involves tissue remodeling movement; joint derangements require specific movements to restore proper alignment.
Outside of mechanical problems there are structural, chemical/inflammatory, and nervous system problems, among others. Most healthcare providers and patients conclude that symptoms are from a structural issue because of unreliable orthopedic tests and MRIs. Orthopedic tests are false positives in the presence of mechanical derangements and MRIs consistently show abnormalities that are irrelevant. An expert mechanical exam is needed. -- Laura
I always write about not basing orthopedic treatment on imaging findings. We should also not base our treatment on clinical findings that appear to be structural without repeatedly moving the spine and/or extremity. Clinical orthopedic tests for the shoulder have been proven to be unreliable (for example, tests for rotator cuff tears, labral tears, impingement, or tendinopathy). McKenzie clinicians move your spine and extremities, looking for immediate cause and effect. Here, while it looks like the patient has a shoulder problem, when the McKenzie clinician moves her thoracic spine, it resolves. -- Laura
When people twist or roll an ankle, the common diagnosis is that the ligaments are sprained. However, the joint itself is also affected! Here, a patient who twisted her ankle is treated successfully with simple repeated movements of the ankle JOINT. Therefore, the ankle JOINT was injured, not the ligaments. She was discharged with full recovery at visit number 2.
Clinicians MUST assess joints as joints are injured far more commonly than soft tissues such as muscles, tendons, and ligaments. (I learned how to assess joints like this through my post-doctoral studies with the McKenzie Institute, not in school.) -- Laura
The McKenzie method, aka mechanical diagnosis and therapy (MDT), is an assessment and treatment approach for musculoskeletal (orthopedic) problems, head to toe. The assessment is crucial; successful patient outcomes only occur with correct classification combined with paired treatment. MDT’s focuses include utilizing repeated movements, patient self-treatment, and injury prevention.
The most common of the four MDT classifications is derangements (at least 70% of all orthopedic problems!). Derangements – misaligned joints – create pain locally or distant from the joint (eg calf pain coming from the spine) and obstruct movement. Importantly, they’re usually rapidly reversible using specific movements to restore proper alignment. Clinicians not trained in MDT most significantly don’t recognize derangements and therefore don’t efficiently treat the bulk of patients’ complaints.
The other three are tissue dysfunctions, posture syndrome, and “other.” Tissue dysfunctions include joint tissue problems (eg frozen shoulder) and muscle/tendon tissue problems (eg Achilles, patella, rotator cuff, and elbow tendinopathies). In general, treatment involves progressive tissue loading to stimulate remodeling, typically taking a few months. Posture syndrome is rarely encountered and is treated with education. “Others” are problems such as post-surgical conditions, centrally-dominated pain, structural deformities, inflammatory processes, and many others. They’re treated with protocols tailored to the individual issue. -- Laura
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