My biceps is usually in quite a shortened position due to shoulder flexion and elbow flexion. Ditto for my neck flexors and hip flexors. But they’re not actually shortened (or tighter than normal). I have full flexibility in each of those muscle groups. Muscles can indeed become shortened, but it’s not a given they will get short if they spend most of their day like that.
Again, there are ways to test muscle length/flexibility. I don’t rely on muscle length/flexibility tests alone because they are not very specific. That is, when you test the flexibility of a muscle, you are also testing other structures. What I do if I suspect muscle shortening is perform the muscle length test and note the findings. Then I will do dynamic movement testing and assess the effect on the muscle length test when re-tested. If we rule out everything else, and the muscle stays tight, then we can diagnose muscle tightness.
But my distinct point here is that we can’t make an assumption based on daily positions or activities. If you think “hip flexors get tight” because they’re shortened all day, well then what about all the other muscles that are shortened all day? Isn’t it more likely that something else is going on in the hip area? Things can be figured out with competent testing - not assumptions. -- Laura
There are many goals when it comes to working with orthopedic disorders, but these are the objective health parameters I aim to achieve: full range of motion, full strength, full nerve extensibility, and good mechanics. Mechanics, loosely defined as how you move, is more subjective than the others, but there are norms with quality of movement too.
Full, pain-free function, or being able to do what the patient wants to do, is the most important, but functional ability typically relies on these four domains. In the event we cannot achieve full range of motion or full strength etc. - which can happen for various reasons - our goal simply becomes to achieve the maximum possible. (Other goals with care: efficiency, risk minimization, fostering patient independence, and teaching prevention strategies.) -- Laura
A stress test on a treadmill, hooked up to monitors, indicates how your heart functions when challenged. Repeated movement testing, which I perform and prescribe, indicates how your joints, muscles, and nerves function when challenged. Pictures tell us how things are at rest but not how they behave. And orthopedic special tests (OST) tell us how things are with a static test or with one movement. Barring a major structural problem, most problems are functional - and require dynamic testing (repeated movement testing) to arrive at a diagnosis. Repeated movement testing is one of the hallmarks of the McKenzie method.
Repeated movement testing is exactly what it sounds like. After I get a verbal history and note physical baselines such as range of motion, strength, and nerve tension, I choose a movement to be performed repeatedly and then assess the effect on symptoms and the baselines from the physical exam. The repeated movement I choose to test is based on several factors. An example of a repeated movement would be performing 10 shoulder internal rotations or 10 lumbar extensions.
An important adage is: correlation doesn’t equal causation. One can assume one's neck or back hurts because of stress. Or one could investigate to see if stress and symptoms are simply correlated and not causal. An key step is to specifically look for a musculoskeletal cause to musculoskeletal complaints. It’s quite common that when people report stress they also report more time hunched over a computer or books or postures or activities that are different than what is typical for them. If there’s a musculoskeletal cause, then it’s almost always fixed with specific movements and postural changes. If the true cause is stress, then there are varied treatments aimed at generalized stress relief (not my domain of expertise). -- Laura
Outside of post-surgical scenarios and fractures, it’s rare an orthopedic boot is necessary. I’ve seen them prescribed inappropriately many times. Severely restricting or eliminating movement to that extent with an immobilization boot is the last option for orthopedic disorders. For example, you don’t want to boot a tendinopathy! As I always say, it comes down to competent diagnosing.
Not only are patients often getting incorrect treatment for their ankle/foot complaints, but walking around on an uneven surface can disrupt other parts of the body. A boot can jack you up both literally (by an inch or more) and figuratively. It’s common for people to complain of knee, hip, or back symptoms because of walking around in a boot. For those who do need to wear a walking boot, I usually recommend buying something to attach to the other foot (such as an “Evenup Shoe Leveler”) to level the feet or simply wearing a higher shoe on the unaffected foot. -- Laura
The McKenzie Method is first and foremost an assessment approach to determine what the patient needs. It is not just a set of techniques or exercises, although the McKenzie Method does also include a treatment approach for those who are found to need therapy. (Most orthopedic disorders can be addressed with therapy vs invasive care.) The assessment (also known as an evaluation) may tell me a patient needs an injection, needs rest, needs surgery, or needs any number of exercise or manual interventions.
I learned skills in DPT school, at various continuing education courses, from other clinicians, etc. I continue to learn various techniques such as Mulligan techniques in order to have more tools to help patients, though I usually find the McKenzie Method treatment approach works best. You can have a zillion skills, exercises, and techniques in your repertoire, but the key is knowing when to use each one - and I find I can best make that determination based on a McKenzie Method assessment. -- Laura
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. 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. There are many treatments I use more commonly than simple muscle/tendon stetching. 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).
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
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