The Main Point Isn't That Most Mechanical Disorders Can Be Fixed With Movement. It's That Most Orthopedic Disorders Are Mechanical.
Diagnosing a problem is always the most important step. Then you match the treatment to the diagnosis. When we diagnose orthopedic disorders we can think of 3 main categories: mechanical (or functional) problems, structural problems, and inflammatory problems. A huge problem I see in medicine is problems being diagnosed as structural or inflammatory when in fact they’re mechanical.
What do I mean by mechanical? Problems that are affected by movement, usually fixed with movement, and, significantly, not structural or inflammatory. My skill set is in treating these problems, which are >90% of problems. (My skill set is also in diagnosing which problem you have to begin with. If it’s structural or inflammatory, I refer you to a clinician who treats those.)
A structural problem is like a fracture, tear, stenosis, or dislocation. They cannot be fixed with movement; they need a separate treatment approach. I’ll say this again: very often people’s tears, etc. are diagnosed as structural and recommended a structural-problem solution like surgery when in fact the tear is not structurally unsound. Instead, the tear is causing or is related to a mechanical problem, which can be fixed with movement. People move and function just fine with “structural” problems “diagnosed” by imaging all the time!
Inflammation won’t be fixed with movement. In the acute stage inflammation can often be fixed with rest/time. In a sub-acute or chronic phase, other anti-inflammatory treatments may be necessitated.
Some may argue that central sensitization is its own category, which I'm fine with. But a central processing problem such as that may be better classified as a neurological versus an orthopedic disorder. There’s room for debate.
When I assess patients I’m asking: is this mechanical, structural, inflammatory, or other? By asking the right questions, listening, and expertly moving patients (when safe), we can figure it out. If someone has a structural or inflammatory problem, they won’t get better with movement. But they are the outliers, and you have to use repeated movement testing (when safe) to discern if someone’s tear, for instance, is truly a structural problem or a more easily fixable mechanical one. -- Laura
Here’s an example. If I have you bend your knee 30 times and then we assess and you have more knee bend, well, we’ve observed a change. But what if we’ve changed your knee straightening ability as well? Whenever I move a joint in one direction repeatedly a crucial thing for me to assess is if we change motion in the other directions of the joint. If you didn’t know what to assess you could incorrectly believe that since we assessed and observed a positive change (increase) in knee bend, performing the knee bend is beneficial - when it’s actually not.
Here’s another example. Say I move your low back into extension 30 times and I want to know if we’ve changed your three ankle baselines (findings). While it’d be great if all three signs changed with 30 extensions of the low back, I want to prioritize change in the “easier” signs first. That is, the baselines/findings I deem most likely to change first versus something more demanding that will likely take more reps over time. For instance, I’d expect range of motion or strength to change before I’d expect hopping ability to change. If we move your lumbar spine in order to assess the effect on your ankle, I also want to test the impact on your lumbar spine’s ability to move in other directions (as I explained in example one).
So, we can, and want to, observe change using cause-and-effect analysis for orthopedic disorders. But, more important than just observing change is observing change in things that matter the most at the time, the pieces that tell us the most information. That’s what expertise is. -- Laura
Most, if not all, people can recognize that the food you eat influences your health and that many health problems that arise can therefore be addressed with changing what you eat. If, however, diet seems too simple to be effective, then I understand why movement likewise seems too simple to be effective. After all, Americans have been conditioned to believe that fixing health problems necesitates solutions based on chemistry, technology, and devices.
I say leave all the fancy gadgets like laser, needling, and cupping for the small, small minority of people who need them for their orthopedic disorders. It’s worth pointing out that even with all the recent technological advances in the fields of medicine and orthopedic medicine, it’s a hard argument to make that overall outcomes are any better. Metabolic disorders and orthopedic disorders currently represent major problems in this country. Specific food is often the answer - and specific movement is too. -- Laura
If I had to pick the one most important thing for preserving musculoskeletal health it would be maintaining full lumbar (low back) mobility. Of course it’s optimal to have normal mobility in every joint (including the mid back and neck joints) as well as normal strength, normal nerve length, and normal movement patterns throughout your body. But if I take into consideration prevalence of pain, amount of potential disability, and level of contribution to other disorders, then - if I had to prioritize one thing to focus on - maintaining low back mobility rises to the top.
Pain in the low back is one of the most common complaints among people, typically recurs, and often creates significant disability. Significantly, if a low back is not moving well then it can cause or contribute to any number of disorders from the low back down. A low back that is not moving well makes it hard for the lower extremities to move well (not to mention the rest of your spine) and can also cause the nerves exiting the low back to become irritated/pinched/compressed. Since these nerves control the lower extremities, if they are irritated there can be referred pain, numbness, or tingling into the lower extremities as well as weakness and poor balance. (Nerves control it all!)
So if you have full mobility of your low back (flexion, extension, left side glide, and right side glide), maintain it. Maintenance looks like different things for different people, but if you spend 10 seconds every day to at least check, you should have your full range of motion. If you don’t have your full mobility then we need to figure out what specifically you need to do in order to achieve it. (And if you don’t know if you have your full mobility, there are tests we can do to figure it out.) -- Laura
When using one crutch (or cane, etc.) because one side is injured, it’s typically most helpful to use that one crutch on the non-injured side since arms swing opposite legs. Meaning, with normal gait, when your right foot goes forward, your left arm goes forward. Unweighting the injured side by putting some weight through a crutch on the opposite side thus ensures that you move as biomechanically normal as possible - which is important not only with respect to walking as efficiently as possible, but also in preventing other problems from walking like this. If your right lower extremity is injured and you use a crutch on your right arm then you’ll have to lean/sway much more to the right than you would normally. It’s also awkward and inefficient because you’ll have to move your right arm forward simultaneously with your right leg, which, as I pointed out, is unnatural.
Your abdominal muscles (in the front of your trunk, not in your back) do the real work when it comes to sit-ups. Many structures are of course still involved with this exercise, though, as with any movement. When someone tells me that sit-ups hurt his back my thought is that repeated joint activity (flexion) causes his back pain. With sit-ups, the spinal joints flex, or bend forward. If repeated muscle activity was the problem causing the pain, we’d expect the pain to be in the abdomen, where the muscles actually are.
Location of pain and provoking factors are just two pieces of the puzzle when it comes to diagnosing, but they do tell me two important things. One, in this scenario the person likely has the diagnosis of joint derangement (versus a muscle or other problem). And, two, it’s unlikely the person will need spinal flexion to get better, since it is clearly provocative. (Thus it’s more likely he’ll need another spinal direction to get his joints working properly again - and therefore be able to soon tolerate all the flexion in sit-ups.) -- Laura
Remember when your hip ached for no apparent reason and then it just went away a few weeks later? Or when you woke up with a stiff neck and after a day of moving around it got significantly better? I find most orthopedic aches and pains stem from joints not moving well. It’s easy for joints to get disturbed (especially given we tend to move them predominantly only in a few ways), but these problems often cause only minor complaints which do self resolve. Just continuing to move, possibly with a little rest, usually allows the joint tweak to work itself out.
In contrast to what most orthopedic clinicians believe, I don’t think that neuromuscular reeducation, strengthening, or passive modalities like laser are usually required. If they were so essential, I don’t think we’d see so many aches and pains resolve without them.
People that seek medical care, people that I treat, typically have these joint issues, too - they just haven’t gotten better on their own. What I find is that while most of these people do need movement, certain movements are better than others. Often we have to minimize the movement that seems to be perpetuating the issue as well. I typically have patients do just one movement at a time. Of course I do find some people have tendon, muscle, or nerve problems - and they get treated differently. However, I find around 80% of patients’ complaints stem from joints. In the McKenzie method we call them joint derangements. Mulligan calls them positional faults of the joint. -- Laura
People clearly have differing ideas, but, even when presented with the same information, people can interpret it differently based on their currently-held worldview. Here is the most classic example I can come up with in terms orthopedic thinking: shoulder impingement. The predominant worldview (in the US at least) is that muscles, joints, tendons, and neural patterns around the shoulder are functioning improperly as a unit and therefore during overhead movements the subacromial space is impinged causing pain. My view is that in over 90% of cases one specific thing is not working correctly.
The prevailing treatment for the common worldview is simultaneously stretching or releasing one or more muscles, loading certain tendons, strengthening many muscles, and moving certain joints. I remember I used to give patients at least seven things to do at one time when I had that belief system, which I was taught.
My current view is that most patients need to move just one particular joint or tendon. That particular movement is often, but not always, included in the array of movements listed above, which is interesting but not surprising since the normal treatment includes so many things! So if people get better with the standard approach, people believe it’s correct.
My understanding now, however, is that the reason they got better is because they included the one thing they needed - and the rest was superfluous and, at worst, a waste of time and resources. My patients with shoulder pain with overhead movements almost always get just one exercise to do at a time, which may or may not change over time. (For me, what other clinicians diagnose as shoulder impingement, I diagnose as several different things: cervical derangement, thoracic derangement, shoulder derangement, and shoulder contractile dysfunction.)
It’s interesting to think about how our belief systems can inform how we understand the evidence. Clearly those who believe the predominant worldview and those who believe the MDT-leaning view interpret the fact that people get better with standard shoulder impingement treatment very differently. As I wrote recently: I am interested in what works, but I’m more interested in what works best. - -Laura
There’s a reason why if I’m treating spinal pathology, or if I’m curious about the relationship of the spine to the patient’s extremity complaint, I a) only prescribe one movement at a time and b) assess the effect of the exercise on the patient’s baselines before allowing it. Even though you may think the spine is in neutral or is not moving when an extremity exercise is being performed, there’s a strong chance that the spine is influenced. Sidelying clams, biceps curls, squats, rows, leg lifts, as examples, can easily impact the spine.
It should go without saying that a strengthening exercise for a hip muscle influences the hip joint, a rhomboid exercise influences the shoulder, and a triceps dip influences the elbow. But we must not forget about the influence on other nearby joints, namely spinal joints. And we must be deliberate when assessing cause-and-effect to determine whether an exercise is warranted. It's not difficult to take spinal baselines, implement an extremity exercise, and then re-test to see if the spinal baselines have changed. Knowing to do that, and how to do that, is where the skill lies. -- Laura
When atraumatic problems occur it's usually because a problem someone knew he already had has worsened, a problem someone didn't know he had has worsened, or a problem he or science didn't know how to test for and/or define has worsened. It’s not unusual that symptoms don’t become apparent - or symptoms don’t reach the threshold of impacting your life - until they’ve been percolating (silently or noisily) for years.
Does aging give you lung cancer, or does smoking every day for 50 years give you lung cancer? Does aging give you low back pain, or does a life moving around lacking full low back mobility since you fell off a horse when you were 11 give you back pain? Does aging give you severe headaches, or does growing up inhaling toxic fumes nobody knew were toxic give you severe headaches? Figuring out what causes problems is not necessarily easy, but it’s overly simplistic to attribute the onset of symptoms to a body simply getting older. There are normal changes associated with aging (in essesnce these diffuse changes are aging), and then there are problems. -- Laura
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