If an Orthopedic Study Doesn't Investigate Spinal Involvement, I Probably Won't Like the Study4/28/2020 Given how often I see patients whose non-spinal pain is related to their spine, I make sure to investigate the spine as a possible contributor or cause. As I’ve said before, that investigation varies in time based on the case.
If I read a study on patients diagnosed with “patellofemoral pain syndrome” or “shoulder impingement” and there is no mention of clinically looking into the effect spinal movements have on the person’s complaints, I take that study with a grain of salt. I use the word “clinically” on purpose: you cannot rule in or out spinal involvement solely with an image. At least 25% of people’s shoulder and knee pain I see is actually a spine problem, addressed with moving the spine. I also say “probably” in this post on purpose. If an orthopedic study looks at people who have traumatically fractured their tibias, that is a different ball game. Most orthopedic problems, however, aren’t obvious traumas. -- Laura
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1. How long has it been this way?
2. What brought this about and what brings it about? 3. Is it limited actively? 4. Is it limited passively? 5. Is there pain with active ROM? 6. If so, when? If so, where? 7. Is there pain with passive ROM? 8. If so, when? If so, where? 9. How does the end of the ROM feel? 10. Is it consistently like this, or does it vary? There are more concerns regarding the whole patient presentation and problem at hand, but these focus in on range of motion (the entire motion available to a joint). Presumably I’m only discussing ROM with a patient if it’s problematic. This may seem like a lot, but it really only takes a few minutes to get these verbal and physical answers. Knowing the questions to raise is step one, knowing how to physically test it (the easiest part) is step two, and knowing how to interpret the findings is step three. --Laura The McKenzie method (MDT) is the system that determines what the patient needs so it is inaccurate to say someone isn’t a “McKenzie patient.” Most often the assessment reveals that the patient would benefit from a movement-based protocol. But assessments can reveal patients need anti-inflammatory intervention, surgery, rest, non-musculoskeletal care, etc. A feature that’s wonderful about MDT is you can recognize when the person doesn’t need to be in your office. Compared to my career before I started using MDT, I know much sooner when movement is inappropriate. -- Laura
There are many things that can go wrong with a joint. What I call joint derangement is when the joint isn’t sitting quite right - which I find to be the most common joint problem. Derangements vary widely in severity and can rapidly change. There could be structural changes in a joint due to arthritis or tears in ligaments or menisci. These (and many other examples) are addressed in their specific ways.
Joint capsule problems are less prevalent. The patients I’ve seen with capsular problems (manifested primarily as pain and tightness at the end range of a joint’s movement(s)) are mostly patients with frozen shoulder and patients who are older. There are distinct ways to address this problem as well. Capsular tissue problems tend to take considerably longer to fix than derangements. -- Laura Yes, injured structures can be fragile, but your spine is not inherently fragile. It is no more fragile than your ear, knee, or foot. The spine is well designed, just like the rest of your body, to withstand considerable demand. And it is just as resilient as the rest of you to bounce back from injury.
Things go wrong. Things happen. We get ear infections. We twist our knee. We break our foot. We injure our spines too. And when things go wrong anywhere in our body, they are almost always fixable. Stop telling people spines are fragile. And stop listening to people who tell you they are. -- Laura Elbow pain with push-ups does not mean doing push-ups created the problem. Knee pain triggered by squatting does not automatically incriminate squats. While we usually have to avoid triggers temporarily in order to heal, that is not to say we avoid them because they caused the problem to begin with. Triggers, once the cause of the problem is correctly addressed, cease being triggers. Sometimes a trigger is the same thing as the cause, but in my experience that is not common.
-- Laura Joints behave differently loaded (weightbearing) versus unloaded (non weightbearing). This applies to extension, flexion, etc. - all planes of motion. Just picture your ankle: if you are moving your ankle while lying down, you are moving your foot as your leg is stationary. But if you are squatting in standing your leg is moving as your foot stays stable. These are quite different ankle joint movements, with different forces.
I assess and treat patients using repeated movements. I am SPECIFIC with the exercise I investigate as well as with the one I prescribe a patient, which includes whether the movement is performed loaded or unloaded. Loaded knee flexion may have no effect for a patient, but unloaded knee flexion may prove beneficial. Loaded lumbar extension may make a patient’s symptoms worse, yet unloaded lumbar extension may work. Because I consider loaded and unloaded movements different, I have more movements available to me. While that may seem overwhelming, it’s not. There are patterns and clues in the history and mechanical exam that lead me (by implementing the method) to explore one movement compared to others. --Laura Hamstring pain is posterior thigh pain. Quadriceps pain is anterior thigh pain. IT band pain is lateral thigh pain. Adductor pain is groin pain.
Of course it fits that people who aren’t clinicians would label pain using structures they know. And it’s obvious most people can name big muscle groups! My issue is when clinicians inappropriately do it. If the patient uses this language, in an effort to create rapport, I may use it with interactions with that patient as well. Mimicing language can be a nice therapeutic tool that is easy to implement. (I typically will adopt the patient’s word for describing his or her own symptoms, for example; my favorite instance being my patient who referred to his radiating leg pain as his “lightning bolt.”) I’d prefer, however, to use the correct language if possible since accurate patient education regarding his or her problem is key to a successful outcome. I do not use these terms to refer to these parts of the body outside of that specific patient context, though. Yes, if the patient has true hamstring, quad, ITB, or adductor pathology, these words are clearly apropos. But those patients (especially among non-athletes) are rare. In most cases a patient’s posterior, anterior, or lateral thigh pain or groin pain is referred pain from the spine or hip. --Laura Certain diagnoses create constant symptoms. Certain diagnoses create consistent symptoms. Constant numbness, tingling, pain, etc. means it’s there every waking moment. It may vary in intensity, but it’s there regardless of your activity or position. Consistent is similar to predictable. Each and every time I jump my knee hurts. Each and every time I bend to put on my shoes my calf feels like it’s on fire. Each and every time I play golf three days in a row my shoulder acts up. As a clinician, I need to know which questions to ask and then how to interpret the patient’s answers to accurately diagnose.
-- Laura Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience] Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases] Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases] The point is we don't know which scenario applies to you until we move you. -- Laura |
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