A friend recently asked me for some advice when we were out at dinner. He said he was getting sharp lateral knee pain - so much so that he couldn't kneel anymore to play with his boys on the floor.
My McKenzie method training emphasizes determining which activities make the symptom worse (or produce the symptom) and which activities make the symptom better, so I asked him some questions. He related that the symptom of pain is produced ONLY with kneeling. He is able to walk, jump, and even play basketball without any problems.
I admit, years ago, before I became more skilled at the McKenzie method, his verbal history would have seemed non-informative at best, perplexing at worst. Now, however, his history screams one thing at me: SPINE! It seems that when his lumbar spine is extended his knee is fine and when his lumbar spine is flexed (kneeling sitting on his heels) his knee hurts.
I assessed the knee: full, painless extension and flexion with passive overpressure. I then looked to "clear the spine." I tested his lower extremity myotomes: deficits. I tested his lumbar spine mobility: deficits. We moved his lumbar spine repeatedly into end-range extension - first without pressure and then with overpressure - and tested his kneeling ability. Much better.
His home exercise program is repeated lumbar extension to end-range with overpressure and posture correction. He, of course, also has to temporarily avoid activities of sustained lumbar flexion. We will see if this exercise achieves full resolution of his symptom; we may have to move his spine in a different direction. It is clear, however, that his spine is involved. And my experience leads me to hypothesize that his spine is the only structure at fault here, which should be rapidly fixable using the the McKenzie method.
"Clearing the spine" is of the utmost importance. I have written about this before. The spine is involved in almost every orthopedic issue to at least some degree. (The spine also plays a role in seemingly "non-orthopedic" pathology.) I implore clinicians treating orthopedic pathology to learn how to do it effectively so that they don't miss all of these diagnoses like I used to. -- Laura
I recently treated a patient who is emblematic of a slew of patients, especially baby boomers. She came to me with an MRI showing severe spinal stenosis - and several other spinal irregularities. She had been referred to a surgeon, but, luckily, as the idea of surgery at age 83 did not appeal to her, ended up coming to me instead. As we talked during the evaluation, it was clear that she already had two strong impressions. One, the stenosis was the cause of her symptoms. And, two, her stenosis was an irreversible disorder that would possibly get worse without surgical intervention. She had met a former patient of mine and had called me on the off chance physical therapy could help.
Stenosis refers to the narrowing of an opening. In the spine, stenosis commonly refers to narrowing of the opening through which nerves pass secondary to either bony overgrowth (eg osteophytes) or disc height loss. These changes in the spine are quite prevalent. Can stenosis be symptomatic? Yes. Irreversible without surgery? Yes.
But ... can stenosis (true, bony stenosis) be apparent on imaging and not be the cause of the patient's symptoms? An even louder yes. Very commonly.
In this patient's case, other spinal irregularities were observed on imaging as well. However, she had left her doctor's office believing that the stenosis was producing her symptoms. How was that determined? Diagnosing stenosis on imaging alone is not enough. A patient deserves a thorough physical examination to determine the cause of her symptoms, and then deserves a treatment plan specifically targeting that cause. Upon moving my patient's spine in different directions during her physical evaluation - I use the McKenzie method of mechanical diagnosis and therapy - I noted a favorable response to spine extension. In her case, over the course of four visits, she responded very well to sustained extension in prone. -- Laura
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