How often are patients seeking care for something they’ve had before? Learning about the nature of a problem, which lends itself to recurrence prevention is - in addition to resolving the problem - extremely valuable. If you understand the basic concepts and have a prevention plan to minimize chances it happens again, you’re much better off than a person whose problem just resolved.
Are there inexplicable things that happen to our bodies? Of course! Your hip is killing you one day and then the next day it’s like nothing happened. We can’t pretend to know everything. But for the problems we can diagnose (and fix), learning strategies to prevent recurrence is a close second to getting better in my book in terms of goals. It’s about getting better and staying better. -- Laura
The term “muscle memory” is familiar, but I think “joint memory” also exists. Muscle memory refers to engrained changes in the muscle as well as in the brain. Muscle and joint memory are often inextricably linked; for instance, when repeating pull-ups, both get habituated to that pattern.
However, what I want to highlight is the positional aspect of joints versus the pattern aspect. Whether it’s due to lifestyle, an event, or obvious injury, an altered resting position can be established for a joint. In the face of irreconcilable injury, this demonstrates the body’s resilience, as the body accommodates, creating a new normal. (Think of the historical images of a new acetabulum being formed due to a fractured hip.)
Subtler changes are more likely. If your neck always looks down, it makes sense that subtle changes are occurring at the joint level (not the obvious manifestation of "horns" written about in the news recently). If you have a fall jarring your low back that resolves on its own with time, it’s possible you have altered joint alignment. (That’s why having an expert check your musculoskeletal system after an injury is important if you want to ensure things are working normally, even in the absence of pain.)
This phenomenon does not preclude resolution of this positioning or of symptoms. But when I encounter patients who have had longstanding symptoms, it enters my mind that their joints may be accustomed to positions that are not purely anatomical. If a patient has had a subtle lumbar shift for 20 years, doesn’t it make sense the joints are accustomed to that position?
Put simply, if a joint problem has been there for a long time, once fixed, I find patients need to be more on top of motion checks ad infinitum to ensure the joint stays fixed and doesn’t “remember” its old ways. For short-term problems in which the joint has only been impacted for weeks/months, patients can usually get away with less in terms of lifetime prevention strategies. -- Laura
Orthopedic special tests (OSTs) are clinical tests to aid with diagnosing. For example, there are tests that assess the integrity of the ACL, the presence of tendinopathy in the elbow, tears in the rotator cuff muscles, and problems with the meniscus. They usually name a structure that is the problem. But do they?
While I believe there are some OSTs that are helpful diagnostic tools (like the Lachman test for the ACL), most are not. In fact, I rarely use them to help with diagnosing a person’s problem because of this lack of validity. And, as I’ve said before, most problems are due to function, not structure, anyhow.
For instance, say I perform the empty can OST (which indicates a supraspinatus problem) and get a positive test, meaning it reproduces the person’s shoulder pain and/or tests weak. Then the patient does repeated movements of the neck and the test changes to negative. Does the empty can really tell me there’s a problem with the supraspinatus? Maybe indirectly, but it’s not the part (source) of the problem that needs to be addressed. Does it make sense that neck mechanics can influence how it feels when you push down on someone’s outstretched arm? Of course. -- Laura
The perfect position is the position that reduces, abolishes, or prevents symptoms. And if a lumbar roll doesn’t reduce, abolish, or prevent symptoms, then it is not indicated. A roll may make symptoms worse initially, but, as therapy progresses, it becomes helpful. Or it may only be tolerated for 20 mins but eventually is useful for long stretches. Its use should always be assessed, not recommended without reasoning.
When it comes to prevention, often that looks like a person who doesn’t have symptoms in sitting but has trouble rising, especially with straightening his low back. Or it may look like a person who has no pain all day sitting at work but then pain in the evenings at the gym. If using a lumbar roll all day prevents pain later at the gym, then it is indicated.
Lumbar rolls can be extremely effective as can any decent lumbar support built into a chair. The point is usually to reduce prolonged spinal flexion or enhance extension. Lumbar rolls can be easily added, adjusted, and removed. They can come in the form of a rolled up sweatshirt, household pillow, or something purchased. I’ve had patients support their low backs with water bottles and purses. I myself used my wallet while driving once. Their low cost and ease of use make them potent tools for helping those with musculoskeletal complaints. -- Laura
Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
I follow a method in that I use an algorithm, an approach, guidelines. The method does not say you absolutely must do this or that. I’ve said this before, if a handstand makes your knee pain go away, then you’re doing handstands. A handstand is obviously not taught as a movement to relieve knee pain within the McKenzie method — but the thought process that gets you there is exactly what the method offers. No one skilled in utilizing the McKenzie method would be dogmatic and tell me not to prescribe something if I had a sound reason to do so. The reasoning matters.
Let’s pretend that when I ask the patient what makes her knee pain better, she replies handstands. I’ve never heard that before, but I ask the question because I actually care about the answer. So I take her knee baselines (ROM, strength, function) and her lumbar baselines (ROM, nerve tension) and then we apply what the patient says is beneficial: handstands. We retest the baselines. If they improve and remain better, handstands become the home protocol.
The field of medicine, given it’s both a science and an art, hinges on flexibility. The dogma of “one size fits all” is at odds with treating unique individuals. I utilize the McKenzie method because it gives me the best guiding principles to help people get better faster and stay better longer. -- Laura
The speed with which I say that is noteworthy considering years ago that question wasn’t high on my list. When you effectively probe patients about their symptoms (most notably via a good verbal history), you’ll notice it’s actually not that common for people to have a symptom in only one isolated spot. A man might come see you because the front of his right knee hurts, but with questioning you find it’s also sometimes on the left knee and his back gets tight sometimes. Or a woman has left neck pain but when you do movement testing she notices right neck pain too. Or a kid says the outside of his elbow hurts but, yes, the inside of his elbow is tingly.
Where the symptom is is extremely important - regarding someone’s history, during the physical exam, and during repeated movements. The pain someone is describing could be in a completely different area (for example, wrists hurting with prone lumbar extension) or it could be relevant. Where the pain is matters in terms of both diagnosis and treatment; if I didn’t have that information I’d be lost. Most importantly, it tells me information about which structure is misbehaving (significantly, joint vs musculotendinous tissue), which movements are likely to be beneficial, and how to interpret the effect of movements. -- Laura
For the Lower Body, The Most Significant Aspect of Sitting All Day is Lumbar Flexion, Not Hip Flexion
I know this because I test it versus make assumptions. The hips and lumbar spine are physically close to each other, but tests can easily differentiate the two. We can move the lumbar spine without moving the hip and vice versa.
As I’ve written before, I strongly disagree with the popular idea that prolonged sitting (which puts the hips in flexion) leads to tight hip flexors which leads to pain in the hip flexors. That theory falls apart on so many levels. For starters, since when do tissues (especially “tight” tissues) hurt when put on slack? What is actually happening in the majority of patients who experience anterior pelvic and hip pain in sitting (the “hip flexor area”) is they are experiencing referred pain from the lumbar spine, which is also almost always in flexion when seated. In a smaller number of cases, the pain is referred from the hip joint(s).
If you have pain, you can’t just assume it’s from the muscle in that area. Often it’s coming from somewhere else, which I usually address with specific movement. You’ll get better faster - and stay better longer - if you treat the actual problem. -- Laura
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