Depending on where a muscle originates and where it inserts, it can move the bones of your body in a specific way. It’s rare that a muscle even works in isolation. A certain muscle or muscle group may need to be a focus of rehab in the case of a problem, but there’s no hierarchy of prestige in the human body. (I’m not talking about the heart, diaphragm, etc.) Your psoas is not the key, nor is your core (a group of several muscles). No one muscle will ensure health or prevent injury.
The relative importance of a muscle is circumstantial, based on what a particular individual’s needs are. For example, a shot putter, to improve performance, will focus on different muscles than a cyclist. Someone whose goal is to be able to get up easily from a low couch will have different needs as well. -- Laura
I appreciate having a method of approaching the body when it comes to musculoskeletal problems. With regards to any problem, I have an order of investigation: the spine, local joints, tissues, and other. When it comes to an extremity, I always look at the related spinal segments. With extremity joints, I always look at active motion, passive motion, strength, and function. With regard to movement testing, I look at the sagittal plane first and then the frontal or transverse planes (except in rare cases). I use the least amount of force first and add force incrementally only as needed. There are many other examples of how the McKenzie method embodies a systematic approach.
The point here is that diagnosing and treating can be simplified according to the core principles. Care is not based on a hodgepodge of tests. For instance, if you only learned how to treat shoulders using the McKenzie method, you should be able to apply that to hips - and vice versa. The more you use the method, the more efficient you become at implementing it. -- Laura
In brief, spinal nerves are responsible for sensation in a certain area and power to certain muscles. There are thirty-one spinal nerves, numbered according to the area of the spine where they emerge. We often name nerves that are the combination of two of more spinal nerves, such as the sciatic nerve, which is the combination of lumbar nerves 4 & 5 and sacral nerves 1, 2, & 3. (The sciatic nerve is usually irritated by way of the fact that one of its five spinal nerve roots - at the level of the spine - is irritated. As I’ve written before, nerve entrapments in the periphery, outside of the spine, are rare.) Spinal nerve roots are commonly irritated.
In contrast, cutaneous nerves, which are named, are responsible for sensation in a certain area, but do not power muscles. In the absence of direct trauma or compression (including due to surgery), it’s rare to irritate these nerves.
Even though their sensory areas overlap, in the presence of a sensory problem (numbness, tingling, pain), there’s a way to determine which is at fault. We have clinical nerve tension tests, muscle power testing, and repeated movement testing to indicate which nerve is the problem. We don’t have to guess. -- Laura
Differential orthopedic diagnoses for shoulder blade pain include a strain/pull/tear to any of the muscles in the area (there are many) and a shoulder joint disturbance. It’s very rare that you injure one of those muscles - and shoulder joint derangements only infrequently refer pain posteriorly to the shoulder blade. Can a frozen shoulder refer pain back there as well? Sure. But that’s not usually going to be the chief complaint of someone with a frozen shoulder.
The joints in the cervical spine and the thoracic spine can refer symptoms to many areas, and the shoulder blade is a big player. With altered electricity coming from irritated spinal nerves, it’s not uncommon to find spasms or trigger points in the shoulder blade muscles. Those findings are the symptoms, not the culprit. Local weakness can also be a finding due to spinal nerve irritation. I find that in nearly every case I’ve seen in which the person complains of shoulder blade pain (or ache or tightness), we can fix it with repeated or sustained movements of the spine - in the sagittal, frontal, or transverse plane. -- Laura
The glutues maximus, gluteus medius, and gluteus minimus are innervated (powered) by the nerve roots L4, L5, S1, and S2, which exit the spinal cord in the low back. A muscle can only achieve optimal strength and efficiency if it’s getting an undisturbed supply of electricity. I hear loads and loads of people talk and talk about problematic weak glute muscles. I usually don’t find weakness. Instead, I find that it’s almost always inhibition - a fuse box (spine) problem. Most low back problems are at the levels L4, L5, S1. Is it any surprise then that the nerves to the glutes may be compromised? There does not have to be back pain for a nerve irritation to be present.
If we prove that your nerves are indeed working well (which we do by clinically moving your low back, and sometimes hip, repeatedly - not by looking at an image), and your glutes are still problematically weak, then we can begin all those glute exercises such as squats, lunges, donkey kicks, clamshells, crab walks, sidelying leg lifts, lateral step downs, bridges, and so on. If a professional wants to diagnose “weakness,” then he/she better have first at least ruled out inhibition. Not only does that save months of work, but it gets at the real diagnosis. When a muscle doesn't demonstrate the strength it should, I check the fuse box. -- Laura
Just because something happened recently does not necessarily mean it needs to “settle down” or “take some time” to get better. We can do better than making assumptions that the time frame alone of an injury tells us the diagnosis and, therefore, the prognosis. Time frame is just one factor. Why assume the remedy is time when you can investigate to see if there is a more appropriate (and faster) solution?
In general terms, when I diagnose problems, there are three main categories: joint problems, tissue problems (capsules, tendons, and muscles), and other problems. Within the “other problems,” which encompasses many distinct issues, each a small overall percentage, is “acute trauma.”
For me to arrive at the diagnosis of "acute trauma,' I have to rule out other diagnoses. I don’t assume that since you hurt your hip playing soccer four days ago, that your pain and limitation is automatically a result of its acuteness. Most significantly, I need to rule out that you have a joint disturbance - especially given joint disturbances are the rapidly resolvable problems. There’s a good chance that your hip joint could respond favorably to directional preference exercise. In that case, you don’t need to just wait for time to run its course - you can fix it quickly, sometimes within a day or two. If a structural compromise (like a fracture or major tear) is suspected, that may also be further investigated at the appropriate time to rule in/out.
If I do actually diagnose a problem as “acute trauma,” which, importantly, means it’s not something else (or something else yet), then treatment is geared more toward non-provocative mid-range movements and general movements (like walking) that similarly do not exacerbate symptoms. Anti-inflammatory intervention may provide some help, but not always. The plan in this case is to give it a few more days (because acute trauma by definition does get better with time) and then reassess to try to determine a more specific diagnosis. -- Laura
We don't have to assume a muscle is tight or a muscle is weak. We don't have to assume a joint is obstructed or a joint capsule is restricted. We don't have to assume a muscle is inhibited. We don't have to assume a structure is inflamed. We don't have to assume a nerve is compressed or entrapped. There are tests for these things.
These problems are distinct and can be distinguished from one another through competent and thorough testing. Sometimes that testing takes five minutes in the office. Sometimes it takes movement testing at home for two weeks. If needed, in rare cases we also have imaging testing to rule in or out fractures, relevant structural compromises, and sinister pathology. The heart of the matter is we don’t have to assume. I’ve spent over a decade learning and perfecting this testing so I can find the problem fast and then instigate the correct treatment. Differential diagnosing ability is central to helping people. -- Laura
Most of orthopedics is getting joints moving better, getting nerves conducting electricity and moving better, and getting tendons functioning at full capacity. Rare is the case that true strength needs to be built in a muscle or muscles to resolve a problem. Those scenarios include when atrophy is creating problems (secondary to a number of possible factors) and when there has been injury to a specific muscle. While I often use general “strengthening” exercises as an adjunct to the primary intervention, the intent there is to get the musculoskeletal system moving and working again, not strengthening. Of course, muscular strength, which takes significant time to build, has myriad positive effects on the body, and I wholeheartedly support strength training in general. However, when problems arise, specific distinct solutions are typically called for. -- Laura
I recently saw a social media post entitled “Prone Exercise Progression for Low Back Pain.” If only it were that simple! There is no "prone exercise progression" for low back pain. Prone exercises are used for certain diagnoses with certain patients. Pain, after all, is not a diagnosis. We don’t treat heart pain or lung pain - we treat the underlying diagnosis. Will I allow that there are rare cases in which we can’t establish a true cause? Sure. But in those cases you get there by ruling out a multitude of possibilities.
Not only can we do better than treating the symptom of pain, but we can be specific about what each individual needs. A prone exercise progression will help some people with some diagnoses. It will also do nothing for some people and will make some people worse. You can try whatever you find on the internet if you want. We all do it from time to time. But success is more likely when you have an individual diagnosis and plan. -- Laura
Structures other than muscles can be tight. For example, nerves can get tight. Clinically we say they have lost extensibility, are compressed, or are entrapped. However, they do effectively get “tight” in many cases. Joint capsules can also get tight, as can the joints themselves. I usually use the word obstructed when referring to joints, but, to most patients, they in essence feel tight.
Tightness is also a common referred sensation. With referred symptoms, people tend to name the muscle where they feel the symptom. For instance, if the joints in the low back are referring symptoms to the front of the thigh, people usually say (and assume) they have a quadriceps problem. Understanding the concept of referred symptoms is crucial ... but it’s also very important to recognize that it’s not just pain, numbness, and tingling that can be referred. It’s also common to have referred sensations that feel tight, achy, or even hot or cold. -- Laura
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