Even small, very-fixable problems can cause a lot of pain (or other symptoms). And very often that pain is magnified or compounded by fear - fear of more pain; fear of not being able to move, to work, to return to exercise; fear of the need for invasive treatment. If people had a basic understanding of how the musculoskeletal system worked, they would be better equipped to fix their problems themselves. More importantly, though, they would not have to be so afraid and anxious as they would know that almost all problems are fixable with movement.
I severely burned my hand once. Despite immediately submerging my hand into an ice bath, the pain was intense. As I cried, I repeated aloud to myself: it’s just pain, it’s just pain, it’s just pain. I intrinsically knew it wasn’t something that was going to cause any real problem and I wanted to assure myself that I had nothing to fear. In essence I wanted my cognitive brain to override my emotional center and let the facts win. I simply had to minimize the pain as much as I could, get through it, and I would be fine. People often know this when it comes to cuts, bruises, burns, and the like. They know that despite pain, they don’t have much to fear. This needs to translate to musculoskeletal problems as well. -- Laura
There is a reason some interventions need to be done frequently. When I diagnose orthopedic problems, the frequency of the intervention in the initial phase of rehab is paramount. We brush our teeth frequently throughout the week to keep our teeth clean. What I investigate with patients is: will frequent movement (specific movement) get your body healthy? Once we get it healthy, frequency, like with teeth brushing, is reduced to keep it healthy. -- Laura
So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did).
Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
If you indeed have problematic scar tissue (it happens), it will be consistently tight or painful when it is put on tension. There won’t be normal days and tight days. Or good mornings and bad afternoons. Or pain-free months and painful months.
Scar tissue is normal, and only sometimes becomes a problem. When appropriately challenged with movement, it will normally become as elastic as the tissue it replaced (the previously injured tissue). Think of a cut on your skin. Scar tissue will replace the skin that’s been cut and, almost always simply through normal daily life, you will gain full mobility of that tissue. In the event the scar tissue hasn’t been moved well for years, it may not be possible to get it as elastic as the prior tissue was.
This premise applies to cut skin as well as tissue injuries inside the body. Tight tissue is tight tissue - and, though it can be lengthened with movement, it will not demonstrate variability when problematic. This is why I am sure to ask patients if their complaint is consistent (meaning each time) or variable; it’s an important part of differential diagnosing. Before we start to think scar tissue is your problem it has to at least fit this one basic criterion. -- Laura
If you want an awesome golf swing, a great squat, a long triple jump, or even an efficient gait, the component parts need to be working normally. You want these component instruments - joints muscles, nerves, etc. - to be functioning individually before you start to program or re-program patterns. The independent parts will improve as a unit when the swing or squat is practiced - and we don’t want to engrain abnormal unconscious patterns if we don't have to.
Take running as an example. If you’re lacking normal dorsiflexion that can affect how you run. Worse case scenario, that leads to injury at the ankle or somewhere else. Best case scenario, it doesn’t matter at all. Could your dorsiflexion normalize simply by running? Maybe. I am more exact, however; I investigate how to get a patient more dorsiflexion (there are many causes). There are so many moving parts when it comes to the symphony of running and I realize most people who run aren’t going to check all these things. But if your goal is performance and/or you’re interested in investing time and energy in perfecting your running, it behooves you to see to it that the individual parts work well. -- Laura
Saying you treat pain is like saying you treat sneezing or itching - they're symptoms. You can manage pain, but you’re not, in essence, treating it. You treat the cause of the pain. When people ask me if I treat shoulder pain or jaw pain, etc., I know what they mean. The short answer is: I primarily evaluate to see if I can help with what is causing the pain.
Pain management strategies (such as ice, heat, unloading, medication, creams, gentle movement, and so on) have value, and I recommend them as needed. The goal, however, is to find and fix the cause of someone’s pain (musculoskeletal or other) just like you figure out why you’re sneezing or itching. Are there cases when a cause cannot be deduced? Sure; but they are rare and, by methodically eliminating diagnoses, you still should be left with only a few reasonable hypotheses. -- Laura
A positive FABER test does not incriminate just the hip & SI joints; it can be positive in the case of lumbar pathology as well. FABER stands for Flexion, ABduction, External Rotation. It's a test in which, in supine, the hip is placed in that position, like a figure 4. As with almost all orthopedic special tests (OSTs), I use the FABER as a baseline that informs my thinking — not as a test that tells me a diagnosis.
Just like basic range of motion, strength, or the ability to do a functional activity can be a baseline, so can a test. The FABER test, after all, judges range of motion and its effect on symptoms. As we implement an intervention, we examine if and how baselines change. I know what I expect to see change for each specific diagnosis.
So if I note that FABER is positive on the left and/or right, the questions become: Is it relevant? And: Will it change? Based on that particular baseline and all the other information I’ve gathered (verbal and physical), we apply specific movements and assess the result. I know there's a strong chance lumbar procedures, hip procedures, and/or SIJ procedures can change the FABER test. -- Laura
If I tell you to push your knee into full extension 10 times every day preventatively, will that alone do the trick? In my experience, no (because people won’t). What if I teach you that, on days when you have to kneel and sit cross-legged a lot for your job as a preschool teacher, you need to do at least 10 knee extensions to balance it out? Or if I teach you that on days when you wake up and your knee is a bit achy, you need to perform the exercise then - as many reps as it takes? Or if you sit on a plane for 8 hours, you should do the knee extensions when you land?
My teaching patients why they need to do a particular exercise is more important than giving a generic prescription. Telling a patient that doing 10 knee extensions a day will help is true (for a patient who resolved his problem in therapy with knee extension). But it’s more effective to explain that, well, you might not need it that much and you might need it more than that. You may never need it again! But ... you do need it when your knee is stiff and when your day has involved a lot of time in the other direction. Of course you need to do it when it’s achy (especially to prevent it from turning into pain), but by doing the exercise preventatively, we don’t expect it to get achy often.
Equipping patients with knowledge makes treatment more effective by, in essence, making it more individualized. All of the factors mentioned above affect how much you’ll need your knee exercise in the future. By being able to read the signs, though, you can figure out what causes your knee pain to recur and what the optimal prevention program for you entails. -- Laura
If there is continuous assault on your body, there can be a continuous inflammatory response. Think of something piercing your skin. As long as it’s there, it’s likely your body will continue to fight it with inflammation. Or if you’re constantly exposed to a personal allergen (environmental, food, etc.), that can also happen.
The same premise applies to what can be called mechanical problems (most orthopedic problems). When a joint is not moving well, it can produce inflammation as a primary response, or there can be inflammation secondarily. Same goes if a nerve is not moving well. I don’t typically see tight or injured muscles directly causing long-standing inflammation, but they could secondarily.
The crux of the matter is: you can treat the inflammation or you can treat the source. Sometimes you’ll want to do both, but unless there’s a strong argument to do so, I prefer focusing time and energy on the cause. It can take work sometimes to find the source considering all the facets of the human body, but there is a reason someone has never-ending inflammation - and it’s usually fixable. When it comes to the musculoskeletal system, it’s usually joints not moving well, which we address with specific movement. -- Laura
My thoughts on posture's relevance to specific patients and the general public. Its importance doesn’t have to be a guessing game. We can test it. Every clinician should. (9 minutes) -- Laura
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