There are many goals when it comes to working with orthopedic disorders, but these are the objective health parameters I aim to achieve: full range of motion, full strength, full nerve extensibility, and good mechanics. Mechanics, loosely defined as how you move, is more subjective than the others, but there are norms with quality of movement too.
Full, pain-free function, or being able to do what the patient wants to do, is the most important, but functional ability typically relies on these four domains. In the event we cannot achieve full range of motion or full strength etc. - which can happen for various reasons - our goal simply becomes to achieve the maximum possible. (Other goals with care: efficiency, risk minimization, fostering patient independence, and teaching prevention strategies.) -- Laura
A stress test on a treadmill, hooked up to monitors, indicates how your heart functions when challenged. Repeated movement testing, which I perform and prescribe, indicates how your joints, muscles, and nerves function when challenged. Pictures tell us how things are at rest but not how they behave. And orthopedic special tests (OST) tell us how things are with a static test or with one movement. Barring a major structural problem, most problems are functional - and require dynamic testing (repeated movement testing) to arrive at a diagnosis. Repeated movement testing is one of the hallmarks of the McKenzie method.
Repeated movement testing is exactly what it sounds like. After I get a verbal history and note physical baselines such as range of motion, strength, and nerve tension, I choose a movement to be performed repeatedly and then assess the effect on symptoms and the baselines from the physical exam. The repeated movement I choose to test is based on several factors. An example of a repeated movement would be performing 10 shoulder internal rotations or 10 lumbar extensions.
An important adage is: correlation doesn’t equal causation. One can assume one's neck or back hurts because of stress. Or one could investigate to see if stress and symptoms are simply correlated and not causal. An key step is to specifically look for a musculoskeletal cause to musculoskeletal complaints. It’s quite common that when people report stress they also report more time hunched over a computer or books or postures or activities that are different than what is typical for them. If there’s a musculoskeletal cause, then it’s almost always fixed with specific movements and postural changes. If the true cause is stress, then there are varied treatments aimed at generalized stress relief (not my domain of expertise). -- Laura
Outside of post-surgical scenarios and fractures, it’s rare an orthopedic boot is necessary. I’ve seen them prescribed inappropriately many times. Severely restricting or eliminating movement to that extent with an immobilization boot is the last option for orthopedic disorders. For example, you don’t want to boot a tendinopathy! As I always say, it comes down to competent diagnosing.
Not only are patients often getting incorrect treatment for their ankle/foot complaints, but walking around on an uneven surface can disrupt other parts of the body. A boot can jack you up both literally (by an inch or more) and figuratively. It’s common for people to complain of knee, hip, or back symptoms because of walking around in a boot. For those who do need to wear a walking boot, I usually recommend buying something to attach to the other foot (such as an “Evenup Shoe Leveler”) to level the feet or simply wearing a higher shoe on the unaffected foot. -- Laura
The McKenzie Method is first and foremost an assessment approach to determine what the patient needs. It is not just a set of techniques or exercises, although the McKenzie Method does also include a treatment approach for those who are found to need therapy. (Most orthopedic disorders can be addressed with therapy vs invasive care.) The assessment (also known as an evaluation) may tell me a patient needs an injection, needs rest, needs surgery, or needs any number of exercise or manual interventions.
I learned skills in DPT school, at various continuing education courses, from other clinicians, etc. I continue to learn various techniques such as Mulligan techniques in order to have more tools to help patients, though I usually find the McKenzie Method treatment approach works best. You can have a zillion skills, exercises, and techniques in your repertoire, but the key is knowing when to use each one - and I find I can best make that determination based on a McKenzie Method assessment. -- Laura
How do I increase a person's ankle dorsiflexion range of motion? There is no one way to fix a sign/symptom. I can name ten possible things I would do to increase a person's dorsiflexion depending on the source of the deficit. A sign or symptom is not a diagnosis. You diagnose the problem that causes the sign/symptom and provide the appropriate treatment for that diagnosis. It’s the same as with other medical problems. There’s not one way to relieve head pain nor one way to increase low blood pressure. You figure out the reason (the diagnosis) and address that.
I know I sound like a broken record, but people want to oversimplify orthopedics when it actually takes solid diagnostic skills to achieve effective care. If a patient of mine has decreased dorsiflexion, that is just one piece of data in isolation. Combined with the other data I obtain (verbally and physically) and combined with the response to repeated dynamic testing, that piece becomes more intelligible. If you think you simply need to stretch your Achilles to gain more dorsiflexion, by all means, go ahead. It will help sometimes, but it’s not high on my list of treatments I use to gain dorsiflexion. There are many treatments I use more commonly than simple muscle/tendon stetching. So the answer to how I increase dorsiflexion is: “It depends.” -- Laura
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