Ultrasound imaging (USI) may be one of the newer forms of imaging, but newer doesn't mean better. USI for abdominal organs and the uterus is valuable, but its value when it comes to musculoskeletal problems is not convincing. A new study in Physical Therapy in Sport entitled “Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study” does not find a correlation.
The study looked at the Achilles tendons of 29 dancers with no pain nor functional problems - 58 tendons total. With USI, 62% of the young women had at least one abnormal tendon. Of the 58 tendons, 26 were abnormal when examined using USI. This study also points to others that do not find a relationship between what USI shows and pain.
How is this applicable? Say one of these dancers with an abnormal tendon starts having pain in her Achilles after the study. It’s easy to assume that the tendon - which was abnormal on USI - is the problem. However, given that it was abnormal without pain, it makes sense that something else could be causing pain - perhaps something that cannot be visualized. For that reason, we should test a person’s musculoskeletal system by moving her musculoskeletal system. Versus imaging, that gives us improved chances to find the true source of the problem. --Laura
It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee.
It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura
If you fix a medical problem by eating well for a month, it's silly to expect the improvement to stick if you return to eating crap. The same applies to mechanical, or orthopedic, problems. Consider movement (and sustained positions) your “diet” when it comes to mechanical problems. There are certainly some mechanical problems that never have to pay attention to diet again. But for most, it matters. There’s no hard and fast rule; each patient’s case is unique, and is understood during the treatment process.
If nothing in a person’s life changed except she bought a new sports car, used it a lot, noticed lumbar stiffness getting out of the car she never had before, and a week later she had an L5 radiculopathy to her big toe, there’s a great chance that position is a factor. Let’s say that point is confirmed during treatment. Meaning, sitting in the sports car now exacerbates leg symptoms and/or obstructs low back movement. After resolving the patient’s low back derangement, does that mean she can never use that car again? Probably not. But it’s likely she’ll do much better long-term if she adjusts the car’s seat, or does her corrective exercise before and after car rides over 30 minutes, or makes sure to check her low back motion after being in the car. In this scenario, resuming her old “diet” of just hopping in her sports car - and adopting that specific mechanical seated position - without thinking twice will likely lead to recurrence. -- Laura
Over thirty minutes, I review the basic principles of the McKenzie method, how it contrasts with other approaches, common misconceptions, and what a typical evaluation is like. Enjoy! -- Laura
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
Find more information about the world of diagnosing and treating orthopedics here!