There are diverse opinions when it comes to orthopedics. And you should feel free to explore the myriad thought processes, approaches, opinions, techniques, etc. But when your goal is to fix something, you need to focus on one approach. Let one chef take over, even if just for the time being. Not only does that allow you to focus all your time and energy on the game plan in front of you, but it, most significantly, gives it the greatest odds of success.

If I want someone to repeatedly flex his spine, but another clinician wants him to repeatedly extend it - well, those are obvious contradictions. Doing both at the same time in this example would make zero sense and would preclude either approach from working. Outside of obvious examples, though, there are more subtle ways that things get derailed. For instance, if I tell someone she has a terrific prognosis if we follow these four steps, but her primary care physician keeps telling her therapy won’t help because the x-ray looks bad, then things often stall.

Research all the different options first if you really want to, but give just one approach, just one clinician, the title of head chef at a time. If it’s concluded that another perspective is needed, then you can move on. As the saying goes: we can't have too many cooks in the kitchen. -- Laura

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

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.
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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

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 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

​Yes, some patients have problems that cannot be fixed with movement. But how will you know unless you test movements and interpret the effect? In almost all orthopedic cases, diagnosing should involve repeated movement testing. Morton's neuroma is currently diagnosed by imaging and provocation testing, but, as Michael David Post and Joseph R. Maccio's paper "Mechanical diagnosis and therapy and Morton's neuroma: a case-series" demonstrates, a repeated movement exam is needed to assess if patients will benefit from repeated movements.

If you take people with no toe pain and put them in an MRI, many will have neuromas. So we know they can be present without causing pain. When patients do have pain, then, we can't assume their neuroma is the cause. We need to investigate if the spine is the cause or the toe joint is the cause. Additionally, assuming a neuroma is causing pain still doesn't mean the patient won't do well with repeated movement treatment (but you have to find the correct movement).

What percentage of patients who complain of toe pain receive a competent repeated movement exam? How many with toe complaints will have a clinician investigate their lumbar spine? And what percent will even be recommended to see a movement-based therapist if the image shows a neuroma? If these three patients hadn’t resolved their problems in just a few visits with repeated movement, what types of therapies, injections, surgeries might they have had? In this case series, three patients with medically-diagnosed diagnosed neuromas abolished their toe pain with repeated movements, with those results remaining at one year. One patient required repeated movements of the lumbar spine (low back) and two patients needed repeated movements of the affected toe.

When it comes to movement testing, I believe in end-range repeated movement testing that investigates the relevant spinal segments as well as the relevant affected joint(s). This is the core foundation of the McKenzie method. Movement testing is not the same as orthopedic special tests or palpation tests or provocation tests. It means repeatedly moving a person in the clinic and at home and evaluating the effects if has on the person’s symptoms and mechanics. Looking at a picture and seeing if something hurts when you press on it is rarely enough. -- Laura

​Let’s say I am helping someone fix her shoulder derangement. If I have the correct diagnosis, I expect significant improvement quickly with an exercise in a specific direction - and eventual 100% return to normal. Let’s say we figure out that direction (often it’s extension or functional internal rotation). By finding that positive response to that direction of movement, we confirm our diagnosis and therefore establish a reasonable prognosis.

Now, here are other factors that could affect the ability to get the problem 100% resolved: patient’s shoulder position at work, at play, while sleeping; patient’s compliance with the home program; patient’s performance of the exercise; stress level; diet; lifestyle factors (eg smoking); other health issues; environment; genetics; patient’s belief system/expectations; how the problem affects the patient’s life; and other people’s input/opinions.

For this reason, I often use the words “should,” “likely,” and “in most cases.” Yes, there are many problems that, in my head, I think are 100% fixable; but I know that, until something is 100% fixed, it’s not a given. There are numerous factors when it comes to addressing problems with the human body and mind. As a clinician, I set expectations based on interpreting all the available data. -- Laura