My biceps is usually in quite a shortened position due to shoulder flexion and elbow flexion. Ditto for my neck flexors and hip flexors. But they’re not actually shortened (or tighter than normal). I have full flexibility in each of those muscle groups. Muscles can indeed become shortened, but it’s not a given they will get short if they spend most of their day like that.
Again, there are ways to test muscle length/flexibility. I don’t rely on muscle length/flexibility tests alone because they are not very specific. That is, when you test the flexibility of a muscle, you are also testing other structures. What I do if I suspect muscle shortening is perform the muscle length test and note the findings. Then I will do dynamic movement testing and assess the effect on the muscle length test when re-tested. If we rule out everything else, and the muscle stays tight, then we can diagnose muscle tightness.
But my distinct point here is that we can’t make an assumption based on daily positions or activities. If you think “hip flexors get tight” because they’re shortened all day, well then what about all the other muscles that are shortened all day? Isn’t it more likely that something else is going on in the hip area? Things can be figured out with competent testing - not assumptions. -- 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
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
Clinicians should base diagnosis and treatment on tests that are reliable and valid. I have attended courses that taught me how to determine sacral and facet positioning with my fingers. Only later did I realize that stuff was ridiculous. When you palpate (touch) a structure at rest, for starters, you’re touching many structures. In addition, it doesn’t consider referred pain. For instance, if I touch your Achilles tendon and it feels thickened or it feels painful to the patient, I can't make strong inferences from that other than it feels thickened or it feels painful to the patient. It doesn't help with diagnosing what is causing those phenomena. If you want to use that as a baseline test and see if it changes with the intervention, that is fine; but that is not the original intent of these palpation tests that are commonly taught, which are geared more to defining (diagnosing) a problem. Palpation during movement tests are similarly flawed - most notably because they purport that clincians can reliably detect small amounts of movement. Reliablitiy is not only in question when the same clinician performs the test on different occassions, but is clearly questionable when it comes to comparing several clinicians. We’re better than saying we know the diagnosis by eliciting pain when we touch something (which is below skin and everything else). And we’re better than saying we know the diagnosis based on (allegedly) feeling a 5-degree rotation in a joint. -- Laura
If the diagnosis is a structural problem, then the location of pain is almost always where the structural lesion is. Structural lesions with bones, muscles, tendons, ligaments, discs, cartilage, and menisci create local symptoms. The main exception is when structural lesions occur with nerves, in which case symptoms can travel along the nerve. So if what you suppose is a problem in a structure changes location, it’s more likely that instead of there being a problem with the structure, there’s a problem with how things are functioning - which is the majority of problems. With functional problems (that is, something is not working well instead of a structure actually being broken), it's common for pain to change location. Muscle strain, tear, pull pain doesn't move. It's where the strain, tear, pull is. -- Laura
Perhaps if people consider common “medical” problems, they can better understand musculoskeletal problems. While a cough may feel like it’s coming from the throat, plenty of things can cause a cough. It can be due to a problem in the stomach, lungs, sinuses, nose, mouth, or throat. A quality verbal history and evaluation will steer the clinician’s investigation into the cause (diagnosis).
While your knee may hurt, plenty of things other than your knee can cause your knee pain. While your hands may be tingling, plenty of problems other than hand problems can cause that tingly sensation. While your shoulder may not rotate, there may be a cause other than your shoulder. While your calf muscle may be weak, there could be a cause other than your calf muscle.
Signs and symptoms such as a cough, pain, paresthesia, decreased mobility, and weakness are pieces of data which help us understand the problem. The location of signs and symptoms is not necessarily the location of the diagnosis. -- Laura
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
Here are the top four reasons I can fix my orthopedic problems quickly. One, I address them as soon as they happen. Two, I know what to do. Three, I know what temporarily not to do. And, four, I have confidence in the methodology. I think the fourth reason is the most salient. I don’t get sidetracked by an uncle telling me to just get a shot. Or another clinician giving me his/her two cents. Or Google recommending medicines, oils, or any number of theories and movement programs. We all have aches and pains from time to time. By understanding orthopedics and how to approach problems methodically and effectively, even if I know my recovery will take some time, I know the prognosis, don’t have fear, and don’t waste time on unnecessary interventions. -- Laura
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