Tugging on a hose (nerve) will not be effective if something is compressing it. Several things can compress nerves in our bodies. In contrast, if a nerve is adhered to something, tugging it (typically called flossing, stretching, or gliding) is indicated. I tell patients with nerves that aren’t moving as well as we’d like that we first check to see if someone is “stepping on the hose.” If we investigate and find that to be the case, we work to remove the compression. If we rule that out, then we can start to glide the nerve to increase its length. Performing gliding without investigating potential compression will often get you nowhere - just like pulling on a hose while someone’s foot is on it won’t get you anywhere. -- Laura
Try to get to, and understand, the “why.” Why is my leg restless? Why is my patellofemoral joint hurting? Why is my bowel irritable? Why is my head aching? Why is my nerve pathological? Why is my IT band painful?
We unfortunately do not have an answer 100% of the time, but it’s close. And there is usually at least a strong hypothesis. It may take more than one clinician. If you strike out with one, try another. Once you uncover the “why,” you can treat that. -- Laura
Rolling an ankle impacts more than ligaments and tendons. The ankle joints (there are several) are obviously involved - and possibly the structures that get injured. Before I jump to the conclusion that pain and tenderness on the lateral (outer) aspect of the ankle is coming from the lateral ligaments, I move the joints to assess the effect. The joints of the ankle can create pain anywhere near the joints. If a joint is indeed the culprit, most will resolve rapidly with directional preference exercises. If a ligament is to blame, then traditional treatment of a ligament sprain is indicated. Looking for the problem that usually gets better the fastest not only makes diagnostic sense, but also benefits the patient. Who doesn’t want to get better as fast as possible? -- Laura
You need to investigate the source of your complaint - and not make assumptions. A spinal curve, flat foot, bowed leg, askew elbow, elevated shoulder, etc. may or may not be related to your current complaint. If your abnormality, or deformity (we all have them to some extent), has been around for years and your complaint is new, the odds that they are related decreases. If you noticed they occurred at the same time, the odds increase. Too often people make assumptions without understanding how to repeatedly move the body to test for any relationship. -- Laura
When reaching hard enough, will you feel pulling in your hamstrings? It’s likely. Tendons and muscles (unlike other structures) will usually allow you to eek out another centimeter in pursuit of your toes, which you’ll feel. But “feeling it there” does NOT mean that is necessarily the limiting factor. To touch your toes you’ll need sufficient hip mobility, low back mobility, and sciatic nerve length for starters, not to mention mid back mobility and even arm length! Whereas so many (I want to say most) fitness professionals and medical clinicians alike make assumptions such as this, I critically assess why someone cannot do something. We move your body in various ways repeatedly to understand the source of a complaint or functional deficit. And by the way: it’s usually not your hamstrings.
The large majority of patients I see have problems that can be resolved with physical therapy. However, when evaluating a patient - or over several visits - it sometimes becomes clear that a different intervention is needed. For example, oral medication, injection, surgery, cognitive therapy, and so on. My first question to myself as a clinician is always, “Is this person in the right place?”
Physical therapy is a great place to start for most people complaining of orthopedic problems, though, given it is indeed where most people need to be and given it’s non-invasive and carries little to no risk. I say that at least 80% of people I see benefit from what we can do together. That is partly due to the fact that I briefly speak with patients first before seeing them. But I still see patients that do not respond and therefore make an appropriate referral/recommendation. No intervention treats everything. The objective is to get a quality diagnosis and choose the best intervention based on the diagnosis. I diagnose based on repeatedly moving the body, which I find to be most effective.
Can we at least agree that a muscle spasm creates a shortening of the muscle as it performs its action? When you have a true calf cramp your foot starts to plantar flex (point down). When your hamstring spasms, your knee bends. When your toe flexors cramp, your toes curl. And so on. (There can be many causes of these muscle spasms including musculoskeletal, nutritional, and others.)
So, if your low back muscles were in true spasm, they (primarily extensors which extend - or backward bend - your low back) should pull you into backward bend. Why don’t they? Because while you feel muscular symptoms, it’s rarely (I want to say never) a true muscle spasm. Instead, it’s pain referred from the nearby low back joints. These muscular symptoms can be horrendous, but they are driven by the joint; and once you start to get the joint moving correctly again, the muscular symptoms calm down.
Many patients with low back problems actually lean forward or are stuck forward due to the joint derangement, which further disproves the common theory that muscle spasm is the problem and is what needs to be treated. -- Laura
Inflammation is rarely the main cause of complaints. And before any symptoms are addressed with pharmaceutical anti-inflammatories or injections, a quality clinical exam must be performed. Typically a mechanical problem will be found - which is treated with targeted movement. While inflammation may indeed be present, it almost always resolves once the real mechanical cause is resolved. Inflammation is usually therefore a symptom (not a cause).
If a patient does not respond to mechanical care, chemical (anti-inflammatory) care may be indicated. I have suggested anti-inflammatory measures in just 4-5 patients in the past couple years. So if your knee keeps swelling, for example, the question is why. A joint disturbance (derangement) can easily cause consistent inflammation. So can any number of problems.
I clearly remember one patient years ago who had years of knee pain with episodes of swelling that got so bad she had it drained many times. An avid runner, she was sidelined. The issue was coming from her low back and after 5 visits of different movements, her knee was good to go. Once her muscles had their electricity restored in the spine they could control to the knee so it didn’t reactively hurt and swell. -- Laura
Regularly sitting for prolonged periods, especially slouched, can lead to orthopedic problems. But the problems arise almost always from joints, not muscles. I continually hear people (health professionals, notably) declare that sitting’s “shortened” position of the hip flexors can cause painful, tight hip flexors. Granted this doesn’t affect all sitters (nothing does), but if large amounts of time in shortened states can lead to painfully tight muscles, then where is the observable pattern? Why aren’t more biceps affected secondary to prolonged elbow bending? Where’s the complaint of painful anterior neck muscles as our heads are so often forward?
Though I make my case verbally, people won’t budge. It’s likely the only way to prove my point would be to demonstrate an evaluation and treatment of someone with this given “diagnosis.” In the absence of that, I put forth that, one, we have ways of clinically determining if this is occurring, which, importantly, involves ruling out joints and nerves. Two, if we consider joint mechanics, deranged upper-mid lumbar segments and hip joints can send referred/radicular pain to the hip flexor area. Deranged elbows usually refer pain to the medial, lateral, or posterior elbow. And neck derangements typically send pain posteriorly and laterally – rarely anteriorly. The deranged joint pattern is observable. --Laura
Here’s a list of exercises I may prescribe for a person who complains of shoulder pain. I’m sure I’m missing a few, but my point is to illustrate that “shoulder pain” is a symptom, not a diagnosis. There's no universal fix for pain in the shoulder just like there's no universal fix for head pain or chest pain. I evaluate the person, make a diagnosis, and find the specific exercise a patient needs. Patients almost always get just one exercise at a time.
-seated cervical retraction
-seated cervical retraction-extension
-seated cervical retraction-extension-rotation
-seated cervical extension
-seated cervical flexion
-seated cervical protrusion
-seated cervical lateral flexion toward
-seated cervical lateral flexion away
-seated cervical rotation toward
-seated cervical rotation away
[all of the above also in supine]
[all of the above also sustained]
-seated thoracic extension
-seated thoracic lateral flexion toward
-seated thoracic lateral flexion away
-seated thoracic rotation toward
-seated thoracic rotation away
-seated thoracic flexion
-prone cervical retraction
-prone cervical extension
-prone thoracic extension
-supine thoracic extension over a fulcrum
[all of the above also sustained]
-shoulder functional internal rotation
-shoulder internal rotation
-shoulder extension with internal rotation
-shoulder horizontal abduction
-shoulder horizontal adduction
-shoulder functional external rotation
-shoulder external rotation
-shoulder internal rotation in flexion or abduction
-shoulder external rotation in flexion or abduction
[shoulder exercises also with resistance]
-shoulder caudal glides
[all movements may also be performed as clinician mobilization]
Find more information about the world of orthopedics here!