We don't have to assume a muscle is tight or a muscle is weak. We don't have to assume a joint is obstructed or a joint capsule is restricted. We don't have to assume a muscle is inhibited. We don't have to assume a structure is inflamed. We don't have to assume a nerve is compressed or entrapped. There are tests for these things.
These problems are distinct and can be distinguished from one another through competent and thorough testing. Sometimes that testing takes five minutes in the office. Sometimes it takes movement testing at home for two weeks. If needed, in rare cases we also have imaging testing to rule in or out fractures, relevant structural compromises, and sinister pathology. The heart of the matter is we don’t have to assume. I’ve spent over a decade learning and perfecting this testing so I can find the problem fast and then instigate the correct treatment. Differential diagnosing ability is central to helping people. -- Laura
I recently saw a social media post entitled “Prone Exercise Progression for Low Back Pain.” If only it were that simple! There is no "prone exercise progression" for low back pain. Prone exercises are used for certain diagnoses with certain patients. Pain, after all, is not a diagnosis. We don’t treat heart pain or lung pain - we treat the underlying diagnosis. Will I allow that there are rare cases in which we can’t establish a true cause? Sure. But in those cases you get there by ruling out a multitude of possibilities.
Not only can we do better than treating the symptom of pain, but we can be specific about what each individual needs. A prone exercise progression will help some people with some diagnoses. It will also do nothing for some people and will make some people worse. You can try whatever you find on the internet if you want. We all do it from time to time. But success is more likely when you have an individual diagnosis and plan. -- Laura
Part of effective diagnosing is understanding the basics of how joints, muscles, and nerves work. People with low back pain commonly think they “pulled” a muscle. They may have. I will allow that it is possible. However, in ten years of work, not once have I diagnosed someone with a pulled or strained muscle (or tendon) in his low back. (It’s almost always a joint-driven problem - and joints can refer pain to muscles.)
A symptomatic pulled (also known as strained or torn) muscle - anywhere in the body - will hurt when contracted. Each personal case is different, but at some angle and with some type of resistance, when that disrupted muscle is asked to contract, it will provoke pain. The second finding with pulled muscles is that they often hurt when put on tension (stretch). This may or may not create a minimal range of motion loss in the plane in which the muscle is on tension. Third, when the affected muscle is on slack (at rest) and not contracting, nothing should happen and range of motion should be full.
An extensor muscle performs extension. If it is pulled you’ll usually find painful resisted extension, pain at end range of flexion with minimal to no motion loss, and full pain-free passive extension. This applies to extensor muscles everywhere, including in the low back. Therefore, if passive low back extension (prone, using the arms or a machine) is limited or painful, I’m not likely dealing with a muscle problem. If standing extension is pain-free but limited, I’m also likely not dealing with a muscle problem.
Again, knowing the foundations of biomechanics is essential. Just that simple piece of information can allow me to rule out a muscle. Unfortunately, many people (including clinicians) don’t apply these fundamental rules to diagnosing problems. Muscles can hurt due to referred pain, so just because pain is felt in a muscle doesn’t mean the muscle is the problem. A competent diagnostic process will provide the answer. -- Laura
The supraspinatus is the most commonly affected rotator cuff tendon/muscle. It helps lift the arm up, out to the side. When people encounter pain or difficulty lifting their arm like this, they like to jump to the conclusion that the rotator cuff (or supraspinatus) is to blame. Sometimes it is. However, despite the fact that MRIs regularly show changes or “abnormalities” with the supraspinatus tendon or muscle, other mechanisms are at play when it comes to lifting your arm. The supraspinatus does not work in isolation (things rarely do). Problems with joints, capsules, and nerves can also make lifting your arm painful and/or weak.
When I say supraspinatus “problem” I am referring to a tendinopathy, tear, pull, or strain. How I rule in a supraspinatus problem, given no red flags. Step One: Rule out neck derangement. Step Two: Rule out mid back derangement. Step Three: Rule out shoulder derangement. Step Four: Rule out frozen shoulder. Step Five: Rule in supraspinatus problem.
Some of these steps can be completed by asking a few questions. Some require movement testing. The most important point is to recognize that other things can also create weak and/or painful shoulder abduction or a positive “empty can” or “full can” orthopedic special test. -- Laura
Why testing a movement at home for 48 hours has so much value. The end goal is to always help someone get better, but that process is only efficient when you first understand the problem at hand. Testing a movement for a few days gives us important diagnostic information, which in turn gives us treatment information. -- Laura
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
The speed with which I say that is noteworthy considering years ago that question wasn’t high on my list. When you effectively probe patients about their symptoms (most notably via a good verbal history), you’ll notice it’s actually not that common for people to have a symptom in only one isolated spot. A man might come see you because the front of his right knee hurts, but with questioning you find it’s also sometimes on the left knee and his back gets tight sometimes. Or a woman has left neck pain but when you do movement testing she notices right neck pain too. Or a kid says the outside of his elbow hurts but, yes, the inside of his elbow is tingly.
Where the symptom is is extremely important - regarding someone’s history, during the physical exam, and during repeated movements. The pain someone is describing could be in a completely different area (for example, wrists hurting with prone lumbar extension) or it could be relevant. Where the pain is matters in terms of both diagnosis and treatment; if I didn’t have that information I’d be lost. Most importantly, it tells me information about which structure is misbehaving (significantly, joint vs musculotendinous tissue), which movements are likely to be beneficial, and how to interpret the effect of movements. -- Laura
I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests.
Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation.
That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura
My appointments are investigative - moving this way or that way and assessing the effect minutes or even seconds later - and then prescriptive. To my great curiosity, I’ve had patients respond positively to a movement/exercise (that is, symptoms or movements immediately improve) and state it was probably due to their recent injection or their pills. It doesn’t work quite like that. Cortisone from three days ago was a constant during our entire time together; the variable was the performed movement. The same goes if you've been on a Medrol dose pack for 5 days. While these may have an overall positive influence, they are not the variable we are experimenting with in the clinic.
I am deliberate in my clinical testing specifically so that we can establish cause and effect and not base decisions on probabilities. (Was it the medicine? Was it time? Was it therapy? Was it sleeping in a weird position?) Let's be as precise as possible. Just as I know how to anticipate the result of an intervention, the other clinician giving you the injection or prescription should also be able to tell you what to expect from the shot or pills. -- Laura
Again, it boils down to function vs structure. Most problems are things not functioning well - not structural damage. Think thyroids under or over producing hormones, hearts not pumping blood efficiently, bacterial infections in the gut.
In the musculoskeletal system it’s often nerves misfiring, joints not moving well, muscles not activating. Movement testing reveals these. Structural musculoskeletal issues, though, primarily need imaging to be visualized; they’re hard to see with the naked eye. Those who believe musculoskeletal problems are largely due to structural damage (I do not) therefore usually rely on imaging. A glaring problem with imaging, however, is that people with no complaints will have structural changes upon imaging. That those “changes” become “damage” in the presence of complaints is an unsubstantiated leap.
I use movement to test (and treat) the structure and function of people’s musculoskeletal system. In the event a relevant structural issue that will not respond to therapy is suspected, the individual is referred to the appropriate clinician. -- Laura
Find more information about the world of diagnosing and treating orthopedics here!