The technology we have to see what is going on inside our bodies is tremendous. However, it is not always helpful. Just like many of us develop wrinkles and gray hair, orthopedic changes in our body are normal. Since we know that many people have these changes (eg disc bulges or cartilage defects or neuromas) WITHOUT symptoms, we should realize that if a person has complaints we cannot automatically blame these changes. A thorough clinical exam with repeated movement testing is necessary for diagnosis. We find that the bulk of patients just have a joint that's not sitting quite right which can be resolved with movement.
If the patient's complaint is not resolving within several visits using the McKenzie method, then an image may be warranted to see if there is a structural finding that is consistent with the patient's complaint. This is rare, however - the percentage of times I request a patient get an image is under 5%. -- Laura
Mechanical pain isn’t a new concept - it’s the most common kind of pain. Besides pain, tightness, numbness, clicking/locking, and tingling are also possible symptoms. The bad news is usually mechanical problems are diagnosed incorrectly as structural problems (eg torn meniscus). The good news is almost all are fixable - if you find a clinician who can diagnose and treat them, like a McKenzie expert.
Mechanical problems are those that, simply, can be fixed with movement. Examples include pinched nerves, dysfunctional tendons, pulled muscles, and frozen shoulders. However, the biggest subset of mechanical problems is joint derangements. Derangements (misalignments) are when something (somehow!) obstructs the joint, such as a fat pad; a herniated/bulging disc; a bone fragment; or a piece of meniscus, labrum, or cartilage. Treatment for muscles/tendons involves tissue remodeling movement; joint derangements require specific movements to restore proper alignment.
Outside of mechanical problems there are structural, chemical/inflammatory, and nervous system problems, among others. Most healthcare providers and patients conclude that symptoms are from a structural issue because of unreliable orthopedic tests and MRIs. Orthopedic tests are false positives in the presence of mechanical derangements and MRIs consistently show abnormalities that are irrelevant. An expert mechanical exam is needed. -- Laura
Osteoarthritis (OA) is prevalent with aging. So is gray hair. And wrinkles. OA is a form of joint degeneration, just like gray hair and wrinkles represent types of degeneration. But we think of hair and skin changes kindlier, accepting them as normal, harmless parts of getting older.
OA, on the other hand, gets a bad rap – a painful rap – when in fact it can also be normal and harmless. An association between OA and pain is unfortunately widely believed. If someone’s knee hurts and a knee MRI shows osteoarthritis, we quickly blame the osteoarthritis for the pain and tell ourselves that it can’t be fixed (unless we have surgery). When our head or skin hurts, do we automatically blame our grays or our wrinkles?
It is clear OA doesn’t necessarily cause pain because we find plenty of OA in people without pain. In fact, a person over 60 undeniably has OA somewhere in her body. Pain in a joint may be from OA, but it may also be from an irritated nerve, a dysfunctional tendon, or a misalignment in the joint – which are all typically very fixable! Expert McKenzie clinicians identify (and then treat) the true cause of someone’s pain. -- Laura
Tendon issues are unfortunately incorrectly diagnosed all the time. That is, issues that are not tendon problems are diagnosed as tendon problems. “Issues” and “problems” refer to tendinopathy, tendinosis, tendonitis, and tendon tears. We have hundreds of tendons in our bodies; they are pieces of tissue that connect our muscles to our bones. Those that get an unfair share of the blame are the four rotator cuff tendons in the shoulder, the two main tendon groups at the elbow, the Achilles tendon of the ankle, and the patellar tendon at the knee. This frequent misdiagnosis happens for two chief reasons.
One, tendon problems are common on images such as MRI so, in the absence of an expert clinical mechanical exam, the tendon is identified as the culprit simply because of a picture. The concern with this is that tendon problems are common on images such as MRI in people with NO pain or other symptoms. So if Sarah has a large supraspinatus tendon tear on her MRI and no shoulder pain and John has a large supraspinatus tendon tear on his MRI and does have shoulder pain, can you assert that the supraspinatus tendon tear is causing his pain? Not from that information alone, you can’t.
(Say your car starts acting funny. You open up the hood to take a quick look. You see a lot of leaves around the engine. Can you assume that the leaves are causing the problem? Or would your mechanic need to run some diagnostic tests? After all, we know that there are plenty of cars with leaves stuck under the hood that run just fine.)
The second reason for this misdiagnosing conundrum? Lack of expert clinical “mechanics.” When I first began as a physical therapist, if a patient came to me with shoulder pain (with or without an MRI report), I performed the orthopedic shoulder tests I learned in school. While there are several tests aimed at diagnosing a rotator cuff tendon problem, these tests are actually not very good. They can regularly be positive when something other than the tendon is at fault. If physical therapists, orthopedists, general practitioners, surgeons, chiropractors, athletic trainers, etc. are still basing their diagnoses (and subsequent treatment) on these tests, they are missing a lot of crucial information.
Once I learned during my post-doctoral coursework that other problems can mimic tendon problems, I began looking for these in the clinic. And, lo and behold, most of the time it is something else causing the patient’s problem. The top two problems that mimic tendon problems are misalignment in the spine joints whose nerves send signals to the area of the tendon (eg the neck) and misalignment in the extremity joint closest the tendon (eg the shoulder).
How do I diagnose a tendon problem then? These are my top two criteria:
In closing, don’t jump to conclusions based on an image or the location of pain. A lot of shoulder pain is coming from the neck or from a shoulder joint that is not sitting properly – not a rotator cuff tendon. Likewise, a lot of pain on the outside of the hip is coming from the low back or from a hip joint that is not sitting properly – not the gluteal tendon. Our bodies are beautiful in their intricacy and nuance, making my job as a mechanical therapist exciting. It is the ability to understand this nuance that makes a clinician effective at diagnosing and treating. --Laura
Joel Laing, a McKenzie specialist in Australia, gives a great demonstration of a rapidly resolvable shoulder issue - specifically, shoulder pain and loss of motion. The wonderful thing about the McKenzie method is that we are trained to actually LOOK for these problems. I was not trained to look for these problems during my physical therapy doctoral program. Now that I know how to diagnose these issues, most patients get better in a handful of visits or less versus weeks/months of PT.
In his case he needs to repeatedly move his shoulder backwards with his palm down. Typically when we find the healing movement the patient needs, the patient does a few sets per day. As Joel also points out, there are often certain movements that make the problem worse as well. While the shoulder heals, we usually ask the patient to avoid those motions for a few days if possible.
When it comes to shoulder pain, the top two diagnoses I see are:
1. The pain is actually coming from the neck or upper mid-back, so we treat the spine with movement and the shoulder pain goes away.
2. The pain is quickly resolvable with targeted shoulder movement (like in Joel's case).
Don't let shoulder pain affect your life; in the large majority of cases we can get it better fast. And don't get a diagnosis based on an MRI. Most people over 30 will have problems in the shoulder on an MRI. Since problems on an image (a torn labrum, degenerated tendons, a torn rotator cuff, bone spurs) are so prevalent in people without pain, what you see doesn't necessarily correlate with your pain. You instead need a quality McKenzie clinical exam. -- Laura
I recently treated a patient who is emblematic of a slew of patients, especially baby boomers. She came to me with an MRI showing severe spinal stenosis - and several other spinal irregularities. She had been referred to a surgeon, but, luckily, as the idea of surgery at age 83 did not appeal to her, ended up coming to me instead. As we talked during the evaluation, it was clear that she already had two strong impressions. One, the stenosis was the cause of her symptoms. And, two, her stenosis was an irreversible disorder that would possibly get worse without surgical intervention. She had met a former patient of mine and had called me on the off chance physical therapy could help.
Stenosis refers to the narrowing of an opening. In the spine, stenosis commonly refers to narrowing of the opening through which nerves pass secondary to either bony overgrowth (eg osteophytes) or disc height loss. These changes in the spine are quite prevalent. Can stenosis be symptomatic? Yes. Irreversible without surgery? Yes.
But ... can stenosis (true, bony stenosis) be apparent on imaging and not be the cause of the patient's symptoms? An even louder yes. Very commonly.
In this patient's case, other spinal irregularities were observed on imaging as well. However, she had left her doctor's office believing that the stenosis was producing her symptoms. How was that determined? Diagnosing stenosis on imaging alone is not enough. A patient deserves a thorough physical examination to determine the cause of her symptoms, and then deserves a treatment plan specifically targeting that cause. Upon moving my patient's spine in different directions during her physical evaluation - I use the McKenzie method of mechanical diagnosis and therapy - I noted a favorable response to spine extension. In her case, over the course of four visits, she responded very well to sustained extension in prone. -- Laura
I realize I sound like a broken record, but I can't stress this enough: just because something is identified on an x-ray, MRI, or CT scan, does not mean it is causing a problem! Because so many people WITHOUT symptoms have abnormalities, it's clear we can't use imaging to diagnose orthopedic pathology. Instead, patients need a clinical exam in which the structures of the body are stressed in order to determine what the root of the pain/numbness/tingling/etc. is. This chart has some great statistics! Say you're over 40, for example: there's a 68% chance some of your disks are degenerated, a 45% chance some disks have shrunk in height, a 50% chance some disks are bulging, and a 33% chance some disks are protruded. These spinal changes are therefore quite normal as we age and are not necessarily correlated with symptoms. -- Laura
Last night was a great night! Runner's Depot in Davie hosted my presentation on the spine and how it relates to running injuries. Runners have a reputation for having a lot of injuries and, worse, a lot of recurrent or persistent injuries. The crux of my talk is that a lot of injuries in the lower extremities are misdiagnosed as local injuries and not correctly as injuries originating from the nerves in the lumbar spine. For example, plantar fasciits is commonly misdiagnosed. Yes, it exists, but not as frequently as it is diagnosed. The hallmark sign of plantar fasciitis is extreme foot pain with first steps in the morning. That usually eases throughout the day, but returns each morning since the plantar fascia is on slack all night as you sleep and is then stretched with your first steps out of bed. If that sign is present, I still investigate the spine to rule it out. But when that hallmark sign is absent (for example, the pain is variable throughout the day or week), the diagnosis of a lumbar spine injury is more likely (or another diagnosis). More specifically, a nerve may be being hit or pinched in the lumbar spine and producing pain along the part of that nerve in the foot. IT band issues, patellar tendonitis, hip labral tears, and meniscal damage are a few other pathologies that come to mind when I think about regularly misdiagnosed injuries. Irritated nerves from the spine can produce pain in any area of the lower extremities and must be ruled out in the decision-making process. And remember, just because something is on an x-ray or MRI does not mean it is causing your symptoms. Images are full of problems in people without symptoms so a clinical diagnosis, in which structures and tissues are individually stressed, is needed.
I don't think that spine injuries are more prevalent in runners; nearly everyone will have a spine injury at some point. We just need to be able to diagnose them correctly when they do exist. That way, runners, like everyone else, can get back to doing what they love to do as soon as possible! --Laura
Take a look at this study! 45 volunteers with NO history of hip pain, injury, symptoms, or surgery were given an MRI. (Average age of volunteers: 37.8 years.) MRI's of these asymptomatic participants revealed abnormalities in 73% of hips, with labral tears in 69% of the joints.
I clearly love saying this: just because it's on an image doesn't mean it is causing problems. You need a quality McKenzie mechanical evaluation in the clinic to find out what is actually causing symptoms. --Laura
Check out the short study here: http://ajs.sagepub.com/content/40/12/2720.short
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