As I've written before: most orthopedic answers lie in moving people in directions they don’t usually move into. Top of that list? Yes: extension. How often do you bend your low back all the way back? Your neck? Your shoulder? Your hip?
But that doesn’t mean all problems are fixed with extension exercises. (Taking a step back, not all orthopedic problems are fixed with movement. Over 90% are, but that leaves room for conditions that require different interventions.) A person who responds to exercise, may need repeated rotation, side glide, side bend, flexion, or any combination of movements. I look for the exercise that positively affects a person’s symptoms, movement, and function. It really can be put that simply. While most need some form of extension, there are dozens of potentially therapeutic exercises.
Robin McKenzie did not invent the exercise of extension, but, as far as I know, he was the first to regularly explore if repeated extension (in its various forms) could be therapeutic. It’s really a shame that students (and others) have the notion that there are Williams flexion exercises and McKenzie extension exercises. It is not only an oversimplification - it is wrong. I am having one patient now perform lumbar flexion for her home program - and applying the McKenzie method to her problem is what got me there. -- Laura
I remember thinking years ago how odd it seemed that people’s joint pain (often occurring for no known reason) would be addressed by simultaneously stretching muscles, moving joints, strengthening other muscles, and changing posture (plus ice, heat, US, etc). It didn’t seem logical that all of those pieces fell perfectly into disarray, leading to pain.
Does it make more sense that joint immobility and muscle tightness and weakness led to the impingement, or that the impingement led to those findings? What I find more rational is that a joint impingement, a joint derangement, or, simply put, a joint that’s a bit stuck occurs because, well, joints are mobile things and these things happen. The most obvious example is you unknowingly sleep in a certain position and you wake up with stuck neck joints. Or your shoulder joint gets impinged because you repeatedly move in a new way starting tennis again. Or your low back gets deranged because you sit in the exact same position in your office chair for hours a day. These factors and others can easily lead to minor (fixable!) joint disruptions. In fact, most of these examples, especially the neck scenario, will resolve with daily movement (and possibly a little rest) on their own - no doctors or other help needed.
I deduce in the clinic if a joint is impinged/not moving optimally by repeatedly moving joints and gauging the effect. I don’t rely on “impingement tests.” I secondly don’t believe in the value of imaging except for a small minority of cases. It’s much more likely that the bony configuration of your joint (eg shoulder acromion or hip acetabulum) has been that way, if not your entire life, then most of your life, and therefore this new pain is due to new factors.
To address it, in contrast to the stretching, strengthening, and movement I alluded to above, we look for the specific joint movement that unpinches the joint. It’s typically one that is not regularly performed in the person’s daily life. The theory as to why these things occur is that it’s normal for joints to get a bit stuck if you don’t move them in a variety of directions or if you spend the majority of your time in one uninterrupted direction. They’re so common that most self resolve, but I see the stubborn ones. -- Laura
It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee.
It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura
The term “muscle memory” is familiar, but I think “joint memory” also exists. Muscle memory refers to engrained changes in the muscle as well as in the brain. Muscle and joint memory are often inextricably linked; for instance, when repeating pull-ups, both get habituated to that pattern.
However, what I want to highlight is the positional aspect of joints versus the pattern aspect. Whether it’s due to lifestyle, an event, or obvious injury, an altered resting position can be established for a joint. In the face of irreconcilable injury, this demonstrates the body’s resilience, as the body accommodates, creating a new normal. (Think of the historical images of a new acetabulum being formed due to a fractured hip.)
Subtler changes are more likely. If your neck always looks down, it makes sense that subtle changes are occurring at the joint level (not the obvious manifestation of "horns" written about in the news recently). If you have a fall jarring your low back that resolves on its own with time, it’s possible you have altered joint alignment. (That’s why having an expert check your musculoskeletal system after an injury is important if you want to ensure things are working normally, even in the absence of pain.)
This phenomenon does not preclude resolution of this positioning or of symptoms. But when I encounter patients who have had longstanding symptoms, it enters my mind that their joints may be accustomed to positions that are not purely anatomical. If a patient has had a subtle lumbar shift for 20 years, doesn’t it make sense the joints are accustomed to that position?
Put simply, if a joint problem has been there for a long time, once fixed, I find patients need to be more on top of motion checks ad infinitum to ensure the joint stays fixed and doesn’t “remember” its old ways. For short-term problems in which the joint has only been impacted for weeks/months, patients can usually get away with less in terms of lifetime prevention strategies. -- Laura
Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
For the Lower Body, The Most Significant Aspect of Sitting All Day is Lumbar Flexion, Not Hip Flexion
I know this because I test it versus make assumptions. The hips and lumbar spine are physically close to each other, but tests can easily differentiate the two. We can move the lumbar spine without moving the hip and vice versa.
As I’ve written before, I strongly disagree with the popular idea that prolonged sitting (which puts the hips in flexion) leads to tight hip flexors which leads to pain in the hip flexors. That theory falls apart on so many levels. For starters, since when do tissues (especially “tight” tissues) hurt when put on slack? What is actually happening in the majority of patients who experience anterior pelvic and hip pain in sitting (the “hip flexor area”) is they are experiencing referred pain from the lumbar spine, which is also almost always in flexion when seated. In a smaller number of cases, the pain is referred from the hip joint(s).
If you have pain, you can’t just assume it’s from the muscle in that area. Often it’s coming from somewhere else, which I usually address with specific movement. You’ll get better faster - and stay better longer - if you treat the actual problem. -- Laura
Teaching is the most important part of my job. By teaching patients (versus simply treating), you’ll likely get better outcomes as well as better reduce future need for medical services. When a patient has a joint problem, for example, I want her to understand the full picture. That is, prevalence, common contributing factors, how repeated movement in one direction can yield improvement, how they differ from muscular problems, and so on. If a patient’s low back complaints respond to repeated extension, perhaps (hopefully!) if her knee hurts years later she’ll try repeated knee movements.
The overarching principles of treating joint derangements do not vary despite joints differing in degrees of freedom, anatomy, and demand. Most significantly, the best odds for success without expert help is moving the joint 1. in the direction it rarely goes or 2. in the direction opposite to how it’s stuck or 3. in the direction opposite how it was injured. -- Laura
There is absolutely a time and place for joint replacements. While it’s every patient’s decision, I believe it’s best to explore conservative measures first - if for no other reason than risk alone. An individual’s determination should be based on a collection of facts and viewpoints.
It’s typically true that, when compared to replacement, therapy 1. poses less health risk 2. mandates less time off work 3. costs less 4. instills more self-efficacy 5. hurts less. Of course in the right patient group, it also provides superior outcomes. Within 5 visits I can usually arrive at a prognosis. With a poor prognosis (ie there’s too much structural compromise to improve), presenting the option of a surgical consult makes sense. If a patient explores therapy and a replacement is indicated, little time or money is lost in that endeavor if the therapist is skilled at arriving at a prognosis early.
“How can a person with a given diagnosis of OA who’s been recommended a new knee do well with therapy?” I treat a patient with joint complaints just like everyone else. I diagnose the patient based on a history and movement exam and treat accordingly. Most diagnoses do well with therapy, but in some cases it becomes clear that surgery is needed. -- Laura
If it's accepted that arm and leg pain can originate from the spine, it should be understood that joint pain can as well. I screen the spine with extremity limb and joint complaints. Forearms, thighs, arms, legs, hands, and feet are not entirely different from wrists, hips, elbows, shoulders, knees, and ankles. Limb (between joints) pain is more often coming from the spine than isolated joint pain, but it still happens frequently. Clinicians need to look for this referred and radicular pain. I use repeated movements of the spine to investigate if extremity joint pain is indeed spinal in origin, which could take anywhere from a few minutes to a few visits. -- Laura
Perhaps I am splitting hairs when I differentiate between load and force. However, I think it’s important to refute the common conception that fixing orthopedic problems is all about progressive loading, extreme effort, sweating hard. Most of my patient visits feel more like a visit to the doctor’s office than a visit to the gym. It’s about looking for a solution, devising a home protocol, and education.
While I use loading, what initially fixes most orthopedic problems is not loading in the truest sense. Yes, injured tendons/ muscles need load to remodel and repair. Yes, load is needed to return someone to prior levels of function if there’s been deconditioning. My experience, however, is that most problems involve a joint not moving well ... remedied quickly with movements (forces), usually requiring little muscle action at the problem site. If I diagnose a shoulder derangement, the top two movements I’ll use to reposition the joint are functional internal rotation with a belt (passive) and extension with the patient’s hand on an elevated surface (passive for the shoulder). I envision those more as different forces on the shoulder joint vs different loads. The words don’t really matter, but, to me, the implication does. -- Laura
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