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
1. How long has it been this way?
2. What brought this about and what brings it about?
3. Is it limited actively?
4. Is it limited passively?
5. Is there pain with active ROM?
6. If so, when? If so, where?
7. Is there pain with passive ROM?
8. If so, when? If so, where?
9. How does the end of the ROM feel?
10. Is it consistently like this, or does it vary?
There are more concerns regarding the whole patient presentation and problem at hand, but these focus in on range of motion (the entire motion available to a joint). Presumably I’m only discussing ROM with a patient if it’s problematic. This may seem like a lot, but it really only takes a few minutes to get these verbal and physical answers. Knowing the questions to raise is step one, knowing how to physically test it (the easiest part) is step two, and knowing how to interpret the findings is step three.
There are many things that can go wrong with a joint. What I call joint derangement is when the joint isn’t sitting quite right - which I find to be the most common joint problem. Derangements vary widely in severity and can rapidly change. There could be structural changes in a joint due to arthritis or tears in ligaments or menisci. These (and many other examples) are addressed in their specific ways.
Joint capsule problems are less prevalent. The patients I’ve seen with capsular problems (manifested primarily as pain and tightness at the end range of a joint’s movement(s)) are mostly patients with frozen shoulder and patients who are older. There are distinct ways to address this problem as well. Capsular tissue problems tend to take considerably longer to fix than derangements. -- Laura
Joints behave differently loaded (weightbearing) versus unloaded (non weightbearing). This applies to extension, flexion, etc. - all planes of motion. Just picture your ankle: if you are moving your ankle while lying down, you are moving your foot as your leg is stationary. But if you are squatting in standing your leg is moving as your foot stays stable. These are quite different ankle joint movements, with different forces.
I assess and treat patients using repeated movements. I am SPECIFIC with the exercise I investigate as well as with the one I prescribe a patient, which includes whether the movement is performed loaded or unloaded. Loaded knee flexion may have no effect for a patient, but unloaded knee flexion may prove beneficial. Loaded lumbar extension may make a patient’s symptoms worse, yet unloaded lumbar extension may work. Because I consider loaded and unloaded movements different, I have more movements available to me. While that may seem overwhelming, it’s not. There are patterns and clues in the history and mechanical exam that lead me (by implementing the method) to explore one movement compared to others. --Laura
We accept the fact that realigning a fractured bone creates a brief increase in pain for the greater good, correct? Nobody wants pain, but sometimes pain is a necessary part of getting better. It’s my job to educate patients regarding the multifaceted and subjective experience of pain. If I provide patients with intelligent explanations, any fear or anxiety is usually diminished.
When does getting better with physical therapy permit or even necessitate pain? One example is centralization in a deranged (stuck) joint. If mild pain in the arm moves to the neck as a result of neck exercises, this is a positive outcome, even if the neck pain is temporarily more burdensome. Secondly, pain with specific exercises addressing a dysfunctional knee tendon is necessary, but it should not last long after the exercise is finished. Finally, stretching a frozen shoulder as far as it can go should also hurt, but, again, that pain should not last.
With surgical care for orthopedic problems, anesthesia is used to mitigate pain. With conservative care like physical therapy, patients can use rest, ice, heat, etc. to address any temporary increase in pain.
“Deranged” is not a scary word. It’s simply the term I use when a joint isn’t working perfectly. Moving any deranged joint (like the neck joint example above) can hurt to perform. There are specific rules, however. If we have the correct exercise for that joint, pain should improve with repetitions of the prescribed exercise. It should become less frequent, less intense, or less widespread. Pain after the exercise should not last.
Again, it’s my job to know this stuff and to teach it to patients. There are MANY variables when it comes to pain with rehab which vary according to diagnosis, prognosis, individual, and so on. More pain as a result of physical therapy that actually disrupts a patient’s life is very rare. Through education and following the rules, we can accomplish the long-term goal of eliminating pain with little to no increase in short-term pain. --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
In general, those who strength train work opposing muscles - quads/hamstrings at the knee and biceps/triceps at the elbow, for example. Notwithstanding specific athletic performance needs (a very small population), it’s generally a good idea to balance muscle groups so that innate human biomechanics are not significantly thrown off.
In the same vein, joints should be worked in opposing directions. Knee extension/flexion and elbow extension/flexion, for example. In my book, the most important manifestation of this credo is with spine flexion/extension. While people perform many activities of spine flexion (forward bending), they rarely move into spine extension (backward bending). Considering only the gym, you see squats, burpees, deadlifts, sit ups, hamstring stretching (and more!) involving spine flexion. Only on rare occasions will you see a standing back bend or “cobra” or “upward dog” stretch on the floor. I have no problem with flexion; I just want balance. Public gyms provide a glaring example that people will attend to muscle balance but rarely joint - specifically spinal joint - balance, but this applies to everyday life as well. --Laura
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