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
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
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
Among the many successful patient encounters I had in Peru, an especially memorable case was a male patient around 60 years old who presented with complaints of left knee pain with walking on hills and with squatting. He demonstrated a minimal loss of left knee extension, pain with left knee flexion overpressure and extension overpressure, weakness in the left hip flexor, and movement loss in his lumbar spine. We used squatting as his primary baseline test - it was indeed very painful for his left knee, which also buckled at the bottom of the squat, forcing him to push on a table with his hands to return to standing. Repeated movements in the sagittal plane for the spine had no effect on squatting; nor did repeated movements of the left knee (sagittal and transverse planes). I did not enjoy continually asking him to retest squatting, but that information was crucial, especially considering I would never see him again. I could sense he was growing frustrated as well since, after movement upon movement, squatting remained very painful. It wasn’t until we performed supine rotation in flexion that squatting proved better. With repetition, his squatting ability continued to improve. His knee now had no movement loss and no pain with overpressure and his hip flexor was strong. You could see the excitement on his face; the translator conveyed that the patient was happy and appreciative. I taught him how to perform the maneuver at home and am optimistic that he will be walking and squatting better in the future. -- Laura
Learn more about the world of diagnosing and treating orthopedics here!