So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did).
Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
A positive FABER test does not incriminate just the hip & SI joints; it can be positive in the case of lumbar pathology as well. FABER stands for Flexion, ABduction, External Rotation. It's a test in which, in supine, the hip is placed in that position, like a figure 4. As with almost all orthopedic special tests (OSTs), I use the FABER as a baseline that informs my thinking — not as a test that tells me a diagnosis.
Just like basic range of motion, strength, or the ability to do a functional activity can be a baseline, so can a test. The FABER test, after all, judges range of motion and its effect on symptoms. As we implement an intervention, we examine if and how baselines change. I know what I expect to see change for each specific diagnosis.
So if I note that FABER is positive on the left and/or right, the questions become: Is it relevant? And: Will it change? Based on that particular baseline and all the other information I’ve gathered (verbal and physical), we apply specific movements and assess the result. I know there's a strong chance lumbar procedures, hip procedures, and/or SIJ procedures can change the FABER test. -- Laura
Yes, some patients have problems that cannot be fixed with movement. But how will you know unless you test movements and interpret the effect? In almost all orthopedic cases, diagnosing should involve repeated movement testing. Morton's neuroma is currently diagnosed by imaging and provocation testing, but, as Michael David Post and Joseph R. Maccio's paper "Mechanical diagnosis and therapy and Morton's neuroma: a case-series" demonstrates, a repeated movement exam is needed to assess if patients will benefit from repeated movements.
If you take people with no toe pain and put them in an MRI, many will have neuromas. So we know they can be present without causing pain. When patients do have pain, then, we can't assume their neuroma is the cause. We need to investigate if the spine is the cause or the toe joint is the cause. Additionally, assuming a neuroma is causing pain still doesn't mean the patient won't do well with repeated movement treatment (but you have to find the correct movement).
What percentage of patients who complain of toe pain receive a competent repeated movement exam? How many with toe complaints will have a clinician investigate their lumbar spine? And what percent will even be recommended to see a movement-based therapist if the image shows a neuroma? If these three patients hadn’t resolved their problems in just a few visits with repeated movement, what types of therapies, injections, surgeries might they have had? In this case series, three patients with medically-diagnosed diagnosed neuromas abolished their toe pain with repeated movements, with those results remaining at one year. One patient required repeated movements of the lumbar spine (low back) and two patients needed repeated movements of the affected toe.
When it comes to movement testing, I believe in end-range repeated movement testing that investigates the relevant spinal segments as well as the relevant affected joint(s). This is the core foundation of the McKenzie method. Movement testing is not the same as orthopedic special tests or palpation tests or provocation tests. It means repeatedly moving a person in the clinic and at home and evaluating the effects if has on the person’s symptoms and mechanics. Looking at a picture and seeing if something hurts when you press on it is rarely enough. -- Laura
If someone complains of foot symptoms - pain, numbness, and/or tingling - it can obviously be due to several causes. When investigating to find the source (that is, diagnosing), I collect many pieces of information. First, there’s a good verbal history during which I ask pointed questions. Second, is the physical exam. With the physical exam I look at various things; nerve tension is one of them. If you put the lumbosacral nerves on tension (there are a few ways to test this), and a patient’s symptom appears or increases in the foot, we need to investigate spinal nerve irritation as the potential source. To be clear, a negative tension test does not rule out the spine, but a positive test more strongly rules it in as a possibility. It is common that irritated nerves in the spine create pain, numbness, or tingling in the areas of the body they're responsible for, and the nerves specifically in the low back are responsible for sensation in the feet. -- Laura
A spondylolisthesis can be present and not be related to your symptoms - just like imaging can show non-painful degenerative changes, tears, etc. It sounds scary, but in the absence of recent trauma, there's a strong chance you have a spondylolisthesis that doesn't matter.
Competent clinical reasoning and testing can differentiate if a spondylolisthesis is or is not the generator of symptoms. I find repeated movement testing to be the most valuable method. Physical therapy will not fix a spondylolisthesis, which is a bony structural problem, but can help. However, physical therapy can usually fix other spinal problems, which may be producing your symptoms. An image shows you what’s there, but it doesn’t usually tell you what’s causing symptoms. That’s why you always need competent clinical reasoning and movement testing. -- Laura
The glutues maximus, gluteus medius, and gluteus minimus are innervated (powered) by the nerve roots L4, L5, S1, and S2, which exit the spinal cord in the low back. A muscle can only achieve optimal strength and efficiency if it’s getting an undisturbed supply of electricity. I hear loads and loads of people talk and talk about problematic weak glute muscles. I usually don’t find weakness. Instead, I find that it’s almost always inhibition - a fuse box (spine) problem. Most low back problems are at the levels L4, L5, S1. Is it any surprise then that the nerves to the glutes may be compromised? There does not have to be back pain for a nerve irritation to be present.
If we prove that your nerves are indeed working well (which we do by clinically moving your low back, and sometimes hip, repeatedly - not by looking at an image), and your glutes are still problematically weak, then we can begin all those glute exercises such as squats, lunges, donkey kicks, clamshells, crab walks, sidelying leg lifts, lateral step downs, bridges, and so on. If a professional wants to diagnose “weakness,” then he/she better have first at least ruled out inhibition. Not only does that save months of work, but it gets at the real diagnosis. When a muscle doesn't demonstrate the strength it should, I check the fuse box. -- 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
Nerves becoming trapped outside of the spine are much less common than people think. Commonly talked about examples include entrapment in the ankle (tarsal tunnel), wrist (carpal tunnel), elbow (cubital tunnel), buttock (piriformis) and forearm (pronator teres). If there is trauma to an area, it certainly makes sense that the nerves in the area can be injured and/or the healing process can lead to tissue “entrapping” the nerve. But, without significant trauma, it’s quite rare to see this phenomenon.
While many patients tell me they indeed have carpal tunnel (or whichever), they usually describe symptoms inconsistent with that diagnosis (ie they say it affects the whole hand). Furthermore, they report that no clinician has investigated movements of the neck and mid back as part of the diagnostic process.
The nerves that end up in your periphery are commonly irritated as they exit your spine. If someone has symptoms in both hands or in both ankles, the likelihood that the spine (or something systemic) is the source increases dramatically. So while I agree that peripheral nerve entrapments can exist, I can’t remember the last time I found this to be a patient’s true diagnosis. Getting the correct diagnosis is the most important step in getting better after all. -- Laura
I realize that it often feels good to stretch forward when your back or neck hurts. People even do it when it does hurt because they feel as though they’re getting a “good stretch” that “hurts so good” that they “need.” While I sometimes use forward bending of the spine as the foundation of therapy, it’s rare - under 10%. It does make sense that it can feel good, though! If you temporarily increase space and take pressure off a problem area, it can feel nice. My job, however, is deciding what patients need to achieve real, long-term success. By the time patients see me, they have usually already figured out on their own if something gives them short-term relief (certain stretches, heat, ice, meds, etc.). -- Laura
Learn more about the world of diagnosing and treating orthopedics here!