If you are not well-versed in ruling out the spine as the source of an extremity symptom, you are missing roughly half of the sources of patients’ problems. This issue can be mitigated if the patient has been referred from someone whom you trust has already effectively clinically cleared the spine. Often, however, people with knee pain go directly to a “knee doctor” or those with numb hands visit a “hand doctor” who, in my experience, only examine that specific body part.
A system, an algorithm, is needed to ensure success in any paradigm. In my practice, experience and pattern recognition factor in, but a structured process directs my evaluation and treatment. Most importantly, a patient’s spine is investigated before moving on to an extremity. I’ll say we need to ensure the problem is not coming from a faulty fuse box (since so often it is). How long I spend on this inquiry can be minutes, it can be days - it depends on the individual case.
There is certainly a role for these professionals, but our current utilization methods need revamping. Let’s use extremity specialists only when it’s clear-cut that that intervention would be most effective for helping patients. --Laura
If a patient has knee complaints - and I rule out the spine as the source - I treat the knee with repeated movements. Usually the movement is to address the joint position itself, though sometimes the movement addresses a tendon or muscle. Here McKenzie diplomat Joel Laing demonstrates the movement: knee extension with overpressure in partial weightbearing. I used this with a patient last week in fact! There are many ways to move a knee, but this is one of the most commonly used movements. Please remember, even in the presence of arthritis, meniscus, ligament, tendon, or cartilage damage, in most cases joints can be rapidly fixed with repeated movements. The typical exercise prescription for home for the knee is 10 repetitions every 3-4 hours. McKenzie clinicians are trained to examine whether your problem falls into the 80% of cases which will respond to repeated movements, and to find which movement is best for you. --Laura
I recommend checking the spine first in nearly all patients, but if your symptoms are not improving (even symptoms like sinus congestion!) with whatever treatment, repeated movements are worth a try. The McKenzie method typically uses repeated movements to address patients' symptoms as movement is frequently the best medicine - and carries little to no risk as we use the least force necessary. While my role is to investigate exactly how you need to move, it's true that most therapeutic movements are those opposite our normal joint position. In this patient's case, that means neck retraction (moving the neck back). --Laura
Patient complaint: right Achilles pain preventing him from training and competing (sprinting). By taking a thorough history and mechanical exam, it is clear his pain is originating in his low back. When taking his verbal history, what made me suspect his spine - and not his actual Achilles tendon - is the tendon pain variability, his report of intermittent low back and calf "tightness," and his history of other lower extremity issues.
If a tendon itself is the problem it is very unlikely that it “warms up” and pain during a workout subsides. The more you stress a problematic tendon, the worse it usually gets. However, it is likely that a joint moves from a place causing pain to a harmless position as you move (“warm up”).
When we did the mechanical exam he had an obstruction to movement in his right low back and sciatic nerve tension on his right. When he initially did 10 right, single-leg calf raises, the Achilles burned starting with repetition #2. After repeatedly moving his spine into extension with pressure (about 30 repetitions), this test was much less painful. His homework was therefore spine extension in lying with belt overpressure. After a couple weeks of doing that (10 repetitions every 2 hours), we added spine bending to ensure the injury was fully healed. He was discharged at visit 4 with a prevention and maintenance program.
I gravitated to the McKenzie method because it makes sense - and works. That is why most patients require many fewer visits than with other conservative care approaches, including "traditional" physical therapy. The McKenzie method is predicated on the simple fact that most orthopedic problems are mechanical and therefore can be resolved with a few specific movements (done repeatedly). I cringe when I read most of the orthopedic information out there, including the academic information I learned during my physical therapy doctoral program. It really is no wonder back pain is the number one disability worldwide and there are so many people in pain in the US (despite the wide variety of conservative and invasive treatments available). Plain and simple, I look at the body very differently than most clinicians - and treat differently, too. Nearly all of my patients come to me after having tried other interventions and with diagnoses that I frankly find incorrect. My passion for this extends beyond my office; my goal is to become a faculty member with the McKenzie Institute one day so that I may spread this reliable assessment and treatment approach to as many clinicians - and patients - as possible. --Laura
The primary law with tendons is first clinically (not via imaging) ruling out that it’s not a joint problem masquerading as a tendon problem. Joint misalignments (spine and extremities) can cause pain in tendinous areas and inhibit muscles, which unfortunately leads many clinicians to treat innocent tendons. If the “tendon” is taking forever to heal, it’s likely not the tendon. Tendon/muscle pathology comprises a small proportion of problems.
When it’s indeed a tendon, rehabilitation is relatively straightforward. A tendon’s collagen often needs to be remodeled to become functional again. This is accomplished by regularly (several times per day) loading the tendon for a few months. It may never look normal again, however. Causes why the tendon became dysfunctional initially should be addressed, and proper spine and extremity mechanics should be ensured.
The load a tendon needs is individual-specific. I find the load that creates pain (about 6/10) for 15-20 minutes following the exercise - which may be isometric, concentric, eccentric, or ballistic. Once a load doesn’t meet that criterion, the load is increased so it’s effective. Tendon rehabilitation is largely about 1) ensuring it’s a tendon, 2) educating the patient, and 3) encouraging briefly painful self-management with limited office visits. -- Laura
A mechanical examination begins with a methodical verbal history, typically producing one or two diagnoses to prove or disprove during the examination. Key information I elicit includes location of all/any symptoms, mechanism of injury, injury duration and trend, and activities that worsen/improve symptoms.
In the mechanical exam, I care precisely about tests’ effects. I examine the effect of upright posture. I check active and passive movement at the affected joint(s). If the patient has an extremity complaint, I always look at spine motion too. I often check nerve tension (arm or leg). The patient performs something that generates symptoms, such as squatting or lifting a bag - a “functional baseline.” Strength is also tested: for all upper body complaints I test roughly 8 arm muscles. With all lower body complaints, I test 6 leg muscles. With distinct extremity problems, I additionally strength test the specific muscles at those joints.
Next, most importantly, the patient performs repeated movements in the direction I have determined and we reassess relevant findings (symptom behavior, motion, nerve tension, strength, and/or functional baseline). Based on cause/effect, other directions may be tested. Before leaving, one specific movement is chosen for the patient to perform frequently at home. --Laura
Joint derangements are about 80% of all orthopedic problems. Derangements are when a joint isn't sitting properly, leading to pain, stiffness, tightness, and so on. They are usually rapidly reversible! Unfortunately, people are often given structural diagnoses instead (here, it's an AC sprain) or told they have a muscle or tendon problem.
Since joint derangements comprise the LARGE majority of orthopedic problems, McKenzie experts are trained to look for them first. If a joint derangement is found, we use repeated movements to restore joint alignment. This patient had shoulder pain and limited movement following a car accident. One movement fixes her symptoms (bringing her arm across her body) - and one movement worsens her symptoms (bringing her arm back away from her body). McKenzie experts are trained to find WHICH movement is best for you and use that one movement as the treatment approach. -- Laura
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