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
Yes, injured structures can be fragile, but your spine is not inherently fragile. It is no more fragile than your ear, knee, or foot. The spine is well designed, just like the rest of your body, to withstand considerable demand. And it is just as resilient as the rest of you to bounce back from injury.
Things go wrong. Things happen. We get ear infections. We twist our knee. We break our foot. We injure our spines too. And when things go wrong anywhere in our body, they are almost always fixable. Stop telling people spines are fragile. And stop listening to people who tell you they are.
Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience]
Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases]
Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases]
The point is we don't know which scenario applies to you until we move you. -- Laura
For patients with one-sided neck pain, the large majority of patients have a diagnosis (joint derangement) that warrants movements that go backward (retraction and/or extension) or movements toward (not away from) the side of pain. It is rare that the answer is moving forward (protrusion and/or flexion) or moving away from the side of pain.
This is unfortunately not how most orthopedic clinicians think. Most clinicians (and non-clinicians) tell patients to stretch away from the pain, with neck pain and other pains as well. If you really understand how joints, muscles, and nerves work, however, you would realize stretching away makes no sense in most cases. While this may be commonly disseminated, it is by no means intuitive.
If you have left neck pain, moving into retraction, extension, or left side bend, for example, may initially hurt when performed. My job is to assess the overall response. Does the pain reduce with repetition? Does the pain move? Does movement increase? Does the pain only exist at the end of the movement and then disappear? And so on. To find the correct movement (directional preference exercise), we closely gauge the response.
As always, it boils down to being specific, to diagnosis. But having done this for years and taken time to work with several mentors, we can appreciate patterns and percentages regarding diagnoses. While a small minority of patients with left neck pain will indeed need to move right to get better, the majority will not. With competent use of the MDT system, we quickly deduce the specific movement you need for your specific pain. -- 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
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
Painful thumbs? Numb fingers or hands? Weak grip? The nerves in the neck and the upper mid-back control the hands. Specifically, nerves C6, C7, C8, and T1. (The "C" stands for cervical, which means neck. The "T" stands for thoracic, which refers to the mid-back.) Most hand issues are a result of the nerves in the neck/upper mid-back being compressed. If someone has problems in BOTH hands, the issue is almost ALWAYS coming from the spine. While it is normal for your hand to fall asleep if you lie on it in a weird position, it is not normal to experience numbness/tingling/pain on a regular basis, even with sleeping. If I determine that your hand symptoms are indeed coming from the nerves in your spine, I treat it with two things: movements to decompress the nerves and postural correction. Posture can refer to your sitting, lounging, and/or sleeping habits. I often suggest modifications to your car seat too. --Laura
Centralization is a very important concept, and is well-documented in many research studies. Problems in the spine often cause pain/numbness/tingling in the extremities (legs, feet, arms, hands) as affected nerves carry symptoms along the distribution of the nerve. Centralization is when symptoms move toward the spine. This is a GOOD thing - even if the spine pain is temporarily more intense (before it goes away for good). By the same token, peripheralization is not a good thing. We don't want pain that is moving farther away from the spine into the periphery (extremities). Keep in mind that centralization also applies when left or right low back pain or left or right neck pain moves to the center of the low back or neck.
Not all patients will experience centralization. Some extremity pain just goes away without moving to the spine first. If you are receiving treatment or are just monitoring or treating yourself, remember to avoid things that peripheralize your symptoms and to perform the activities or movements that centralize your symptoms. When I treat patients with spine or extremity symptoms, I use specific movements to elicit centralization - and prevent peripheralization. If you experience centralization, you know you're on the right track!
Your car seat alignment is very important for your health! For starters, we tend to spend a decent amount of time in our vehicles. Additionally, the time spent in your car seat is spent in one position. You're typically not moving around by crossing your legs, shifting your weight, etc. - because you can't. So if you're going to be stuck in one position, it better be the best possible position for your spine and body as a whole.
Three things are crucial: (1) Ensure the headrest is not pushing your neck/head forward. I turned mine around. It took time getting used to being in a NEUTRAL position, but now it feels natural (as it should!). (2) Get your bum level with your knees. No sinking into the seat! If you can't adjust your seat, sit on towels or purchase something. I use a wedge I got from my local Relax The Back store to lift up my hips. (3) Get adequate lumbar support. You might have an inflatable support in your car, but even that might not be enough. I use a firm McKenzie lumbar roll. -- Laura
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