There are many goals when it comes to working with orthopedic disorders, but these are the objective health parameters I aim to achieve: full range of motion, full strength, full nerve extensibility, and good mechanics. Mechanics, loosely defined as how you move, is more subjective than the others, but there are norms with quality of movement too.
Full, pain-free function, or being able to do what the patient wants to do, is the most important, but functional ability typically relies on these four domains. In the event we cannot achieve full range of motion or full strength etc. - which can happen for various reasons - our goal simply becomes to achieve the maximum possible. (Other goals with care: efficiency, risk minimization, fostering patient independence, and teaching prevention strategies.) -- Laura
Proprioception relies on uninterrupted, efficient nerve conduction - for both input and output. So before you start training and (re-)programming nerves for speed, efficiency, and adaptability, you need to ensure their electricity is flowing uninterruptedly. Proprioception, often a component of physical therapy and training, is defined as the "perception or awareness of the position and movement of the body." (Oxford Languages) It makes sense to verify there are no kinks in the hose (nerve) before you try to fix the hose or optimize its ability to do its job. Nerve tension tests are very useful, but I also use repeated movement testing to gauge how well nerves are moving and working. This applies to so many things besides just proprioception. Almost all, if not all, functions in your body are powered by your nerves carrying electricity and information! For almost any complaint, this is my starting point. -- 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
In brief, spinal nerves are responsible for sensation in a certain area and power to certain muscles. There are thirty-one spinal nerves, numbered according to the area of the spine where they emerge. We often name nerves that are the combination of two of more spinal nerves, such as the sciatic nerve, which is the combination of lumbar nerves 4 & 5 and sacral nerves 1, 2, & 3. (The sciatic nerve is usually irritated by way of the fact that one of its five spinal nerve roots - at the level of the spine - is irritated. As I’ve written before, nerve entrapments in the periphery, outside of the spine, are rare.) Spinal nerve roots are commonly irritated.
In contrast, cutaneous nerves, which are named, are responsible for sensation in a certain area, but do not power muscles. In the absence of direct trauma or compression (including due to surgery), it’s rare to irritate these nerves.
Even though their sensory areas overlap, in the presence of a sensory problem (numbness, tingling, pain), there’s a way to determine which is at fault. We have clinical nerve tension tests, muscle power testing, and repeated movement testing to indicate which nerve is the problem. We don’t have to guess. -- 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
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
Tugging on a hose (nerve) will not be effective if something is compressing it. Several things can compress nerves in our bodies. In contrast, if a nerve is adhered to something, tugging it (typically called flossing, stretching, or gliding) is indicated. I tell patients with nerves that aren’t moving as well as we’d like that we first check to see if someone is “stepping on the hose.” If we investigate and find that to be the case, we work to remove the compression. If we rule that out, then we can start to glide the nerve to increase its length. Performing gliding without investigating potential compression will often get you nowhere - just like pulling on a hose while someone’s foot is on it won’t get you anywhere. -- Laura
Many, many bodily joints and tissues need to function well to be able to fully bend forward. Poor hamstrings, though … they always get blamed!
To regain forward bending ability, I hardly ever loosen patients’ hamstrings. However, say a patient did simply need looser hamstrings - then clinical care is hardly needed. (Stretching is not rocket science!) With consistent home stretching, hamstring length better consistently improve.
In almost all cases, forward bending is limited because lumbar structures are moving improperly. Usually it’s that the joints themselves are misaligned. In other cases, compressed/adhered/trapped nerves create nerve tension that limits this movement (with or without contemporary joint malalignment).
Forward bending (lumbar flexion) is usually restored once we get the patients’ lumbar structures moving properly again. Importantly, using forward bending to achieve this is beneficial in only a small group of patients. More commonly I utilize lumbar extension or sidegliding.
So why do people say they “feel it” in their hamstrings? It’s either that they’re actually feeling the sciatic nerve(s) pull or that, in attempting to bend further, their body eeeks out more motion in the only structures it can – muscles and tendons – so they “feel it” there. Expert mechanical clinicians know better. --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
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