A stress test on a treadmill, hooked up to monitors, indicates how your heart functions when challenged. Repeated movement testing, which I perform and prescribe, indicates how your joints, muscles, and nerves function when challenged. Pictures tell us how things are at rest but not how they behave. And orthopedic special tests (OST) tell us how things are with a static test or with one movement. Barring a major structural problem, most problems are functional - and require dynamic testing (repeated movement testing) to arrive at a diagnosis. Repeated movement testing is one of the hallmarks of the McKenzie method.
Repeated movement testing is exactly what it sounds like. After I get a verbal history and note physical baselines such as range of motion, strength, and nerve tension, I choose a movement to be performed repeatedly and then assess the effect on symptoms and the baselines from the physical exam. The repeated movement I choose to test is based on several factors. An example of a repeated movement would be performing 10 shoulder internal rotations or 10 lumbar extensions.
Clinicians should base diagnosis and treatment on tests that are reliable and valid. I have attended courses that taught me how to determine sacral and facet positioning with my fingers. Only later did I realize that stuff was ridiculous. When you palpate (touch) a structure at rest, for starters, you’re touching many structures. In addition, it doesn’t consider referred pain. For instance, if I touch your Achilles tendon and it feels thickened or it feels painful to the patient, I can't make strong inferences from that other than it feels thickened or it feels painful to the patient. It doesn't help with diagnosing what is causing those phenomena. If you want to use that as a baseline test and see if it changes with the intervention, that is fine; but that is not the original intent of these palpation tests that are commonly taught, which are geared more to defining (diagnosing) a problem. Palpation during movement tests are similarly flawed - most notably because they purport that clincians can reliably detect small amounts of movement. Reliablitiy is not only in question when the same clinician performs the test on different occassions, but is clearly questionable when it comes to comparing several clinicians. We’re better than saying we know the diagnosis by eliciting pain when we touch something (which is below skin and everything else). And we’re better than saying we know the diagnosis based on (allegedly) feeling a 5-degree rotation in a joint. -- 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
I appreciate having a method of approaching the body when it comes to musculoskeletal problems. With regards to any problem, I have an order of investigation: the spine, local joints, tissues, and other. When it comes to an extremity, I always look at the related spinal segments. With extremity joints, I always look at active motion, passive motion, strength, and function. With regard to movement testing, I look at the sagittal plane first and then the frontal or transverse planes (except in rare cases). I use the least amount of force first and add force incrementally only as needed. There are many other examples of how the McKenzie method embodies a systematic approach.
The point here is that diagnosing and treating can be simplified according to the core principles. Care is not based on a hodgepodge of tests. For instance, if you only learned how to treat shoulders using the McKenzie method, you should be able to apply that to hips - and vice versa. The more you use the method, the more efficient you become at implementing it. -- Laura
I remember thinking years ago how odd it seemed that people’s joint pain (often occurring for no known reason) would be addressed by simultaneously stretching muscles, moving joints, strengthening other muscles, and changing posture (plus ice, heat, US, etc). It didn’t seem logical that all of those pieces fell perfectly into disarray, leading to pain.
Does it make more sense that joint immobility and muscle tightness and weakness led to the impingement, or that the impingement led to those findings? What I find more rational is that a joint impingement, a joint derangement, or, simply put, a joint that’s a bit stuck occurs because, well, joints are mobile things and these things happen. The most obvious example is you unknowingly sleep in a certain position and you wake up with stuck neck joints. Or your shoulder joint gets impinged because you repeatedly move in a new way starting tennis again. Or your low back gets deranged because you sit in the exact same position in your office chair for hours a day. These factors and others can easily lead to minor (fixable!) joint disruptions. In fact, most of these examples, especially the neck scenario, will resolve with daily movement (and possibly a little rest) on their own - no doctors or other help needed.
I deduce in the clinic if a joint is impinged/not moving optimally by repeatedly moving joints and gauging the effect. I don’t rely on “impingement tests.” I secondly don’t believe in the value of imaging except for a small minority of cases. It’s much more likely that the bony configuration of your joint (eg shoulder acromion or hip acetabulum) has been that way, if not your entire life, then most of your life, and therefore this new pain is due to new factors.
To address it, in contrast to the stretching, strengthening, and movement I alluded to above, we look for the specific joint movement that unpinches the joint. It’s typically one that is not regularly performed in the person’s daily life. The theory as to why these things occur is that it’s normal for joints to get a bit stuck if you don’t move them in a variety of directions or if you spend the majority of your time in one uninterrupted direction. They’re so common that most self resolve, but I see the stubborn ones. -- Laura
Orthopedic special tests (OSTs) are clinical tests to aid with diagnosing. For example, there are tests that assess the integrity of the ACL, the presence of tendinopathy in the elbow, tears in the rotator cuff muscles, and problems with the meniscus. They usually name a structure that is the problem. But do they?
While I believe there are some OSTs that are helpful diagnostic tools (like the Lachman test for the ACL), most are not. In fact, I rarely use them to help with diagnosing a person’s problem because of this lack of validity. And, as I’ve said before, most problems are due to function, not structure, anyhow.
For instance, say I perform the empty can OST (which indicates a supraspinatus problem) and get a positive test, meaning it reproduces the person’s shoulder pain and/or tests weak. Then the patient does repeated movements of the neck and the test changes to negative. Does the empty can really tell me there’s a problem with the supraspinatus? Maybe indirectly, but it’s not the part (source) of the problem that needs to be addressed. Does it make sense that neck mechanics can influence how it feels when you push down on someone’s outstretched arm? Of course. -- Laura
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