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. ​

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.
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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

Ever wonder why, with all the technological medical advances in orthopedics, our population doesn’t seem better? In conservative care, there’s been electric stimulation, ultrasound, laser, and less techy modalities such as tape and soft tissue tools. Outside conservative care, we’ve gone so far as to make injecting steroids, fusing spines, electrifying nerves, and removing and replacing whole joints commonplace!

Perhaps the worst offender is the MRI. Imaging is certainly warranted in a few situations (as is surgery), but it’s current widespread use isn’t. Not only is this expensive for society, but overreliance is bad medicine: MRIs cannot reliably demonstrate cause and effect regarding symptoms and they often create needless fear in patients’ minds that they’re degenerating.
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The human body has an amazing capacity to heal itself; orthopedic issues such as fractures, tears, disc herniations, sprains, etc. are regularly alleviated with time, not medical intervention. However, when a body’s independent healing falters, learning the right movement (and learning which to temporarily avoid) is key. Immobilization is rarely necessary. A clinician who uses her ears and brain to thoughtfully understand a patient’s problem should realize that a self-management protocol based on movement – nature’s best remedy – is almost always the best medicine. -- Laura

Mechanical pain isn’t a new concept - it’s the most common kind of pain. Besides pain, tightness, numbness, clicking/locking, and tingling are also possible symptoms. The bad news is usually mechanical problems are diagnosed incorrectly as structural problems (eg torn meniscus). The good news is almost all are fixable - if you find a clinician who can diagnose and treat them, like a McKenzie expert.

Mechanical problems are those that, simply, can be fixed with movement. Examples include pinched nerves, dysfunctional tendons, pulled muscles, and frozen shoulders. However, the biggest subset of mechanical problems is joint derangements. Derangements (misalignments) are when something (somehow!) obstructs the joint, such as a fat pad; a herniated/bulging disc; a bone fragment; or a piece of meniscus, labrum, or cartilage. Treatment for muscles/tendons involves tissue remodeling movement; joint derangements require specific movements to restore proper alignment.

Outside of mechanical problems there are structural, chemical/inflammatory, and nervous system problems, among others. Most healthcare providers and patients conclude that symptoms are from a structural issue because of unreliable orthopedic tests and MRIs. Orthopedic tests are false positives in the presence of mechanical derangements and MRIs consistently show abnormalities that are irrelevant. An expert mechanical exam is needed. -- Laura

When people twist or roll an ankle, the common diagnosis is that the ligaments are sprained. However, the joint itself is also affected! Here, a patient who twisted her ankle is treated successfully with simple repeated movements of the ankle JOINT. Therefore, the ankle JOINT was injured, not the ligaments. She was discharged with full recovery at visit number 2.

​Clinicians MUST assess joints as joints are injured far more commonly than soft tissues such as muscles, tendons, and ligaments. (I learned how to assess joints like this through my post-doctoral studies with the McKenzie Institute, not in school.) -- Laura
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The article Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial reveals no difference between the fake (or sham) surgery and the real surgery. 

This type of shoulder surgery, know as subacromial decompression (SAD) is unfortunately still prevalent in the U.S. In this research study, both the sham surgery group and the real surgery group had something important in common: in both groups the shoulder joint was irrigated. Essentially the joint was power-washed. I believe this to be the key part of the intervention, the reason why both the fake and real surgeries provided the same results.

What I find in the clinic is that many joints have a piece of debris obstructing the joint's motion and causing pain. In the extremity joints this is thought to be a piece of fat, cartilage, bone, tendon, or similar. Of course, this can be effectively "power-washed" with repeated movement, too. My job is to find the movement that moves that piece of debris out of the way.  My patient's job is then to perform that movement throughout the day and temporarily avoid movements in the opposite direction.

If you have been contemplating shoulder surgery, please read this study and/or contact me with any questions. Hopefully medical providers will no longer suggest this as an option. -- Laura