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Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
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Sometimes lots of exercise and activity is warranted, but not usually. It’s important to realize that the large majority of a patient’s recovery occurs outside of my office. That being said, we best utilize our time together figuring out what needs to be done when you leave. We investigate which movements or exercises are best for you to do on your own time. We also spend time discussing your prognosis, trouble shooting, reviewing how to self-assess, and so on. If a patient is under the impression that she goes to physical therapy to do her exercises and then does little to no work at home, that ensures very slow progress at best. I love going to the gym (I first joined Gold’s Gym way back when I was 17), but what I offer patients is more critical thinking and problem solving versus a place to work out. -- Laura
This is a simple way to categorize approaches to fixing an orthopedic issue: surgically invasive, other invasive, and not invasive. You always want a diagnosis first, and since clinicians in orthopedics diagnose with different approaches, a second opinion is warranted if you are not pleased with your options or progress. (I diagnose primarily via a method of repeated movements, which, on the whole, is more helpful than diagnosing via imaging.)
We all know what surgery is. In my opinion it should be the last resort. Among the many reasons why, surgery (or intentional trauma) should be picked last because of the relative risk. The “other invasive” group includes prolotherapy, PRP, cortisone or any other injection, stem cells, dry needling, pharmaceuticals/supplements, and so on. Things that generally penetrate or enter a person’s skin/body. In the category of “not invasive” are movement, clinician techniques like mobilizations, various modalities such as heat and ice, and others. Each category has pros and cons. What I find encouraging in this day of costly high-tech alternatives is that an expert program based on movement will still fix most problems! -- Laura Perhaps I am splitting hairs when I differentiate between load and force. However, I think it’s important to refute the common conception that fixing orthopedic problems is all about progressive loading, extreme effort, sweating hard. Most of my patient visits feel more like a visit to the doctor’s office than a visit to the gym. It’s about looking for a solution, devising a home protocol, and education.
While I use loading, what initially fixes most orthopedic problems is not loading in the truest sense. Yes, injured tendons/ muscles need load to remodel and repair. Yes, load is needed to return someone to prior levels of function if there’s been deconditioning. My experience, however, is that most problems involve a joint not moving well ... remedied quickly with movements (forces), usually requiring little muscle action at the problem site. If I diagnose a shoulder derangement, the top two movements I’ll use to reposition the joint are functional internal rotation with a belt (passive) and extension with the patient’s hand on an elevated surface (passive for the shoulder). I envision those more as different forces on the shoulder joint vs different loads. The words don’t really matter, but, to me, the implication does. -- Laura Simply put, therapy makes something that isn’t working, work again. Performance, on the other hand, makes something that already works, work better. There is overlap between the two realms, but it’s not as large as many seem to think. If you understand how to fix a torn muscle, you likely have a basic understanding of how to maximize performance of a normal muscle. Likewise, if you understand how to make a normal heart become more efficient, you’ll have modest knowledge of what happens when something goes wrong.
Having been a relatively high-level athlete myself, I am comfortable in the world of performance (fitness and sport performance). However, that is not my expertise. As I value expertise, I advise people within my area of expertise (orthopedic therapy) and refer people to other professionals for guidance in other fields. Do you run a 9-minute mile and want to run a 6-minute mile in 3 months? Do you want to improve your vertical leap by 25% before next season? My role in these situations is to ensure no orthopedic problem is stopping you (which is an important step!). That it, things work well, they are just not conditioned for that higher level of performance. While I could certainly help in the performance realm, if you want the best, most efficient training plan, I am not your person. Overlap most concretely occurs when a high-performing patient is nearing the end of therapy. My job is to restore a patient’s body to the patient’s individual normal. If her normal is playing professional soccer and I can get her only 75% of the way there (at which point her body is way above universal norms), that is the time for a performance specialist to take the lead to get her to 100%. -- Laura There are many theories about what is happening when someone’s body malfunctions (mechanisms), many theories about how best to remedy the problem (treatment), and, to my chagrin, also many theories about what successful outcomes entail. I enjoy educated debate about the first two, but don’t fully understand why there is so much disagreement over the final piece, optimal outcomes. (Yes, financial gain is a contributing factor in the American medical system.) The interesting point is that if all clinicians align with regard to best outcomes, the first two should more easily fall into place. Optimal orthopedic patient outcomes entail:
1. Meeting the patient's goals. If they are not realistic, input from the clinician is appropriate.2. Fostering patient independence at every turn. Patients need to be educated in regard to every facet of their care and be given control over their recovery. 3. Efficiency regarding time, cost, and risk mitigation. (Experienced MDT clinicians average around 6 visits with patients.) 4. Ensuring full/maximal musculoskeletal system health (eg range of motion, nerve extensibility, strength, etc.). 5. Teaching prevention strategies. Patients must understand how to keep their problem from returning and how to self-monitor for recurrence to minimize reliance on the medical community. If we get these things right - no easy task - then I don’t care if you got there because you believe the joint moved and therefore uninhibited a muscle or because you stretched a muscle and subsequently the joint improved (mechanism). I don’t care if you had the patient do 20 calf raises 6 times a day or 100 calf raises 2 times a day (treatment approach). But if one outcome takes longer, costs more, relies more heavily on clinician assistance, or doesn’t achieve full range of motion, then that is a suboptimal outcome - and a better approach is necessary. -- Laura If a person says a previous treatment helped, more questions are indicated. I want to understand more. For example: What exactly helped? Did anything make you worse? How long did the benefits last? Do you still perform any part of that treatment?
Often times, with discussion, it becomes apparent that there was not in fact a direct cause and effect. In many cases the person’s symptoms improved or resolved because he or she simply stopped performing the aggravating activities (or simply due to time). Then, once those activities were resumed, symptoms returned. Knowing the person’s history informs current diagnosis and treatment. Accurate understanding is the key, however - which is accomplished by knowing which questions to ask and how to interpret the answers. --Laura If a patient has knee complaints - and I rule out the spine as the source - I assess (and usually 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 joint pain 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 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. -- 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 |
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