​Diagnosing a problem is always the most important step. Then you match the treatment to the diagnosis. When we diagnose orthopedic disorders we can think of 3 main categories: mechanical (or functional) problems, structural problems, and inflammatory problems. A huge problem I see in medicine is problems being diagnosed as structural or inflammatory when in fact they’re mechanical.
What do I mean by mechanical? Problems that are affected by movement, usually fixed with movement, and, significantly, not structural or inflammatory. My skill set is in treating these problems, which are >90% of problems. (My skill set is also in diagnosing which problem you have to begin with. If it’s structural or inflammatory, I refer you to a clinician who treats those.)

A structural problem is like a fracture, tear, stenosis, or dislocation. They cannot be fixed with movement; they need a separate treatment approach. I’ll say this again: very often people’s tears, etc. are diagnosed as structural and recommended a structural-problem solution like surgery when in fact the tear is not structurally unsound. Instead, the tear is causing or is related to a mechanical problem, which can be fixed with movement. People move and function just fine with “structural” problems “diagnosed” by imaging all the time!

Inflammation won’t be fixed with movement. In the acute stage inflammation can often be fixed with rest/time. In a sub-acute or chronic phase, other anti-inflammatory treatments may be necessitated.

Some may argue that central sensitization is its own category, which I'm fine with. But a central processing problem such as that may be better classified as a neurological versus an orthopedic disorder. There’s room for debate.

When I assess patients I’m asking: is this mechanical, structural, inflammatory, or other? By asking the right questions, listening, and expertly moving patients (when safe), we can figure it out. If someone has a structural or inflammatory problem, they won’t get better with movement. But they are the outliers, and you have to use repeated movement testing (when safe) to discern if someone’s tear, for instance, is truly a structural problem or a more easily fixable mechanical one. -- Laura

Most, if not all, people can recognize that the food you eat influences your health and that many health problems that arise can therefore be addressed with changing what you eat. If, however, diet seems too simple to be effective, then I understand why movement likewise seems too simple to be effective. After all, Americans have been conditioned to believe that fixing health problems necesitates solutions based on chemistry, technology, and devices.

I say leave all the fancy gadgets like laser, needling, and cupping for the small, small minority of people who need them for their orthopedic disorders. It’s worth pointing out that even with all the recent technological advances in the fields of medicine and orthopedic medicine, it’s a hard argument to make that overall outcomes are any better. Metabolic disorders and orthopedic disorders currently represent major problems in this country. Specific food is often the answer - and specific movement is too. -- Laura​

If, after your orthopedic surgery, you have full range of motion, full strength, full nerve extensibility, full function, and no symptoms, then, no, you don’t need more care such as physical therapy. You can return to your prior way of life.

How often is that the case? I’m not going to say it never happens, but it’s very rare.

Orthopedic surgery, by necessity, almost always affects tissues that weren’t the problem. Ergo, returning to normal after surgery involves more than just the problematic tissue healing. Other things have to heal correctly as well. (For instance, the muscles that were cut through to get to the injured bone.)

If you care about having a well-functioning musculoskeletal system (I advocate you do!), then you need a clinician who can ensure that your motion, strength, and nerve length are normal and you need to be able to achieve your full function without problems. (Full function includes everything from sitting to sleeping to running ultramarathons - it’s individual.) That particular clinician can work in any clinic/capacity as long as he/she is competent at these facets of orthopedics.

This, of course, begs the question, if surgery is rarely needed and, when needed, is rarely needed in isolation, why do we put surgery on such a pedestal? -- Laura

The McKenzie Method is first and foremost an assessment approach to determine what the patient needs. It is not just a set of techniques or exercises, although the McKenzie Method does also include a treatment approach for those who are found to need therapy. (Most orthopedic disorders can be addressed with therapy vs invasive care.) The assessment (also known as an evaluation) may tell me a patient needs an injection, needs rest, needs surgery, or needs any number of exercise or manual interventions.

I learned skills in DPT school, at various continuing education courses, from other clinicians, etc. I continue to learn various techniques such as Mulligan techniques in order to have more tools to help patients, though I usually find the McKenzie Method treatment approach works best. You can have a zillion skills, exercises, and techniques in your repertoire, but the key is knowing when to use each one - and I find I can best make that determination based on a McKenzie Method assessment. -- Laura

When clinicians think of joint mobilizations, they think of clinicians moving joints at the level of the joint with their hands, which is true. This applies to the spine as well as the extremities. However, joints can be less-precisely mobilized - or moved - without that specific technique. In fact, if my goal for a movement is to move a joint versus, say, stretch something or strengthen something, I call it a joint mobilization. More loosely, we can just call it a movement or an exercise, but the intent is what matters - and the intent is to move the joint in a specific direction (its directional preference).
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Sometimes the technique or the force applied by a clinician via mobilization or manipulation is necessary temporarily. But in the large majority of cases diagnosed as joint derangement, patients can learn how to mobilize themselves. In the trickier cases, we might have to figure out how to get assistance from some equipment at their home or from another person. When mobilizations (with or without a lot of force) are necessary as treatment, the results will be better the more often you do them. That said, in order to get those reps, it’s imperative we teach patients how to self-mobilize the best we can. The McKenzie method is predicated on teaching people how to self-treat in order to improve outcomes. My hands aren’t magic and I’m here to teach. -- Laura

If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.

With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.

There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura

There are diverse opinions when it comes to orthopedics. And you should feel free to explore the myriad thought processes, approaches, opinions, techniques, etc. But when your goal is to fix something, you need to focus on one approach. Let one chef take over, even if just for the time being. Not only does that allow you to focus all your time and energy on the game plan in front of you, but it, most significantly, gives it the greatest odds of success.

If I want someone to repeatedly flex his spine, but another clinician wants him to repeatedly extend it - well, those are obvious contradictions. Doing both at the same time in this example would make zero sense and would preclude either approach from working. Outside of obvious examples, though, there are more subtle ways that things get derailed. For instance, if I tell someone she has a terrific prognosis if we follow these four steps, but her primary care physician keeps telling her therapy won’t help because the x-ray looks bad, then things often stall.

Research all the different options first if you really want to, but give just one approach, just one clinician, the title of head chef at a time. If it’s concluded that another perspective is needed, then you can move on. As the saying goes: we can't have too many cooks in the kitchen. -- Laura

Saying you treat pain is like saying you treat sneezing or itching - they're symptoms. You can manage pain, but you’re not, in essence, treating it. You treat the cause of the pain. When people ask me if I treat shoulder pain or jaw pain, etc., I know what they mean. The short answer is: I primarily evaluate to see if I can help with what is causing the pain.

Pain management strategies (such as ice, heat, unloading, medication, creams, gentle movement, and so on) have value, and I recommend them as needed. The goal, however, is to find and fix the cause of someone’s pain (musculoskeletal or other) just like you figure out why you’re sneezing or itching. Are there cases when a cause cannot be deduced? Sure; but they are rare and, by methodically eliminating diagnoses, you still should be left with only a few reasonable hypotheses. -- Laura