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
When the public hears that all it takes is a quick MRI to know what their orthopedic problem is, it can be hard to educate regarding the importance of movement testing. Sometimes it only takes a few minutes, but movement testing may take more time. However, even if I have to test someone using movement for a couple weeks, we do save time in the long run. Repeated movement testing - combined with clinical reasoning of course - tells me which type of treatment is appropriate (physical therapy, injection, medicine, surgery, etc.) or if another form of testing (ie imaging) is needed. It also tells me, if physical therapy is indicated, what specific treatment is called for. We want to match treatment to the correct diagnosis. -- Laura
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