People clearly have differing ideas, but, even when presented with the same information, people can interpret it differently based on their currently-held worldview. Here is the most classic example I can come up with in terms orthopedic thinking: shoulder impingement. The predominant worldview (in the US at least) is that muscles, joints, tendons, and neural patterns around the shoulder are functioning improperly as a unit and therefore during overhead movements the subacromial space is impinged causing pain. My view is that in over 90% of cases one specific thing is not working correctly.
The prevailing treatment for the common worldview is simultaneously stretching or releasing one or more muscles, loading certain tendons, strengthening many muscles, and moving certain joints. I remember I used to give patients at least seven things to do at one time when I had that belief system, which I was taught.
My current view is that most patients need to move just one particular joint or tendon. That particular movement is often, but not always, included in the array of movements listed above, which is interesting but not surprising since the normal treatment includes so many things! So if people get better with the standard approach, people believe it’s correct.
My understanding now, however, is that the reason they got better is because they included the one thing they needed - and the rest was superfluous and, at worst, a waste of time and resources. My patients with shoulder pain with overhead movements almost always get just one exercise to do at a time, which may or may not change over time. (For me, what other clinicians diagnose as shoulder impingement, I diagnose as several different things: cervical derangement, thoracic derangement, shoulder derangement, and shoulder contractile dysfunction.)
It’s interesting to think about how our belief systems can inform how we understand the evidence. Clearly those who believe the predominant worldview and those who believe the MDT-leaning view interpret the fact that people get better with standard shoulder impingement treatment very differently. As I wrote recently: I am interested in what works, but I’m more interested in what works best. - -Laura
If neck, mid, back, or shoulder blade symptoms are worse with driving or after driving, it’s worth considering your car posture. The same applies to symptoms anywhere in the head, face, shoulder or arm, all the way to your fingers. (The lower portion and bottom seat can play a role in low back and leg problems.) Most cars put the mid back in flexion and the neck in flexion and/or protrusion. In other words, the mid back joints are rounded and the joints of the neck are either bent forward or pushed forward.
If a posture has no effect on symptoms while you’re in the position nor after, and if your movement ability is not negatively affected, then there’s no problem. For a lot of patients with upper body complaints, though, posture in the car does warrant discussion. Many patients note driving is exacerbating and many patients spend a fair amount of time in their cars. The good news? With all of the patients’ cars I’ve assessed, adjusting the ergonomics of the car is easy and inexpensive. The theme is usually (if not always) to get the upper body straight, not flexed. The hardest part is for patients to get used to it - but that beats symptoms! -- Laura
Differential orthopedic diagnoses for shoulder blade pain include a strain/pull/tear to any of the muscles in the area (there are many) and a shoulder joint disturbance. It’s very rare that you injure one of those muscles - and shoulder joint derangements only infrequently refer pain posteriorly to the shoulder blade. Can a frozen shoulder refer pain back there as well? Sure. But that’s not usually going to be the chief complaint of someone with a frozen shoulder.
The joints in the cervical spine and the thoracic spine can refer symptoms to many areas, and the shoulder blade is a big player. With altered electricity coming from irritated spinal nerves, it’s not uncommon to find spasms or trigger points in the shoulder blade muscles. Those findings are the symptoms, not the culprit. Local weakness can also be a finding due to spinal nerve irritation. I find that in nearly every case I’ve seen in which the person complains of shoulder blade pain (or ache or tightness), we can fix it with repeated or sustained movements of the spine - in the sagittal, frontal, or transverse plane. -- 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
The supraspinatus is the most commonly affected rotator cuff tendon/muscle. It helps lift the arm up, out to the side. When people encounter pain or difficulty lifting their arm like this, they like to jump to the conclusion that the rotator cuff (or supraspinatus) is to blame. Sometimes it is. However, despite the fact that MRIs regularly show changes or “abnormalities” with the supraspinatus tendon or muscle, other mechanisms are at play when it comes to lifting your arm. The supraspinatus does not work in isolation (things rarely do). Problems with joints, capsules, and nerves can also make lifting your arm painful and/or weak.
When I say supraspinatus “problem” I am referring to a tendinopathy, tear, pull, or strain. How I rule in a supraspinatus problem, given no red flags. Step One: Rule out neck derangement. Step Two: Rule out mid back derangement. Step Three: Rule out shoulder derangement. Step Four: Rule out frozen shoulder. Step Five: Rule in supraspinatus problem.
Some of these steps can be completed by asking a few questions. Some require movement testing. The most important point is to recognize that other things can also create weak and/or painful shoulder abduction or a positive “empty can” or “full can” orthopedic special test. -- Laura
I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests.
Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation.
That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura
Here’s a list of exercises I may prescribe for a person who complains of shoulder pain. I’m sure I’m missing a few, but my point is to illustrate that “shoulder pain” is a symptom, not a diagnosis. There's no universal fix for pain in the shoulder just like there's no universal fix for head pain or chest pain. I evaluate the person, make a diagnosis, and find the specific exercise a patient needs. Patients almost always get just one exercise at a time.
-seated cervical retraction
-seated cervical retraction-extension
-seated cervical retraction-extension-rotation
-seated cervical extension
-seated cervical flexion
-seated cervical protrusion
-seated cervical lateral flexion toward
-seated cervical lateral flexion away
-seated cervical rotation toward
-seated cervical rotation away
[all of the above also in supine]
[all of the above also sustained]
-seated thoracic extension
-seated thoracic lateral flexion toward
-seated thoracic lateral flexion away
-seated thoracic rotation toward
-seated thoracic rotation away
-seated thoracic flexion
-prone cervical retraction
-prone cervical extension
-prone thoracic extension
-supine thoracic extension over a fulcrum
[all of the above also sustained]
-shoulder functional internal rotation
-shoulder internal rotation
-shoulder extension with internal rotation
-shoulder horizontal abduction
-shoulder horizontal adduction
-shoulder functional external rotation
-shoulder external rotation
-shoulder internal rotation in flexion or abduction
-shoulder external rotation in flexion or abduction
[shoulder exercises also with resistance]
-shoulder caudal glides
[all movements may also be performed as clinician mobilization]
Joint derangements are about 80% of all orthopedic problems. Derangements are when a joint isn't sitting properly, leading to pain, stiffness, tightness, and so on. They are usually rapidly reversible! Unfortunately, people are often given structural diagnoses instead (here, it's an AC sprain) or told they have a muscle or tendon problem.
Since joint derangements comprise the LARGE majority of orthopedic problems, McKenzie experts are trained to look for them first. If a joint derangement is found, we use repeated movements to restore joint alignment. This patient had shoulder pain and limited movement following a car accident. One movement fixes her symptoms (bringing her arm across her body) - and one movement worsens her symptoms (bringing her arm back away from her body). McKenzie experts are trained to find WHICH movement is best for you and use that one movement as the treatment approach. -- Laura
Tendon issues are unfortunately incorrectly diagnosed all the time. That is, issues that are not tendon problems are diagnosed as tendon problems. “Issues” and “problems” refer to tendinopathy, tendinosis, tendonitis, and tendon tears. We have hundreds of tendons in our bodies; they are pieces of tissue that connect our muscles to our bones. Those that get an unfair share of the blame are the four rotator cuff tendons in the shoulder, the two main tendon groups at the elbow, the Achilles tendon of the ankle, and the patellar tendon at the knee. This frequent misdiagnosis happens for two chief reasons.
One, tendon problems are common on images such as MRI so, in the absence of an expert clinical mechanical exam, the tendon is identified as the culprit simply because of a picture. The concern with this is that tendon problems are common on images such as MRI in people with NO pain or other symptoms. So if Sarah has a large supraspinatus tendon tear on her MRI and no shoulder pain and John has a large supraspinatus tendon tear on his MRI and does have shoulder pain, can you assert that the supraspinatus tendon tear is causing his pain? Not from that information alone, you can’t.
(Say your car starts acting funny. You open up the hood to take a quick look. You see a lot of leaves around the engine. Can you assume that the leaves are causing the problem? Or would your mechanic need to run some diagnostic tests? After all, we know that there are plenty of cars with leaves stuck under the hood that run just fine.)
The second reason for this misdiagnosing conundrum? Lack of expert clinical “mechanics.” When I first began as a physical therapist, if a patient came to me with shoulder pain (with or without an MRI report), I performed the orthopedic shoulder tests I learned in school. While there are several tests aimed at diagnosing a rotator cuff tendon problem, these tests are actually not very good. They can regularly be positive when something other than the tendon is at fault. If physical therapists, orthopedists, general practitioners, surgeons, chiropractors, athletic trainers, etc. are still basing their diagnoses (and subsequent treatment) on these tests, they are missing a lot of crucial information.
Once I learned during my post-doctoral coursework that other problems can mimic tendon problems, I began looking for these in the clinic. And, lo and behold, most of the time it is something else causing the patient’s problem. The top two problems that mimic tendon problems are misalignment in the spine joints whose nerves send signals to the area of the tendon (eg the neck) and misalignment in the extremity joint closest the tendon (eg the shoulder).
How do I diagnose a tendon problem then? These are my top two criteria:
In closing, don’t jump to conclusions based on an image or the location of pain. A lot of shoulder pain is coming from the neck or from a shoulder joint that is not sitting properly – not a rotator cuff tendon. Likewise, a lot of pain on the outside of the hip is coming from the low back or from a hip joint that is not sitting properly – not the gluteal tendon. Our bodies are beautiful in their intricacy and nuance, making my job as a mechanical therapist exciting. It is the ability to understand this nuance that makes a clinician effective at diagnosing and treating. --Laura
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
Learn more about the world of diagnosing and treating orthopedics here!