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
Why testing a movement at home for 48 hours has so much value. The end goal is to always help someone get better, but that process is only efficient when you first understand the problem at hand. Testing a movement for a few days gives us important diagnostic information, which in turn gives us treatment information. -- Laura
Ultrasound imaging (USI) may be one of the newer forms of imaging, but newer doesn't mean better. USI for abdominal organs and the uterus is valuable, but its value when it comes to musculoskeletal problems is not convincing. A new study in Physical Therapy in Sport entitled “Ultrasound imaging features of the Achilles tendon in dancers. Is there a correlation between the imaging and clinical findings? A cross-sectional study” does not find a correlation.
The study looked at the Achilles tendons of 29 dancers with no pain nor functional problems - 58 tendons total. With USI, 62% of the young women had at least one abnormal tendon. Of the 58 tendons, 26 were abnormal when examined using USI. This study also points to others that do not find a relationship between what USI shows and pain.
How is this applicable? Say one of these dancers with an abnormal tendon starts having pain in her Achilles after the study. It’s easy to assume that the tendon - which was abnormal on USI - is the problem. However, given that it was abnormal without pain, it makes sense that something else could be causing pain - perhaps something that cannot be visualized. For that reason, we should test a person’s musculoskeletal system by moving her musculoskeletal system. Versus imaging, that gives us improved chances to find the true source of the problem. --Laura
It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee.
It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura
If you fix a medical problem by eating well for a month, it's silly to expect the improvement to stick if you return to eating crap. The same applies to mechanical, or orthopedic, problems. Consider movement (and sustained positions) your “diet” when it comes to mechanical problems. There are certainly some mechanical problems that never have to pay attention to diet again. But for most, it matters. There’s no hard and fast rule; each patient’s case is unique, and is understood during the treatment process.
If nothing in a person’s life changed except she bought a new sports car, used it a lot, noticed lumbar stiffness getting out of the car she never had before, and a week later she had an L5 radiculopathy to her big toe, there’s a great chance that position is a factor. Let’s say that point is confirmed during treatment. Meaning, sitting in the sports car now exacerbates leg symptoms and/or obstructs low back movement. After resolving the patient’s low back derangement, does that mean she can never use that car again? Probably not. But it’s likely she’ll do much better long-term if she adjusts the car’s seat, or does her corrective exercise before and after car rides over 30 minutes, or makes sure to check her low back motion after being in the car. In this scenario, resuming her old “diet” of just hopping in her sports car - and adopting that specific mechanical seated position - without thinking twice will likely lead to recurrence. -- Laura
Over thirty minutes, I review the basic principles of the McKenzie method, how it contrasts with other approaches, common misconceptions, and what a typical evaluation is like. Enjoy! -- Laura
How often are patients seeking care for something they’ve had before? Learning about the nature of a problem, which lends itself to recurrence prevention is - in addition to resolving the problem - extremely valuable. If you understand the basic concepts and have a prevention plan to minimize chances it happens again, you’re much better off than a person whose problem just resolved.
Are there inexplicable things that happen to our bodies? Of course! Your hip is killing you one day and then the next day it’s like nothing happened. We can’t pretend to know everything. But for the problems we can diagnose (and fix), learning strategies to prevent recurrence is a close second to getting better in my book in terms of goals. It’s about getting better and staying better. -- Laura
The term “muscle memory” is familiar, but I think “joint memory” also exists. Muscle memory refers to engrained changes in the muscle as well as in the brain. Muscle and joint memory are often inextricably linked; for instance, when repeating pull-ups, both get habituated to that pattern.
However, what I want to highlight is the positional aspect of joints versus the pattern aspect. Whether it’s due to lifestyle, an event, or obvious injury, an altered resting position can be established for a joint. In the face of irreconcilable injury, this demonstrates the body’s resilience, as the body accommodates, creating a new normal. (Think of the historical images of a new acetabulum being formed due to a fractured hip.)
Subtler changes are more likely. If your neck always looks down, it makes sense that subtle changes are occurring at the joint level (not the obvious manifestation of "horns" written about in the news recently). If you have a fall jarring your low back that resolves on its own with time, it’s possible you have altered joint alignment. (That’s why having an expert check your musculoskeletal system after an injury is important if you want to ensure things are working normally, even in the absence of pain.)
This phenomenon does not preclude resolution of this positioning or of symptoms. But when I encounter patients who have had longstanding symptoms, it enters my mind that their joints may be accustomed to positions that are not purely anatomical. If a patient has had a subtle lumbar shift for 20 years, doesn’t it make sense the joints are accustomed to that position?
Put simply, if a joint problem has been there for a long time, once fixed, I find patients need to be more on top of motion checks ad infinitum to ensure the joint stays fixed and doesn’t “remember” its old ways. For short-term problems in which the joint has only been impacted for weeks/months, patients can usually get away with less in terms of lifetime prevention strategies. -- Laura
Orthopedic special tests (OSTs) are clinical tests to aid with diagnosing. For example, there are tests that assess the integrity of the ACL, the presence of tendinopathy in the elbow, tears in the rotator cuff muscles, and problems with the meniscus. They usually name a structure that is the problem. But do they?
While I believe there are some OSTs that are helpful diagnostic tools (like the Lachman test for the ACL), most are not. In fact, I rarely use them to help with diagnosing a person’s problem because of this lack of validity. And, as I’ve said before, most problems are due to function, not structure, anyhow.
For instance, say I perform the empty can OST (which indicates a supraspinatus problem) and get a positive test, meaning it reproduces the person’s shoulder pain and/or tests weak. Then the patient does repeated movements of the neck and the test changes to negative. Does the empty can really tell me there’s a problem with the supraspinatus? Maybe indirectly, but it’s not the part (source) of the problem that needs to be addressed. Does it make sense that neck mechanics can influence how it feels when you push down on someone’s outstretched arm? Of course. -- Laura
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