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
There’s a reason why if I’m treating spinal pathology, or if I’m curious about the relationship of the spine to the patient’s extremity complaint, I a) only prescribe one movement at a time and b) assess the effect of the exercise on the patient’s baselines before allowing it. Even though you may think the spine is in neutral or is not moving when an extremity exercise is being performed, there’s a strong chance that the spine is influenced. Sidelying clams, biceps curls, squats, rows, leg lifts, as examples, can easily impact the spine.
It should go without saying that a strengthening exercise for a hip muscle influences the hip joint, a rhomboid exercise influences the shoulder, and a triceps dip influences the elbow. But we must not forget about the influence on other nearby joints, namely spinal joints. And we must be deliberate when assessing cause-and-effect to determine whether an exercise is warranted. It's not difficult to take spinal baselines, implement an extremity exercise, and then re-test to see if the spinal baselines have changed. Knowing to do that, and how to do that, is where the skill lies. -- Laura
When atraumatic problems occur it's usually because a problem someone knew he already had has worsened, a problem someone didn't know he had has worsened, or a problem he or science didn't know how to test for and/or define has worsened. It’s not unusual that symptoms don’t become apparent - or symptoms don’t reach the threshold of impacting your life - until they’ve been percolating (silently or noisily) for years.
Does aging give you lung cancer, or does smoking every day for 50 years give you lung cancer? Does aging give you low back pain, or does a life moving around lacking full low back mobility since you fell off a horse when you were 11 give you back pain? Does aging give you severe headaches, or does growing up inhaling toxic fumes nobody knew were toxic give you severe headaches? Figuring out what causes problems is not necessarily easy, but it’s overly simplistic to attribute the onset of symptoms to a body simply getting older. There are normal changes associated with aging (in essesnce these diffuse changes are aging), and then there are problems. -- Laura
An exercise prescription is a prescription nonetheless. And, as such, I attach a gentle verbal warning when instructing patients what to do. Just as a pamphlet attached to a bottle of pills can tell people what to keep an eye on, I let patients know what outcomes are possible with a certain exercise and what to do in the event things trend toward bad or worse.
While I focus more on the problem area, it’s also possible that doing an exercise for the shoulder can cause mid back discomfort - among other examples. I do my best to anticipate this for patients so they do not get worried or panicked. New, unrelated aches from a new movement (muscle or joint related) typically pass quickly. If not, we can usually modify the exercise to minimize or eliminate the new problem. -- Laura
People often remark they have a "tight" or "stiff" joint. Most times people have joints that are actually tight in only one or more directions but perfectly fine in other direcctions. The distinction matters.
Whether or not a joint is restricted in motion in one or more versus all planes of motion is extremely relevant to diagnosing. I know what people mean when they say their joint is tight, but a quality physical exam will easily reveal the specifics, including in which direction(s) motion is limited, how much is missing, and the quality of the movement and accompanying presence of symptoms. Joints have many planes of motion such as flexion, extension, side glide, external/internal rotation, abduction, adduction, and others. Missing motion, combined with a verbal history and other physical tests, helps me know whether the problem is related to a muscle/tendon, the joint itself, a nerve, an infammatory process, and so on. -- Laura
Of course I am a proponent of general movement and general exercise, but a spectrum of attention to detail does exist. If you want to be smart about your mobility and/or exercise workouts, focus more on the movements that you get less in your day-to-day life, whatever that entails.
If, for instance, you sit all day, like many people do, then biking hunched over in the seated position might not be the best way to get exercise unless you’re smart about it and also move in the opposite direction. Likewise, if you sit most of the day, your hip is usually in neutral rotation or external rotation. If you have that knowledge coupled with an interest in above-average health or desire for athletic performance, you likely want to bias hip internal rotation movements in your exercise routine. (So much hip stuff I see on the Internet focuses heavily on moving hips into external rotation compared to internal rotation, which doesn't make much sense!)
This level of knowledge and personalization is certainly rarely taken into account with general classes (yoga, Pilates, Barre, etc.) - and it’s not expected to be. But if you want to be at the end of the spectrum designating excellent health, this information should be taken into consideration. The first general goal is simply to move. But a second goal is to be purposeful about how you move and focus on balance (eg balance between joint flexion/extension, internal/external rotation, and abduction/adduction). Our joints move in lots of different directions, though our everday routine is usually comprised of only some of them. Therefore, use the time you focus on exercise intentionally to help close any gaps. -- 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
I wasn’t taught that lumbar spine range of motion (ROM) included left side glide and right side glide in physical therapy school. Now, however, I find it’s an indispensable part of my lumbar evaluation. In addition to lumbar flexion and extension, I evaluate side glides as a part of the simple range of motion tests. With any range of motion test for any joint in the body, both quantity and quality are assessed. And just like with any spinal or extremity joint, motion that is lacking or painful tells me a lot about the diagnosis and potential treatment options.
I often use repeated or sustained left or right side glides as part of treatment if I diagnose a lumbar derangement. Side glides are tested in free standing (feet under the shoulders, legs straight but relaxed) by pushing the pelvis to one side as far as possible. The lumbar spine therefore glides on the pelvis. This can also be tested on the wall. For treatment procedures, the wall variation is used most often, but I have also utilized side glides in free standing, in a doorway, and in sitting.
One of the several goals of orthopedic care is making sure a patient has full and pain-free motion in all planes of the joint. Maintaining full and pain-free motion is key to preventing recurrence of symptoms as well. If you're not testing this side-to-side motion of the lumbar spine, I think you're missing a lot of important information and treatment potential. -- Laura
Nerves - like discs - often inspire fear in people. Yes, they can be injured just like other structures, but nerve problems are not necessarily more severe than other types of orthopedic problems.
We temporarily impact nerves all the time, stretching them and compressing them just like other structures. You bang your funny bone and your arm throbs for a minute. You sit on your leg and your leg and foot go to sleep for a few minutes. These examples teach us both how resilient nerves can be and how irritation and compression can create symptoms. (Perhaps even more importantly, they teach people that nerves can send symptoms away from where the root of the problem is.) Understanding how your body works is the first step in mitigating fear when something goes wrong.
Most nerve irritation problems I see stem from the nerves being irritated near the spine. These irritations create variable symptoms; it can feel like the numbness and tingling you feel when you compress a peripheral nerve in your arm or leg or it can be pain, tightness, heat, etc. Nerves serve the very important role of relaying information and sensation throughout your body, and, like other structures, they can usually heal given the right environment.
I sat at a performance years ago with my legs crossed for at least 30 minutes without moving. When I went to get up I almost fell because there was little power in my ankle muscles nor was there great sensation. I realized what had happened and I wasn’t afraid. On the contrary, I thought it was really fascinating how I couldn’t lift my foot up at all. I expected it to resolve in 15 minutes or so and it did. I often remember that incident when I happen to be sitting with my legs crossed, the back of one knee over the other.
Big picture: don’t be afraid when it comes to nerves. If they get compressed or irritated wherever in the body, most of the time, by removing the compression (typically with movements) and by giving it an environment to heal, it will heal. To be clear, many neurological symptoms (having to do with nerves) are not orthopedic in nature, but they too can usually be fixed if you get the correct diagnosis. --Laura
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