Are we getting too fancy?

Posted: April 14, 2014 in Uncategorized

 

Earlier tonight I was watching an Inner Circle webinar from Mike Reinold. The webinar was discussing 5 common stretches we probably shouldn’t be doing and like anything else I’ve watched from Mike, it was a nice review with great content. During the Q & A part at the end, a physio asked if we are getting too fancy as new clinicians and favouring movement and neurodevelopmental approaches to assessment in favour of the basics? Are we jumping into Kolar and Yanda before understanding the basic work of Kendal, Magee, and Colby etc? In answering this young physios question, Mike stated:

“We’re seeing a lot of new grads coming out of PT school and they’re FMS certified, maybe SFMA etc. They’re doing PRI and DNS classes. They get all these funky things that they’re doing but they don’t know how to treat a joint. They can’t get people strong and mobile or much of anything else, yet they are trying to stimulate peoples diaphragms. It’s great to have the training in these things, but you must have the basics down first.”

- Mike Reinold, Inner Circle Webinar

I think this was an excellent reply from Mike as I also think social media has “pressured” us to take every con-ed course under the sun in the name of becoming “better”. But is taking seminar after seminar in the hopes of finding answers really making us better? Or is just making us more confused? I think taking con-ed is very important and have done my fare share, but I also think keeping the basics in mind is just as important. We have to understand stages of healing, true pathology, arthro and osetokinematics, normal ranges of motion and biopsychosocial care paradigms before we can start assessing crawling and rolling. These assessments are warranted and should be done, but not because we think we should to be “trendy”. They should be done only when you know exactly why you are doing it and how having that information will alter your subsequent treatment and exercise prescription. In talking to many therapists as of late, I have come to the sad conclusion that many do all kinds of movement’s screens and other fancy assessment techniques, but ultimately utilize the same interventions regardless of what their assessment tells them. Why? Because they don’t yet know what they should do with the information they have obtained. This could be because instead of truly mastering the basics, they have taken course after course but really don’t know what to do with the information they have been given. This may lead to confusion and frustration on the part of the therapist…sort of like paralysis by analysis. Personally I have chosen to slow down my course registrations per year because I believe it’s about quality, not quantity. I rather take a course and master it’s concepts to the best of my abilities before jumping into something else. I used to feel like I had to know it all now. I have a long career ahead of me and will take my time in getting these tools under my belt. I have actually found that I get better results when I stick with one form of care instead of jumping around from technique to technique in the hopes of finding that magic bullet.

I think having the desire to learn more is admirable and is something I can relate to. But I have come to learn that you can’t absorb it all right away. Learning through experiences via treating complex patients and even failing is what makes us better. As long as we are constantly being introspective about our practice and figuring ways to try and be better the next time I see nothing but a bright future for our profession!

Therapydia - Physical Therapy Discovered

 

Therapydia is once again doing their nominations for various physiotherapy related blogs. There are so many amazing webpages by dedicated therapists all around the world and I love being a small part of that world. If you enjoy what I put out and would like to show it, please take a second and nominate jessephysio.com for the chance to win a little reward!

You can access the nomination page here.  Also, be sure to sign up at bottom of page with your email so you can actually vote for the winner on April 14th!

Be better than a sit up…

‘Google’ core training and you will be inundated with all kinds of exercises, tips, “secrets”, and explanations on why any one method is superior to another. Now, I’m not here to say the way I like to do it and the way I give to my patients is best, but I do think it is well informed. Just quickly, the core does not just mean the 6-pack muscles. When I refer to the core for the purposes of this blog post I am referring to the rectus abdominis, transverse abdominis, internal and external obliques, multifidus, and diaphragm. The gluteal muscles can also be thrown in there but the exercises I show in the videos below don’t deal with that as much.

Research tells us that repeated end range flexion is bad for the spine. Professor Stuart McGill from the University of Waterloo has shown in his lab that there are a finite number of cycles of compression a lumbar spinal disc can go through before it herniates. This number is variable between genders and age groups, but it is something to keep in mind. Therefore, I have long done away with sit-ups and crunches as my core exercise of choice. Why speed up the prospect of getting a herniation with my exercise selections? Those exercises aren’t “bad” per se but there are just more optimal choices to train the core functionally and reduce the risk of future injury (notice I didn’t say eliminate the risk…that’s impossible). I have stated before and will again that I believe the true function of the core is not to create movement, it’s actually to resist it. For example, if someone side tackles you while playing football your core doesn’t work to induce movement, it’s working to stabilize and limit how much lateral excursion your body is placed under during the hit. This is what we call reactive core facilitation. The core is preventing spinal injury by limiting movement that might be dangerous for the spine. This ability is trainable and should be for all people from those suffering from back pain to those looking to get stronger for elite athletics. All 3 exercises I will link to are modifiable to make them easier or harder depending on the ability level of the person attempting them.

One big caution: These exercises and their subsequent regressions or progressions should be prescribed to you only after an evaluation has been carried out. Every exercise is a test and if you fail the test with one of these (which is fine), you should be afforded the opportunity to be given exercises better suited to you. A good rehab professional or strength coach can do this…we should at least TRY to make things specific to the client as we can people…maybe a rant on that topic at a later time ;)

So here are 3 anti-movement core exercises that I like giving select clients at my clinic. Each one serves a different purpose and can for the most part be done at home with a band  or weight if a pulley system is not available.  Anecdotally I also like these 3 because clients can “feel” what I’m trying to accomplish with them  if done correctly. This helps with buy in and adherence. Enjoy!

1) Palloff press:

2) Supine single arm chest press:

3) Half kneeling chops:

For those that are super interested, this is an excellent teaser video from Gray Cook talking about side to side asymmetries in the chop pattern of movement. If you are good going to your right, but not your left then something needs to be modified. This is where the help of an expert in rehabilitation/exercise prescription comes in. Showing an exercise is easy… It’s modifying it for the abilities of the person in front of you that takes skill.

Hope you enjoyed.

The Cheerleader 3x3x3 exercise

Photo cred to Mikereinold.com

This is a video of a very simple exercise to help promote scapular retraction that I learned from Mike Reinold . I like exercises that are easy to teach and the patient can feel working almost instantly. This is also just a great exercise to get people out of the anterior tilt and rounded shoulder posture we see with the desk working community. The patient can literally have a band by their desk and bang out a set every hour or two…get that reverse posturing going! Also helps with those with impingement issues related to poor shoulder positioning.

All you need is a theraband and you’re set. As stated in the video, you just take the band between your hands and pull it across your chest, making sure to get a nice scapular squeeze at the end range. After doing 3 reps in the horizontal direction turn the band on an angle and repeat the same motion 3 times. Then turn the band the other way and do it…you guessed it, 3 times! Why 3? I don’t know, I just like it cause I call it the 3x3x3 drill (3 reps in 3 directions for 3 sets = easy for client to remember). This exercise mainly targets the lower trapezius muscle and rhomboids in a reciprocal fashion to pull the shoulders back and tip the scapula posteriorly. It’s cool cause it works both sides at the same time (less time for the patient to worry about exercising)

Again, this is a good exercise for developing posterior chain strength and endurance in the upper body. To get the most bang out of your exercise buck, have your client return the band to the starting position VERY slowly…this will promote great eccentric posterior cuff and shoulder stability…and the client will get a nice burn going.

Enjoy!

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 38,000 times in 2013. If it were a concert at Sydney Opera House, it would take about 14 sold-out performances for that many people to see it.

Click here to see the complete report.

 

Movement: it seems to me that this word has taken on a life of it’s on over the last few years. There was even a very popular book written by a prominent physical therapist with it as the title ‘Movement’.  In and of itself, the term is very ambiguous…what kind of movement are we talking about? There are so many types…off the top of my head:
– Passive range of motion
– Active range of motion
-Arthokinematic movement
– Osteokinemtaic movement
- Functional movement (whatever the hell that means…more on this later)
- Sport specific movement
- Single joint/double joint movement

This list is endless…

With so many avenues one could go with movement, how is one supposed to be a movement specialist? As a physical therapist I am supposed to be a movement specialist with the ability to assess and detect aberrant movement, which maybe causing a problem and then intervene with strategies to overcome these issues. Examples of this may include teaching someone how to walk again after a spinal cord injury, stretching a spastic muscle after a stroke, or teaching someone how to hip hinge so they can squat better. An old school chiropractor might say they are detecting subluxations which are causing a weak muscle thus limiting movement and then manipulate the spine. A Pilates teacher might try and isolate your transverse abdominus to help lumbar stabilization creating more optimal movement patterns. A personal trainer might teach you how to perform a proper pushup to facilitate better movement…again, this list goes on.

Here is the issue that I have with much of this ‘movement based therapy’ so many of us provide…I don’t think we know what the proper way to move is and really, is there even such a thing? Don’t get me wrong, I know that rounding your spine for a deadlift creates torque through the lower back and landing in knee valgus can cause ACL injuries. What I’m saying has more to do with screening of movement. I may use a combination of active range of motion via a selective functional movement screen to determine where I think a problem may exist while a massage therapist uses manual muscle testing to determine an inhibited vs facilitated muscle. We may come to very similar or dissimilar conclusions as to why someone has pain or “dysfunction” and our treatments maybe completely different for the same patient complaint…but we are both “movement specialist”…hmmmm

Imagine a patient with back pain… They can go to a physical therapist, chiropractor, and pilates instructor who all claim to be movement specialists. In my opinion, more times then not each professional will arrive at a VERY different diagnosis and treatment strategy. Who’s to say who’s right? Who’s wrong? And what is the standard we go by to make such determinations? The reality is there is not one standard of care in the movement based world of therapy. I know the FMS people are trying to make a movement checklist, which is good, but it has many loopholes. For instance, doing a movement screen of standardized movements will take two practitioners down very dissimilar roads of rehab. So in this case, the assessment maybe standardized, but the subsequent findings and treatment are most certainly not. I bet if a patient went to a 5 different dermatologist for acne the treatment would be pretty similar. When you see an orthopod for a torn ACL, the treatment is usually pretty standardized.  The same can not be said with the patient with back pain seeking conservative treatment. So are we truly specialized in the assessment of movement? Or are we all doing the best with what we know? (and there is NOTHING wrong with that)

So with so much ambiguity in the term movement, can anyone really be a movement specialist? A specialist by definition is someone who is highly skilled and has detailed knowledge in a specific area of study. As I mentioned earlier, there is no specific area of study in movement because it encapsulates so many different things.

So what is the point in all of this? 

With so much differentiation in how we treat and assess based on our individual training and philosophies, we must still utilize a common panacea to help us understand what it is we do. And my friends, that common panacea is something I like to call research (uh oh, research is boring and so un-radical—this is what I hear a lot!) Research asks a question, uses different methods to try an answer that question and then determines which method works best based on various outcome measures. It does not rely on personal bias, monetary gain from taking a guru course, or personal anecdote. So, remember that patient with back pain who saw a chiro, phyio, and RMT? Well, if each of these professionals utilizes research to guide their practice to at least some extent my hope is that similar conclusions would be drawn based on the existing body of evidence detailing why we have back pain. Of course clinical experience and patient preference play a roll in therapy, but at the end of the day, I want to know if I refer to another physiotherapist they will treat them in a similar way that I would…and they would do that because they to know what research says works and does not work.

There will always be charlatans and snake oil salesmen promoting their methods as the best cure for…whatever. This will never change. It is then incumbent on the evidence informed professional to do what is best for the patient and provide care that we know works. In general this means active patient participation in the form of education of condition, minimizing psychological threats, hands on therapy (again, very ambiguous term), exercise and reassurance. Will this get everyone I see better? Nope. Can I rest assured knowing I’ve done everything my skill set allows be to do while utilizing research to guide me…you bet’cha

In conclusion, I don’t think anyone is truly a movement specialist. I think we need to understand anatomy, biomechanics, physiology, pain science, exercise science and bring it all together using research to treat our clients. This is the kind of specialist I would like to be…

Trigger points are a hot button issue in manual medicine. The research on their existence is sparse and there is considerable amount of subjectivity in the ability to find a Trigger point (TrP). Although their true nature is uncertain, the dominant theory is that a TrP is a small patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp). That small patch of knotted muscle cuts off its own blood supply, which irritates it even more — a vicious cycle called “metabolic crisis.” And when we have a lot of these Trps in various muscles within the body, we call it myofascial pain syndrome…a diagnosis given a lot!

TrP’s are tricky in that they can be elusive to find. For example, did you know anterior wrist pain that is often diagnosed as carpal tunnel actually stems from a TrP in the subscapularis muscle! (a muscle located under your armpit). Therefore, carpal tunnel release surgery may do nothing to help with wrist pain if the TrP of the subscap isn’t released (how that is done is highly debatable and will be discussed a bit).

How do we find these TrP’s?

Pragmatically speaking, I find them by trial and error. For example, if someone comes in with radiating pain down the leg stemming from their butt and I press on one of the hip external rotators (specifically the inferior gemellus muscle….what? You don’t know how to isolate that muscle? Shame on you ;) and it reproduces their leg pain I can be reasonably assure that they have  TrP causing their symptoms. How these tender points developed is also up for debate. But there are schools of thought that say that a TrP can be caused by being sedentary (sitting on your ass all day), over activity within a certain muscle (think over training), trauma to a muscle (think falling down or car accident) or nutrition deficits (such as lacking vitamin D). In all honesty, if someone comes in with pain of insidious onset (no known injury), I have to look for trigger points…It’s a must!

 Okay, so I think I have found a TrP in a muscle, how do I get rid of it? 

This is a hard question to answer as there is no good evidence that any one method is superior to another. In my experience, pinning a muscle at the site of the TrP and having the client actively move through a non to minimally painful range of potion while the TrP is under compression tends to help..similar to ART I would say (?). I also employ proprioceptive neuromuscular facilitation (PNF) stretching to help “trick” the nervous system into letting go of tight bands of muscle. This ‘contract-relax’ method works only after manual “release” of the TrP in question has been achieved (that is my opinion only, FYI). I also know some physiotherapists who use intramuscular stimulation (IMS) to destroy TrP’ whereby a muscle is stabbed at various angles using an acupuncture needle…sound fun, right? Again, the science behind IMS is hit or miss, but anecdotally I have heard great success stories with its use. I commonly hear “it hurt more than pregnancy but it really helped my pain!”

To end off this small introduction on TrP’s I wanted to share with you the top 5 Trigger Points I treat and have had great success with. The “X” on the muscle shows where the trigger point is and the red dots show you where the trigger point can refer pain into….pretty cool pics from http://www.triggerpoints.net

1) Subscapularis  (posterior shoulder, lateral arm and anterior wrist pain)

Subscapularis Trigger Point Diagram

2) Levator Scapulae (chronic neck pain/tightness), pain along the medial scpaular border
Levator Scapulae Trigger Point Diagram

3) Pec minor (anterior shoulder and medial arm pain..symtoms of TOS or numbness into fingers 4 and 5 can be helped with pec minor relase)
Pec Min Trigger Point Diagram

4) Gluteus Medius ( “Sacroiliac joint” pain…always check glute med first! It’s rarely the joint itself causing the pain)

Glut Med Trigger Point Diagram

5) Solues (Plantar facitis..check the solues)
Soleus Trigger Point Diagram

Next time you have a patient with pain without any one particular reason, look for TrP’s…It just might help!

SFMA course review

Posted: October 21, 2013 in Uncategorized

Hello all,

As many of you may know, last week I took the Selective Functional Movement Assessment (SFMA) course in Toronto.  This course explains and teaches how to identify faulty movement patterns that maybe contributing to someone’s pain.  This done through an assessment that is based on 7 top tier movements whereby each one is rated as functional, dysfunctional, painful and non painful (or any combo of the above). From there, we were taught breakouts, which are just ways to further assess why one of the 7 top tier movements maybe dysfunctional by isolating different areas of the body and possible culprits for the dysfunction.

The 7 Top Tier Tests

Why would I want to take such a course? Easy! It’s a pretty cool idea…who doesn’t want to try and tease out the “real” reason someone has chronic shoulder or low back pain? Who doesn’t want to know what specific exercise is best suited for each patient at our clinic? Who doesn’t want a system...and that’s they key for me. This course provides a fantastic check list to systematically assess the body in a movement based way. It gives the therapist a way to create outcome measures based on pre-determined categories that can be consistently followed within and between treatments… I bet some of you reading this are saying “but I already have this..it’s how I normally assess/treat”. And to that I would say you are probably kidding yourself. Many of us (and we all do this) jump into treatment based on what we feel like doing for that particular day. No real plan or thought…we look at a few movements, palpate a muscle or two and off we go…with very little thought for pre and post treatment measurements. I’m not saying we can’t get clients better this way…but what about the ones we don’t? Wouldn’t it better to have a system in place to check off issues that maybe causing pain? That’s what the SFMA provides.  It also provides great pre-and post treatment assessments that a patient can easily see improvement in. ..hello buy in!

I bet from reading all that you think I’m in love with the SFMA. Well, that is true…but with a few key exceptions.  Like I said on the video I’m going to post talking about the SFMA, I still was left wondering how a lumbar spine stability problem can end up with elbow pain (as what was said in the course). These sort of anecdotes were thrown around without very much real explanation, using evidenced based terms that the informed therapist could use to justify what was being said. This is why I left day 1 of the course sceptical. It is so easy to say amazing things and label things as dysfunctional (or whatever), but unless there is rational evidence or even sound logic to back it up I may not be so enthused by it.  I found myself having to really think “why” a lot on this course…and that’s good, but I wish my why’s were answered a bit more. It would be better because I could tell a client exactly why there lumbar spine stability issue is causing their elbow pain with confidence…instead I’m left having to fill in the gaps myself.

Oh, it also pisses me off that to learn the techniques employed to treat many of the problems the SFMA finds you have to take the advanced course…ca’mon man!

Overall I would encourage SOME people to take this course. I personally believe having a few years experience before diving in would be a good idea. You need to see real pathology and pain before understanding the significance of this course (in my opinion). And I want to caution anyone who uses it or wants to take the course to not jump all in. Medical assessment and differential diagnosis can not be forgotten for the sexier and more in vogue functional assessment. Sometimes back pain is just that…back pain! There may not be some crazy anatomical/fascial/kinetic chain link causing it. It may even be serious and that’s why as a medical profession this can’t be all we do.

Here is a video of my friend and colleague, the manual therapist himself, interviewing me about my thoughts about the SFMA course. It’s 22 minutes long  so feel free to fast forward if it gets full :)

Until next time!

What 3 years has taught me

Posted: September 21, 2013 in Uncategorized

Over a year ago I wrote a post about what 2 years as a physiotherapist has taught me and it was well received. Entering my 3rd year as a clinician I think it would be fun and educational for new PT’s to see what I’ve learned over the course of my 3rd year in practice. This has been a challenging year both personally and professionally. On a personal note, I have moved my home and ended a significant relationship and on a professional note I left my old clinic to start out at a new facility in the big city of Toronto. Thus far, moving clinics has been an absolutely amazing decision for me and it’s provided me with so many more opportunities that I didn’t even know existed. I have never been happier professionally than I am right now.
I accomplished a few nice things this year in the physio world that I am proud of. I was a member of the blog team that was selected to go to Quebec City to write about the IFOMPT conference. I got to work with a physiotherapist I respect and am proud to call a friend, The Manual Therapist himself Erson Religioso. He is truly an encyclopaedia and very eclectic in his approach to assessment and treatment. I got to meet and talk shop with Gray Cook, Diane and LJ Lee, Peter O’sullivan, and David Butler. Later on in the year I received my intermediate diploma of manual and manipulative therapy from the Canadian Physiotherapy Association, I became a Titelist Golf Fitness Professional, and I dabbled in teaching clinical labs at a local PT school in Ontario along with lecturing to teenagers about fitness at a fantastic gym in Toronto. Later on this year I will be taking the SFMA course and my level 4’s through the CPA…always more to do!

No such thing!

So without further adieu, here are a few select things I learned in my 3rd year as a physiotherapist:

1) No single method or philosophy will work on every patient that walks in my door. I left my old clinic in part because I felt pressured to adhere to a style of practice I didn’t agree with. It was a philosophy on how the body should be assessed and treated that stopped making sense to me once I got enough experience to question what I was being taught. Did that style of practice work on some patients? Sure it did! Would rubbing their painful back and telling them they will be just fine also have worked? Probably to some extent.

Someone with low back pain from getting hit playing a sport, a sedentary lifestyle, or 20 years of chronic pain should all be treated very differently. In other words, following such things as clinical prediction rules, the pain science biopsychosocial model, or straight biomehcanics will yield different treatments based on the TYPE of patient I am seeing.

This leads me to point #2…and it’s a good one!

2) NO ONE KNOWS IT ALL!! There, I said it. The internet is full of gurus spouting how their method is the missing link to abolishing the world’s pain. I’ll be honest, there have been times I have read testimonials from someone who claims to know how to fix whatever pain and I’ve felt like I must learn what they know…ironically enough, more often than not they were selling a course just so you could learn how to do what they do. How convenient! Look, this is not to say that people who sell courses are just out to make a buck. In fact, I know that is not the case. But I have learned that if you question their methods and their main reply ultimately leads back to them trying to sell you their course than I think they just may be full of it. Prove me wrong…please! I will make special mention of a friend, Dr. Andreo Spina of Funcationalanatomyseminars.com. I have probably asked him over 30 questions on his blog posts and methods and he has personally responded to each and every one of them. He has even private messaged me just to make sure I understood what he was talking about…and I have NEVER taken one of his courses nor has he even tried to sell me one. For that, I plan on doing a bunch of his stuff in the near future. Also because I love what he has to say in the field of sports medicine and functional anatomy…but I digress.

Moral of point #2: Do your own research and don’t believe everything you read. The best people to learn from are those who are willing to admit they don’t know it all but use evidence to back up what they do know. Someone who says “you won’t get it unless you take my course” is full of shit in my opinion…bring on the hate mail!

3) Interdisciplinary facilities are the way to go! I work in a clinic now that has Physio (kick ass ones), Chiro (an awesome one), Sports med docs, Physiatrists, Massage therapists, Chiropodist, Psychologist, Pilates instructors etc. I have been able to sit in with my physiatry boss as he teaches  residents advanced neuro and medical assessment skills…so fun! If you know me you know that I will never give up a chance to learn something and working with such a stellar team of professionals is such an advantage. For example, the physiatrists I work with can come into a treatment session with me and look at something that seems “weird” such as a potential red flag. They have a different and more specialized skill set than myself so having that access is so refreshing. If I worked in a clinic with just physio I would only get physio input, which is not bad at all. Just great to have so many people to bounce ideas off of as well.

My clinic (shameless plug)

4) We are not as specific as we think are being: As someone going through the syllabus system in Canada to become an FCAMPT I am hesitant to write this. On a side note, I have had FCAMPT PT’s get upset with me over some of the stuff I have written on my blog…so I hope this doesn’t piss anyone off. I have read study after study that stipulates in black and white that we really have no clue what segment we are on when we are mobilizing and manipulating the joints of the body. Even better, research now clearly shows that it doesn’t even matter! Just look at the manip used in the CPR guideline for low back pain. It’s a wind ‘em up and crack em approach and magically clients still get better. Can we really determine the exact level of instability with our stress tests? Can we even isolate the joint itself with our stress tests? Do PIVM assessments matter? This time last year I would probably have said YES, of course they do! But as my sceptical brain kept digging, I realized over the course of the year that maybe it’s not as important as we once thought it was… I will leave it at that for now. More hate mail coming my way for sure! Haha

Take a guess at what they found
“The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non-region-specific manipulation techniques in patients with chronic low back pain.”

5) It’s not my job to fix anyone: I no longer think I have magic hands or know exactly what button to press to make someone feel better. Do you know why? Because there ain’t one!! I used to pressure myself into getting everyone 100% better within a 30 minute visit and if they weren’t all better by then than I failed as a physio. This left me going home frustrated and upset many a night. I now know that clients HAVE to be active participants in their recovery. It can not be just me working on them. I said this last year in my 2 year post and I am repeating it again because I keep forgetting it…I don’t fix people, I provide the tools, education and assurance for the clients I see so they can fix themselves. Some may not like that but I don’t really care. Do the odd hands on techniques help someone’s pain? Absolutely they do! And if we’re lucky, that pain stays a way for a while. But if the patient assumes that it was my manip, mob, soft tissue technique (whatever) that cured their pain than I have done a bad job as their therapist. This breads dependency and that’s a one way road to failing. This is HARD guys…really hard! Who doesn’t want to think they have magic hands? Or that they can cure someone’s pain with just their amazing manual therapy skills. It feels amazing when a client hops off my table and thanks me for fixing them…it does! But I know that they will be sore in a matter of days if they go back to doing what ever it was that brought them to me in the first place.

6) It doesn’t have to be complicated: In my 2 year post I wrote about the regional interdependence model and how much I liked and believed in it. I still do! However, I have learned that neck pain can just be neck pain. And ankle pain can just be ankle pain. I don’t need a movement screen to help be tease out the non-painful dysfunction to help me figure out someone has loose ankles or suboccipital tightness due to forward head posture…You may disagree and that’s cool! But I have done quite well treating locally when I feel it is warranted and have had some good results too. Along the same lines as point #4, I don’t think I have ever diagnosed someone neck pain by saying their right C0-1 posterior glide is tight combined with left C2-3 facet hypermobility and a fixated C4-5 IMP glide on the left…yet I have heard other manual therapists make these type of diagnosis’s all the time. Maybe they are just better at me at detecting these things, but I for one don’t know how they can rest their hats on something their colleague next door would not likely find (inter-rater reliability sucks for that stuff). Again, I will concede that maybe there are truly therapists with better hands than me that can feel these tiny nuances and then make a corresponding diagnosis based off of them. I for one think it doesn’t really matter all that much.

There are probably hundreds of little facts I have learned this year as well that are too boring to write about on this blog. These are some of the more holistic ideas that I have adopted in my 3rd year of practice. I’m lucky to report that I love my job and continue to be passionate about it. I really couldn’t imagine doing anything else. I get to help people move and feel better all day…what could be better than that?! I hope in 3 years time I will have learned all new stuff andI will laugh at what I wrote in this blog post. This blog is like a career time capsule in that sense. I am documenting my journey for all to see and enjoy. Let the professional growth never stop!

Till next time!

Jesse

Patellofemoral Pain Syndrome (PFPS) is a common condition encountered in orthopaedic practice. PFPS most commonly presents with retro- or peri-patellar pain associated with positions of the knee that result in increased or misdirected mechanical forces between the kneecap and femur. Climbing stairs, running, kneeling, squatting and long-sitting are frequent pain aggravators. Clinicians have come to understand that the cause of PFPS is not always directly at the knee, realizing the importance of surrounding dysfunctions proximal or distal to the site of pain….we must understand that knee pain is not about the knees (most of the time), a holistic approach must be utilized in both assessment and treatment to figure out why one would present with knee pain.

Here is a list of 4 common reasons for knee pain and a subsequent diagnosis of PFPS (which is a crappy diagnosis)

1) Weak Hips

You’ve probably heard it before, but it’s worth repeating: Weak hip abductor and external rotator strength is a key reason for PFPS. It is believed that weak hips cause medial rotation, adduction and valgus collapse of the tibia and femur leading to excessive joint compression and patellar mal-tracking. This is especially true in women due to the larger Q-angle they present with (wider hips), which makes it all the more important to strengthen the hips as part of a comprehensive treatment approach

“Current research reveals that poor proximal neuromuscular control and/or weakness of the hip musculature may lead to limited control of transverse and frontal plane motions of the hip (especially during single-legged stance). Other evidence suggests such dysfunction can result in dynamic malalignment including components of femoral adduction and internal rotation, valgus collapse at the knee, tibial rotation and foot pronation. Findings of deficits in hip abduction, extension and external rotation strength has also been shown with patients with PFPS. Further, multiple studies by Willson and colleagues demonstrate that there is an increased hip adduction angle in PFPS patients compared to healthy controls”

Journal of Orthopaedic & Sports Physical Therapy 2012; 42(1): 22-29.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females with Patellofemoral Pain: A Randomized Controlled Trial

American Journal of Sports Medicine 2011; 39(1): 154-163A Proximal Strengthening Program Improves Pain, Function and Biomechanics in Women with Patellofemoral Pain Syndrome

See what I’m talking about?

2) Restricted Ankle Dorsiflexion

I wrote an entire blog post about this a few weeks back. Long story short: If you can’t get the 10-15 degrees of dorsiflexion in your ankle that is needed for proper gait or squatting you will ultimately compensate by falling in on your arches thus pronating through your subtalor joint. Just like with weak hips, if you excessively pronate you will tend to have tibial and femoral internal rotation thus placing the knee in an awkward position when doing such tasks as descending stairs. Muscle imbalances my result along with excessive joint compression at the knee causing PFPS symptoms.

I have not come across a lot of studies that specifically look at the effects of ankle dorsiflexion on knee pain but here is what I’ve read to date:

N Am J Sports Phys Ther. 2009 February; 4(1): 21–28
Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner

J Sports Rehab 2012 May;21(2):144-50.
Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat.

“Altering ankle-dorsiflexion starting position during a double-leg squat resulted in increased knee valgus and medial knee displacement as well as decreased quadriceps activation and increased soleus activation. These changes are similar to those seen in people with PFPS.”

Knee to wall test: How I assess ankle doriflexion

3) Lumbar spine pathology:
Conditions like spinal stenosis, arthritis or a disc herniation from L3-4 (most likely) can refer pain down to the knee. The nerves that exit the lumbar spine at certain levels travel down to the knee to provide motor input and sensory output. Thus, irritation of a nerve root in the lumbar spine can be a chief cause of lateral (L5), anterior (L4) or medial (L3) knee pain. Anecdotally, I have treated a few clients with no back or upper leg pain, but complained of tightness and burning at the knee. Once all knee-specific subjective and objective tests are ruled out, it became apparent via dural mobility testing that the knee pain was a function of a lumbar spine pathology.

Quick tip: If a client has unexplained knee pain and you think it maybe neurologically mediated (well, all pain is neurologically mediated…you get what I’m saying though) then test dural mobility and see if that recreates their knee pain. If so, you have a great outcome measure to see if you made a difference post treatment. If a slump test causes burning lateral knee pain, treat the lumbar spine and re-test the slump. Hopefully it’s better afterwards!

4) Hallux Valgus or 1st MTP restriction:
Just like at the ankle, if the 1st toe can’t extend or dorsiflex like it should the foot  will fall into more pronation through midstance to toe off (the big toe has to find a way to get to the ground and it does so by forcing the subtalor joint into pronation). This again leads to dynamic knee valgus and the possibility of PFPS…Knee pain? Check the big toe!

Good ROM

Summary:

  • Knee pain is often multifactorial and keeping in mind regional interdependence yields a more comprehensive assessment and treatment approach
  • Knee pain can have components of articular restriction, dural irritation, tendonopathy or a combination of many things (usually the case)
  • When someone comes in with insidious onset unilateral knee pain and the prescription from their G.P says “overuse injury, treat with ROM, strengthening and stretching of the knee” (what I had last week) you MUST explain to the patient that unilateral overuse with bilateral activity (running etc) is probably impossible.
  • Treat the joints above and below and even on the contralateral side if needed