Clinical Conversations

Vertigo: A mechanical cause and treatment!

The most common cause of vertigo (dizziness) is benign paroxysmal positional vertigo (BPPV) and it is a mechanical disorder. A trained clinician can evaluate and treat this condition based off of the patient’s symptoms. The evaluation consists of moving the head into specific positions. Symptoms of BPPV include vertigo with change in head position, nausea with or without vomiting and disequilibrium (poor balance).


Image of Inner Ear and Vestibular System edited by Dan Yedinak

Vestibular System

BPPV is a curable condition affecting the vestibular system (inner ear). Your inner ear is comprised of 3 semicircular canals (SCC) and 2 otolith organs. These structures detect head movements (acceleration). Crystals called otoconia are embedded in the otolith organs. Sometimes, the crystals can become dislodged and misplace into the semicircular canals. The misplaced crystals result in increased sensitivity to head movements.

Hopes for a Positive Response

I was treating a patient for low back pain when she mentioned that she was experiencing severe episodes of dizziness. I informed her about BPPV and mentioned that the treatment was very simple and effective. She agreed to have an evaluation in hopes for a positive response.

My patient tested positive for BPPV utilizing the Hallpike-Dix test for the left semicircular canals. I also performed a few other tests and exercises to rule out other potential causes for symptoms. Once we had our diagnosis of BPPV, the treatment was very simple.

Improvement in just one week

I took my patient through a series of head movements that reposition the crystals back into the otolith organs (the saccule and ultricule). After performing the repositioning maneuver, baseline symptoms were decreased and she returned the next week without having any severe episodes of vertigo.

BPPV – A Common Vertigo that is Easily Treated

BPPV is the most common cause for vertigo. Luckily, it is very easy to diagnose and treat with a trained therapist. If you or someone you know has vertigo as a result from head movements, have a physical therapist evaluation so that you may start feeling better today!


Ankle pain from the spine?!

By MiKayla Sanocki, SPT

Did you know a back problem can cause symptoms such as pain, decreased strength and decreased sensations into the thigh, calf, ankle or foot? Physical therapists trained in Mechanical Diagnosis and Therapy (MDT) here at Nick Rinard Physical Therapy can determine during the evaluation if any of these lower leg symptoms are coming from your back.

Check out this bizarre clinical presentation we treated at Nick Rinard Physical Therapy:

She did not remember any trauma to the ankle

The patient came to physical therapy for an “ankle sprain” that occurred 3-months earlier.  She stated she woke up unable to put any weight on her right foot. The pain had remained constant in her ankle, so bad at times that she couldn’t walk!  Upon further questioning, the patient revealed what she had been doing the day before: She had driven 2 hours, on her way home from helping clean a house. During the drive she had discomfort in her buttock and hamstring that made her want to pull the car over to stretch.  She did not remember any trauma to the ankle, however, but the ankle pain was the only pain she was experiencing now.

Her ankle pain has caused her to quit running and yoga — two of her favorite activities.

Mechanical Evaluation finds cause in spine

Picture of woman running wearing RinardPT logoDuring the mechanical evaluation we found that certain directions of low back movements decreased the pain in her ankle.  After being sent home with 1 simple exercise to perform every waking hour – which she did perfectly – she returned within 24 hours reporting 90% recovery in pain! Over the next week we were able to progress her exercises and now the patient reports no ankle pain at all. In only 4 visits we were able to abolish her ankle pain, and she is now getting back to running and yoga!

The patient reports, “I now have the tools to prevent the return of my back and ankle pain”.

Treatment at Nick Rinard Physical Therapy vs Traditional PT

In contrast to MDT, traditional PT would not have uncovered the spinal cause of the patient’s ankle pain.  Treatment would have been ineffective since it would have focused only on trying to treat the symptom.

Do you know if your pain in the legs or arms could be coming from the spine?  Come see us at Nick Rinard Physical Therapy and find out! 


Post op shoulder pain was really coming from the neck

Nick Rinard PT ExerciseVery interesting clinical presentation today!  The patient had been treated for neck pain here (Nick Rinard Physical Therapy) in the past with good results.  Later, she developed shoulder pain and consulted her MD, who referred her to an orthopedic surgeon.  There were “findings” on MRI and she ended up getting arthroscopic surgery.  She returned to us for physical therapy to rehabilitate after surgery.

No Surgery Needed

Interestingly, she reported that her surgeon was surprised that her rotator cuff tendons were in “good condition” and did not require a repair – he had noticed that during the surgery procedure itself, apparently.  So, physical therapy should be easy in such cases, right?  No big surgical repair to worry about.  

However, 6 weeks after the operation, her shoulder pain was not subsiding as it should have.  Inflammation normally resolves in that amount of time and she should have been strong enough to resume normal office work duties consisting of keyboard and filing.

Finding the True Cause of the Pain

We had to take a closer look at her neck.  It turned out that her neck was referring pain to the shoulder!  In one neck treatment, the shoulder pain was abolished!  The patient probably had had a recurrence of her old neck problem, it referred pain to her shoulder, and neither she, her MD, nor the orthopedic surgeon considered the true cause of the pain…

This is a frequent occurrence here at Nick Rinard Physical Therapy, where we use the Mechanical Diagnosis and Therapy (MDT) system of evaluation and treatment.  Robin McKenzie started this method and it is the best method – and most supported by research – at getting to the true cause of pain.

Save time, money, and maybe avoid surgery!

If you or someone you know is having any problems that could be mechanical, a thorough mechanical assessment should be performed.  In as little as one visit the problem might be identified and solved, saving a lot of time, money, and suffering!  Plus, the patient might avoid unnecessary surgery!


RinardPT Monthly – March 2014 – Happy St. Patrick’s Day!

Nick Rinard Physical Therapy Logo Traced Outline Image of Man

RinardPT Monthly

Nick Rinard Physical Therapy
9700 SW Capitol Hwy Suite 140
Portland, OR 97219

Volume 6, Issue 2
March 2014

Change Your Clocks! | Happy St. Patrick’s Day! ECLATT Leprechaun Girl Hat Logo

Why Wait?

Too often, we get patients in our office who have been in pain for months (or almost a year in Michael’s case!  Read his story below).  If your pain is not improving on its own, there is NO NEED TO SUFFER!  It could take just 3 visits, like it did for Jane, and you can have the tools to treat your pain and get back to living your life to the fullest.  Most of our patients are able to self-treat their problem in just 6-8 visits.  Get the tools you need now.

Are you currently suffering from pain or injury?
Call 503-244-6232 today!

RinardPT patients get Results:

Don’t take our word for it

“I hurt my knees in October 2013 while in Mexico.  I wish I had called MDT sooner and saved myself four months of pain & difficulty walking.  Going down stairs was especially painful.  In three sessions I am pain free; getting out of bed, walking, and stairs are no longer painful.  Many thanks! ”-Jane 02/12/2014 “I was in a car accident in May 2013.  I had neck pain and stiffness every day after the accident.  I came to MDT of Portland in hopes of being cured.  Within roughly 7 sessions, I would say I no longer have any pain.  Thank you guys very much-you’re all incredible!”-Michael 02/04/2014


Nick Rinard Physical Therapy 4 people jumping on the beachFREE CONSULTATION COUPON

(503) 244-6232
In just 5-10 minutes, MDT can determine if your pain is mechanical or not. If so, we can help get you out of pain and back to enjoying your life.


Remember to “SPRING FORWARD” by one hour on Sunday, March 9th!

ECLATT Reminds you to Change Your Clocks

March Events around Portland

RinardPT Happy St Patricks Leprechaun Girl


RinardPT Monthly – February 2014

Nick Rinard Physical Therapy Logo Traced Outline Image of Man

RinardPT Monthly

Nick Rinard Physical Therapy
9700 SW Capitol Hwy Suite 140
Portland, OR 97219

Volume 6, Issue 1
February 2014

Teaching YOU how to Get RESULTS

since 1999

Dear Friends,
It’s been 15 years since Nick Rinard devoted a physical therapy clinic to practicing Mechanical Diagnosis & Therapy.  In that time, we have helped so many of you get back to a pain-free life.  We’ve received pictures of our patients doing their exercises in all corners of the world, and are so proud of being part of your journey. THANK YOU for giving us all at MDT Physical Therapy the pleasure of teaching you how to get RESULTS!

Are you currently suffering from pain or injury?
Call 503-244-6232 today!

RinardPT patients get Results:

Don’t take our word for it

“I have been cutting hair for 46 years, and I have been experiencing pain in my right shoulder for at least 3 years.  The pain has been getting worse and limiting movement & my ability to cut hair.  2 weeks ago the pain diminished to the point I could forget about it.  I believe this was due to a new set of exercises designed by Megan and am very pleased with my progress. ”
-Curtis 01/21/2014
“Initially my pain level in my right let was a 10.   On my very first visit the pain subsided significantly-to the point that I believed there was some magic happening!  I would never imagined that 2 simple exercises would bring me to a pain level of zero.  The ongoing preventative exercises are part of my daily routine & will continue to be.  I truly appreciate all of the staff.  They are professional & serious about bringing their patients to a pain-free outcome.  Thank you.”-Debbie 01/09/2014


Nick Rinard Physical Therapy 4 people jumping on the beachFREE CONSULTATION COUPON

(503) 244-6232
In just 5-10 minutes, MDT can determine if your pain is mechanical or not. If so, we can help get you out of pain and back to enjoying your life.


Sweet (and Healthy) Chocolates for your Valentine…Or Yourself!


Valentines Chocolates in a Heart Shaped BoxJust use your favorite Valentine-shaped cookie cutters to make these treats!

  • 1 1/2 cup walnuts
  • 8 Medjool dates (these are softer than other dates, and easier to blend)
  • 1/2 cup cocoa (use less if you don’t love dark chocolate)

Blend walnuts in a high powered blender or food processor until a powder.  Pit the dates, then add walnut powder to a bowl and the pitted dates. Using your hands mix the two ingredients together until the dates are completely incorporated.  Add the cocoa.  Shape into a mold. Top with dried fruit, coconut, granola, or peanut butter!


Want more fun and healthy recipes?  See more here:




LOW BACK PAIN—What you should do while waiting for your first physical therapy appointment

LOW BACK PAIN—What you should do while waiting for your first physical therapy appointment…


Sitting Posture Important Low Back PainSit as little as possible.  Standing or lying down are preferable to sitting when in acute low back pain.  If you must sit, sit only in a straight backed chair with good posture.  Avoid couches or soft chairs.  Use a towel roll to support the natural curve of your spine.


Do not bend forwards as in touching your toes when in acute low back pain—even if it feels like you are doing good by  “stretching” the muscles of the low back.  Rather than reaching down to get things, squat down using the legs and keep the back absolutely straight.


Try to lie more on your stomach rather than on your back.  Avoid the temptation to lie on your back with the head and knees propped up—this just rounds the back more and places inappropriate stress on injured structures.

Low Back Pain lie on your stomach not your back


You should stay normally active–in other words try not to stay in bed for long periods.  Move around, take walk if you can.  Do not do the knees to chest exercise you may have learned before.  This is an advanced exercise and usually not appropriate for acute conditions.  It is better in most cases to lie on your stomach and work towards supporting yourself on the elbows.

 Low Back Pain Don't do Knees To Chest Exercises  Low Back Pain Exercise On Stomach Elbow Support

Low back and bilateral leg pain: Our Clinical Case of the Week


Up to 80% of the population will experience low back pain (LBP) at some point in their adult life (Croft et al 1997).  It is estimated that health care costs for low back pain are larger than for any other disease for which economic analysis is available (Maniadakis and Gray 2000) ($31 billion/year).  There is little to no evidence supporting the use of traction, thermal modalities, or electrical stimulation for the treatment of LBP. Unfortunately, these strategies are commonly used for the bulk of LBP treatment.   Many studies conclude that the McKenzie method of evaluation and treatment for LBP is superior to that of standard treatment (general stretching and strengthening).  What makes the McKenzie approach different is its classification system. Based off of symptom response to repeated lumbar spine movements, patients are classified into 1 of 3 syndromes (derangement, dysfunction, postural).  After patients have been classified, their individualized treatment plan is created. The McKenzie method also emphasizes self-treatment and long term symptom management.  I consider this the most valued aspect of treatment, as statistics show LBP is recurring in nature. Let’s review a case of a patient with a very successful outcome utilizing the McKenzie method.


Patient presented to therapy 2 weeks after the onset of LBP with bilateral leg pain.  Patient described sharp pain which radiated down to the left foot and down to the right shin. Symptoms started after a weekend of working (auto mechanic) which involved repetitive bending and lifting of heavy equipment. Patient rated worst pain as an 11/10 for the back and a 10/10 for the left leg, occurring on a daily basis.  Patient was severely limited with walking, sitting and sleep.


Patient demonstrated pain with all lumbar spine motions in standing.  There was no neurological (strength, sensory, reflex, neural tension) deficit.  This is important to test when there is a presence of leg pain.

Baseline symptoms= LBP + left foot tingling.  Patient was asked to bend forward 10 times, touching his toes.  This resulted in increased low back pain, no effect on foot tingling.  Bending backwards 10 times also increased LBP with no effect on foot tingling.  Patient was then asked to lie on his stomach and perform prone press ups (a back bend using arms to push up into extension). This exercise abolished left foot symptoms, better leaving the clinic that day.


Patient was given prone press-ups to be done every hour until his follow up appointment.  The next day, the patient returned to the clinic happily reporting that he had not experienced leg pain in over 24 hours!  The patient was even able to perform tasks associated with moving into his new home that weekend.  In 2 weeks his back pain rating had decreased to a 3/10 and he was experiencing little to no leg symptoms!  Patient continued therapy over the next few months with exercise progressions and modifications as needed.  At discharge, patient was able to perform his duties as an auto mechanic and continue his training as a member of the National Guard.


Do not fall victim to chronic low back pain.  This is associated with huge healthcare costs, over utilization of medication and surgery. All of which would otherwise be avoided with a simple exercise, requiring no special equipment.   The patient from this week’s case left the clinic feeling very empowered by his own ability to treat his symptoms and was no longer considering having major spine surgery.


Pseudo Tennis Elbow: A Commonly Misdiagnosed Mechanical Problem

Test-for-painful-grip,-wrist-and-elbow-extendedLateral epicondylitis, more commonly known as “tennis elbow,” is a pathology that is familiar to physical therapists and the general public.  What is lesser known is “pseudo tennis elbow,” a mechanical problem with a very simple solution!  Unfortunately, therapists whom are not familiar with the utilization of mechanical diagnosis may unknowingly miss this common elbow derangement.  As a therapist practicing the McKenzie method of mechanical diagnosis, I have diagnosed BOTH of my current elbow pain patients as derangements (or pseudo tennis elbow).


Our patient, “Jane” presented to therapy with intermittent right elbow pain, worsening over the last 3 months. Jane reported difficulty with gripping, lifting, carrying and global limited function of the right arm.  Jane described symptoms as “variable” meaning she could perform a task that produced his elbow pain. Then, perform the same task or movement again without experiencing any pain at all!  This variability of pain is the hallmark of a derangement and should not be misdiagnosed as a tendonitis, which would indicate inflammation (in which case pain would be constant).  Jane rated worst elbow pain as a 6/10.

Physical Therapist Evaluation & Findings

Objective findings included pain with passive elbow flexion and extension as well as pain with active wrist extension and with gripping a tennis ball.  Because of my experience as a mechanical therapist, I am familiar with a technique called a mobilization with movement (MWM), developed by Brian Mulligan (a colleague of Robin McKenzie).  The mobilization provides a lateral force over the ulna at the elbow joint. While the patient applied this force, she was able to grip the tennis ball PAIN FREE!  This same technique was applied for other painful baselines and achieved the same results of ABOLITION OF ALL PAIN!  This ability to turn symptoms off with a mobilization indicates an elbow derangement and the MWM is used as the treatment strategy.

Patient Homework and Outcomes

Jane was asked to perform the MWM utilizing the lateral glide while gripping a tennis ball to be performed 10-20 times every hour.  The theory is that this mobilization is repositioning the joint in order for it to articulate correctly, resulting in improved range of motion and strength after.  Jane returned to the clinic the next day with reports of at least 25% improvement! Objective findings were retested and nearly all baselines had improved in less than 24 hours!  Jane returned 1 week later and reported an 85% overall improvement with symptoms.

Get Your Own Mechanical Assessment

Don’t be misdiagnosed! Straightforward pathologies which require one exercise to treat are commonly missed with standard treatment.  This results in extra therapy visits, and more of your time and money.  It is worth your time to see if your pain has a MECHANICAL component.  A simple solution may otherwise be missed.


Tough Chronic Hip Pain – Problem Found and Fixed

Image of Back and Hip Nick Rinard PTThe case study I would like to share with you today is only the second hip derangement of this type that I have seen in 18 years of practice.  “Jim” was a 55 year old male who presented with right hip pain that started for no apparent reason 5-6 months prior to coming to physical therapy.  He said the pain was provoked only when he was walking, but it occurred consistently at a distance of about 50 to 100 yards.  Often it was so painful he could not continue walking.  Jim figured out that changing his right foot position enabled him to walk a little further, albeit slowly, and then he could resume normal walking for another 50 yards or so.  He would change the foot position by stepping partway onto a curb or raised ground such that the outer edge of his foot was tilted up (eversion, as we therapists call it), and then he would angle his right knee inwardly.  That was the only way he had found to improve walking, but the hip just would not stay better.

In desperation, Jim said he had looked online and tried numerous “hip exercises” without any relief.  He consulted his doctor, who recommended MDT, which we do here at Nick Rinard Physical Therapy.


The mechanical assessment was positive for only two findings:  limited and painful hip motion into flexion (folding the knee to chest), and weak and painful testing of hamstring resistance.  The protocol for ruling out a joint derangement is to repeat motions to determine if the baselines change.  The question is which motion to repeat.  One can move either into the most painful direction, go the opposite direction, or check rotations.  I chose to go into the most painful direction, in this case, flexion.  But before testing I wanted to establish how far Jim could walk in the clinic before his pain started.  By the time he walked one length of the hallway and back, he reported pain.  I then instructed Jim to bend his knee to chest (compressing the groin) repeatedly and after 20 to 30 times.  It produced his familiar pain initially, then the pain abolished and his motion increased.  I tested walking after that and Jim said there was no pain even after walking 3 lengths up and back through the hallway!  I gave Jim his exercises and scheduled him for 2 days later.


When Jim returned he reported that he could walk longer distances without the pain starting, however, he still got to the point where he had to modify his foot position in order to continue.  I knew we were on the right track, and the next step in treating a joint derangement is to progress forces.  I did this manually by applying over-pressure, and instructed Jim to do it in standing by folding his chest down to his knee with it supported on a bench or chair.  By the next visit, Jim reported that this had worked very well and he had not experienced any pain at all!  So, the derangement was reduced and I needed to wean him off the home exercises to see if it would return or not.  I gave him the weaning program and asked to see him back in 2 weeks.

Pain Free

After 2 weeks, Jim came back reporting that he had been able to walk unlimited distances!  He resumed walking his dog, going on walks for exercise, and walking wherever, and whenever he wanted.  He reported his longest walk lasted 4.5 hours.  He said there was no return of the original hip pain from which he had suffered for months.  However, on his last two walks, he had started noticing a new hip pain, this time in the front, not on the sides.  I re-checked his baselines and neither flexion motion nor resisted hamstrings were painful.  That meant it could not be a re-derangement.  Resisted hip flexion was painful, and that was new.  I concluded that his sudden ability to walk pain-free resulted in his over-doing it.  Jim had increased walking too fast and gotten a minor tendonitis.  That was easy to treat, and by his next visit, Jim was pain-free again and able to progress walking, though this time more gradually, which was safer.

Successful Treatment

Jim’s hip treatment was obviously a success.  It took only 4 visits.  This hip derangement was unique because the direction that reduced it (flexion); I have only seen one other hip derangement require flexion to reduce it.  The fact that Jim resumed normal activity too fast is typical of reduced derangements – the patient feels so good that they over do it.  Luckily in Jim’s case, we found the new problem and fixed it just as fast as we found and fixed his chronic hip pain.


Can TMJ Pain and Dysfunction be Purely Mechanical?

TMJ pain can be a real problem for its victims, limiting their ability to chew and talk, and interrupting sleep. Often, headaches even limit the person’s ability to concentrate! Various treatments have been proposed to alleviate the symptoms of TMJ (Temporomandibular Joint) pain, many of which are very complex and even invasive. Looking at the TMJ as “just another joint” and not predetermining that it has to be complicated has been very freeing for me in using a mechanical approach. Let me explain using a patient example from this week in clinic.

My approach is modeled after the McKenzie Method of Mechanical Diagnosis and Therapy, although very little about TMJ specifically has been written or published about it. (1)

Symptoms and Experience

Now, about the patient. (Name and other identifying information has been omitted to protect privacy). This patient complained of intermittent left jaw pain with wide opening of the mouth. He stated it only occurred then, and otherwise it really was not painful. However, chewing tough foods, he admitted, was sometimes painful. His worst pain occurred with rapid opening of the mouth and could be as intense as 6 on a scale of 1-10.

Therapist’s Evaluation and Findings

Objective findings were limited and painful opening with slight left deviation, limited and painful protrusion, limited and painful right deviation, and no pain or limitation with retraction, or left deviation. Repeated tests performed actively by the patient of protrusion first, then of right deviation resulted in producing the patient’s symptoms, no worse after, but also no change in baseline ROM or pain. Forces were progressed to patient applied over-pressure to right deviation. The patient reported that this produced his pain initially, then decreased pain as he performed more repetitions. Subsequently, he reported wider opening with less pain!

Patient Homework

Home exercises were assigned, which naturally consisted of patient applied over-pressure into repeated right deviation every hour or two as per typical McKenzie protocol. On the second clinic visit two days later, the patient stated he was already 50% improved! This finding confirmed the mechanical diagnosis of derangement syndrome. In this classification, there is a good prognosis for rapid and lasting recovery from the problem.

Get Yourself Evaluated

This is only one clinical example of a purely mechanical TMJ problem. While there are examples of TMJ issues that are not derangements, or even mechanical, often a mechanical cause of the pain can be found and the patient helped by mechanical therapy. It is well worth a thorough examination to determine if your TMJ pain has a mechanical component, and to get appropriate treatment which would otherwise be missed.