The 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.
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.
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.
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!
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.
This week I will tell you about the rapid recovery of an ipsilateral shift. An ipsilateral shift was described by Robin McKenzie of the McKenzie Method®, and the treatment of this patient of the week follows Mechanical Diagnosis and Therapy® principles exactly as I was taught them. The patient presents with a lateral shift deformity of the trunk shifted away from the side of dominant pain.
Gerry, (not his real name), arrived with his wife to clinic after suffering 10/10 pain in his back, buttock, and thigh, and had a severe ipsilateral shift. This had been present for 2 weeks, and Gerry stated it had recently worsened after a massage session. Gerry could not recall any incident that caused injury or otherwise caused the onset of pain. He stated he had tried standard chiropractic treatment with no effect.
While I was taking Gerry’s history, his wife reported that he had to crawl to get around their home for the first hour after getting out of bed. Even at his best, he could barely make it down the hall to my office. He was completely unable to dress himself, drive or go to work.
The shift made the mechanical diagnosis easy. It was most likely a mechanical derangement. Any attempt Garry made to bend forward or backward resulted in severe pain, and nearly no range of motion. Trying to correct the shift himself, even when leaning against the wall for support, also resulted in severe pain and no gain in range of motion.
Therefore, manual forces had to be applied by the MDT therapist – in this case – me! (I have achieved certification in Mechanical Diagnosis and Therapy® by the McKenzie® Institute, designated by “Cert. MDT”).
Manual shift correction is described in various published works by Robin Anthony McKenzie, the originator of the McKenzie® Method of Mechanical Diagnosis and Therapy®. It involves full body pressure against the hips and opposite side of the trunk provided by the therapist. It can be painful to experience, however, only pain that centralizes is permitted, according to McKenzie®. As I learned in my McKenzie® training from expert therapist Colin Davies, the duration of force application can last a long time – up to 45 minutes. Gerry’s shift was challenging. I applied force for 45 minutes, but still there was only minimal correction of his shift!
By day two, Gerry could walk better, but was still shifted. This time, manual force corrected the shift in 15 minutes. The next day Gerry could correct his own shift and he was not taking any pain medication anymore!
Now, one week later, he is no longer shifted at all. He can dress himself, including his socks and shoes, drive, and go to work. Regarding walking, he only needed to swing his Right arm normally again – he had been supporting his back with it and lost normal gait in the interim. He reported pain levels of 1-2/10.
Treating Gerry was very satisfying. His mechanical diagnosis was clear, treatment was difficult, but not confusing. I credit the McKenzie® Method of Mechanical Diagnosis and Therapy® with giving me the expertise to be so successful in treating this, and other painful spine and joint conditions. Thank you for your interest in the clinical case study of the week!
Nick Rinard MPT, Cert MDT
This is about a shoulder derangement that was identified, and fixed in 10 minutes. But there is more background to the story.
Debbie (a fictitious name for the real person) was training for her first 1/2 Marathon, held in Portland, Oregon. About 3 weeks before the event she presented to physical therapy complaining of pain behind the knee. Such an injury so close to a sporting event is automatically worrisome because it threatens participation. Both Debbie and I were concerned that it could stop her from being able to run the 1/2 marathon!
I performed a mechanical assessment per the McKenzie Method, combined with Cyriax style selective tissue tension tests, and diagnosed the knee pain as “semitendinosis tendinitis”, named according to Laslett nomenclature. It is a lesion of the hamstring.
Although Debbie had good hamstring flexibility, I deduced, based on her history (she was certified as a yoga instructor), that she normally had more. Treatment consisted of stretching out her hamstrings, combined with manual deep tissue mobilization of the hamstring muscle belly. It worked!
She ran the 1/2 Marathon without any knee pain! However, her shoulder became painful during the event! She asked me to look at it 4 days later since it had not subsided on its own.
She presented with what appeared to be a clear contractile lesion of the infraspinatus tendon, with a weak resisted test of lateral rotation. However, there were two pieces of information that were inconsistent with this conclusion. 1) Resisted shoulder flexion was painful with the elbow positioned behind the body, but painless with the elbow in front. 2)
There was no tenderness at all near the infraspinatus tendon, which would be typical , but not required, for the lesion to be harbored in the infraspinatus tendon.
Further mechanical assessment was needed, and this followed the McKenzie Method of Mechanical Diagnosis and Therapy. Repeated tests would differentiate between a derangement and other possible pathologies. I surmised that the arm bone could have been malpositioned in the shoulder girdle from Debbie pumping her arms while running. The logical step was to reverse the activity of arm pumping and correct the derangement. So I instructed her to reach all the way across her body with that arm and then push it further using the other hand. This became less and less painful until there was no pain! Furthermore, it resulted in much less pain produced by resisted flexion afterward! Another exercise–that of rotating the arm bone back into place–worked well also, virtually rendering all prior painful tests, painless!
Needless to say, Debbie was very pleased with both the rapid results with her shoulder, and grateful that her knee pain was treated in time for her to complete her 1/2 marathon!