All posts in Clinical Case of the Week

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!