The case study I would like to share with you today is only the second hip derangement of this type that I have seen. “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.
Assessment
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.
Progress
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.
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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
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A mistake that people often make is waiting too long to start physical therapy treatment for their aches and pains. This commonly occurs because you may be thinking, “this will go away on its own,” or, “it’s just normal for me to feel like this at my age.” I want to clear up some confusion on mechanical pain versus normal muscle soreness that does not require skilled therapy or treatment.
Muscular Pain:
- Experienced after a sudden increase in activity or exercise.
- Running 6 miles when you typically only run 2 miles
- You increased the intensity or length of time to your typical workout
- Will be experienced 1-2 days after the increased activity has been performed and will typically begin to dissipate or be gone in 3-5 days after onset.
- Is typically vague pain or experienced in a general area. The pain will not be sharp or pin-point to a specific area.
- If you’re educated on what muscles perform which actions, the sore muscles will correlate with what activity you were performing.
- Does not have increased or decreased pain associated with positions.
Mechanical Pain:
- May have a sudden onset without explanation of occurrence (you woke up with pain for no apparent reason).
- Will typically have a loss in range of motion. For example: it may be difficult to stand up straight in the morning or after prolonged sitting or driving.
- Will have positions that will increase or decrease symptoms. For example: pain increases with sitting, pain is better while lying down.
If you’re experiencing mechanical pain the sooner you seek physical therapy treatment, the better! A good Physical Therapist can determine which exercises will reduce your symptoms and get you back to doing the activities that you love!
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Thank you Troy for sharing your Nick Rinard Physical Therapy experience on google.
“As a competitive weightlifter, the pain in my back was seriously stalling my training.
Nick really listened and understood my goals and my issues and helped me get rid of the pain I’d been dealing with for over 6 months with only 2 visits and some assigned stretches.
I couldn’t believe it!
I’d seen doctors and other PTs and was about to get an MRI so I could get cortisone shots which was going to take months and only mask the pain if it solved it at all.
My experience was THE BEST.”
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Medication, surgery and physical therapy.
Out of the 3 – Physical Therapy is the first road to take.
- Surgery is not a cure all when it comes to back pain.
- Physical therapy restores movement, function and quality of life.
- Physical therapy is cost saving over medications and surgery.
- Injuries heal quicker with physical therapy.
- Medications are just a quick fix.
- Over the counter medicines have negative consequences with long term use.
- Physical therapy helps manage chronic pain for life.
- Physical therapy manages the effects of arthritis.
- Physical therapy prevents joint pain and instabilities.
- No risk profile for physical therapy.
- Physical therapy is totally reversible and no toxicity.
- Physical therapy is the most organic holistic approach that exists.
- No unknown ingredients.
“Severe back pain/herniated disc.
PT allowed me to avoid cortisone injection or surgery.
Initial progress was spot on.
I owe a debt of gratitude to Nick.
Thank you!
I am fully recovered.”
Brian
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By Krissy Brown
20 Feb, 2025
Clinical Case of the Week, Exercise
arm pain, Best physical therapy, Mechanical Diagnosis and Therapies, misdiagnosed, neck pain, Nick Rinard, pain, results, sensitivity in fingers, Thoracic outlet syndrome, TOS
If you are experiencing pain in your neck, shoulders, arms and sensitivity in your fingers it may be thoracic outlet syndrome (TOS).
Get your accurate diagnosis today at Nick Rinard Physical Therapy.
“I experienced numbness in my pinkie and ring finger on both hands.
I had shoulder pain, especially when doing chest exercises.
Thoracic Outlet Syndrome.
The numbness in my finger has gotten better.
My shoulder pain is gone.
I can do chest exercises now without pain.”
Gordon
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By Krissy Brown
12 Nov, 2024
Clinical Case of the Week, Exercise
exercise, injured, Nick Rinard, Nick Rinard physical therapy, Oregon, pain-free, Portland Oregon, thera-band, treatment
A Nick Rinard Physical Therapy patient emphasizes the importance of health and fitness in the the demanding role of a firefighter.
His home exercise plan is so convenient he can do it while he works!
Thank you for your service and courage you give to the community.
Thank you for sharing your Nick Rinard Physical Therapy story!
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We can get you back to walking, exercising, running, enjoying your sport again….
“I had horrible knee pain that was keeping me from being a mobile as I wanted.
Even just going up and downstairs even hurt.
Dr. Rinard was amazing- best PT experience I’ve ever had.
Exercises were easy to do + only had once/week appointments after the first week.
I can no go down stairs with no pain, one legged lunges without pain, play tennis without pain, + do 5K walks or more without knee pain.
THANK YOU ALL!”
Marla
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“Nick and his team were very friendly and supportive. They worked miracles to give me the tools and information to keep me healthy. They explained everything they were doing and why they were doing it. I was unable to walk going to my first visit and after my session I was able to walk again. Highly recommend Nick and team.”
Ryan
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Today I’d like to discuss the topic of accountability. That which helps you with your home exercise program so that you receive the maximum benefit from your physical therapy. I sought the help of two people I know rarely miss a workout. They use different strategies. One I like to call the “Pregame Plan” and the other is “Dress for Success Method.”
The Pregame Plan:
Every evening Nick lays out his workout clothes so when he wakes up the next morning, he is already prepared to follow through with his exercise agenda. Nick prioritizes self-care by getting his work out done before his work day begins so that he can benefit from the energizing effect of exercise throughout the day.
The Dress for Success Method:
After work each day, Erick changes out of his office attire and into his workout clothes. He allows himself an hour to decompress before heading to the gym. However, because he is already wearing his workout attire, he is prepared to follow through with exercise that day rather than surrender to the couch. Erick also organizes his workouts with his housemates, and they hold each other accountable by asking how each other’s workouts went that day.
What strategies do you use to help you remember to take good care of yourself? Are you more of a Pregame Planner or Dress for Success? Do you have a different method all together? Let us know what is helping you succeed with your accountability.
Margo Burette DPT
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