Clinical Conversations

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.



Side Glides on the Wall – Rapid Recovery of Ipsilateral Shift

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


From Knee Injury to Half Marathon Completion in 3 weeks

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!


To those injured in this terrible Boston marathon tragedy

Building in Boston, MassachusettsOur hearts go out to the survivors and the families of victims at the Boston marathon explosion…

Please pass on the word around town:  MDT Physical Therapy will treat any of the Portlanders (OR) who were injured in this terrible Boston marathon tragedy at no out of pocket costs* to the athletes or their families in 2013.   Please call us at 503-244-6232  for full details & arrangements.

Our prayers go out to you…


*Valid for treatment started in 2013, up to 5 visits if patient has no/poor insurance benefits; proof of presence at the Boston Marathon required. MDT Physical therapy reserves the right to discontinue the offer at any time.