Do you suffer from shin splints?
Plantar fascia pain (heel of your foot)?
Achilles pain in one or both legs?
Pain in the knee or shoulder that is not improving with treatment?
Pain in your elbow that does not improve with hands on therapy?
It is quite amazing how these seemingly persistent problems have a simple mechanical solution. And it is surprising how often the cause of the problem is spine, even when there is no local back or neck pain as the clue!
A recent study by Abady and Rosedale (2016), showed over 1/3 of patients with shoulder pain had a relevant neck component. These were patients presenting with a shoulder complaint, with pain on shoulder movement and pain locally over the shoulder joint. After undergoing an assessment using the McKenzie Method (also known as Mechanical Diagnosis & Therapy or MDT), repeatedly moving the neck rapidly resolved the apparent shoulder complaint.
Another study of patients with knee pain (new study out of Japan presented at Copenhagen 2015 McKenzie Conference) found a staggering 57% of knee pain patients resolved with mechanical loading strategies for the lower back!
Clinically I see this every day, and I would estimate that the % of patients whose problem appears like a local joint problem but proves to come from the spine is close to 50%!
It is for this reason that the research proven MDT assessment of local joint problems recommends screening the spine as the number 1priority on day 1 of any musculoskeletal problem:
MDT Extremity Algorithm Cited in Aytona and Dudley, 2013
How do I know if my problem is coming from the spine?
Getting a thorough mechanical evaluation from a fully qualified McKenzie practitioner is ideal, but as a quick check for you to figure out if the spine is relevant to your problem there is a quick way to test it (note this is clearly not as effective as a proper MDT evaluation)
If you have a lower limb problem, for example:
- Shin splints
- Knee pain
- Plantar fascia pain
- Foot pain
- Hip pain
Choose 2-3 activities that produce you pain that you can easily do now, like a squat, jump, sprint or maybe even walking.
Now to determine if your lower back is contributing to your problem try the following exercise, extension in lying x 10-20 repetitions:
Extension in lying:
Immediately recheck to see if your painful activity has changed. If it has at minimum the spine is a significant component of your problem!
Similarly, if you have an upper limb problem such as:
- Elbow pain
- Shoulder pain
- Wrist pain
- Hand pain
Perform 2-3 activities that produce you pain that you can easily do now, like gripping an object, doing a push up, lifting your shoulder out into its painful range of movement.
Now to determine if your neck is contributing to your problem try the following exercise, Retraction and Retraction-Extension x 20 repetitions:
Retraction and Retraction/Extension in Lying:
Immediately recheck to see if your painful activity has changed. If it has at minimum the spine is a significant component of your problem!
How can a joint problem come from the spine if I don’t have pain in my back or neck?
Whilst the exact mechanism cannot be proven for most people, referred pain is common.
Our brain is not great at identifying the source of the problem, and aching can be felt at a site very distant from the actual location of the problem.
Just look at the common sites of referral from the neck (taken from McKenzie’s Treat Your Own Neck book):
Treat Your Own Neck by Robin McKenzie (third edition, 2010)
These referred arm and shoulder symptoms are common, and when there is local neck pain the neck is suspected by most practitioners. But when the pain is only felt in the elbow, shoulder or wrist without the neck and shoulder blade pain the spine is frequently overlooked.
Most people understand that the lower back can cause leg pain, frequently referred to as sciatica.
Again, these referred symptoms are common, and the public appears to be more familiar with these. However, when the pain is localised to the knee, or foot or Achilles, again the spine is usually overlooked by the treating practitioner.
One explanation may be that the nerve in the lower limb or upper limb is being ‘trapped’ by a local problem such as a disc bulge. And pain can be felt anywhere along the length of the nerve.
Just look at the path of the nerve in the lower leg, and you can see that branches of it supply the Achillies, knee and heel.
And in the upper limb the nerves go through the shoulder, into the elbow, wrist and hand.
Some common examples:
These are some of the problems I see most often, and they are certainly not rare.
Shoulder pain that comes from the neck
- These are common! And they can truly sound like are coming from the shoulder, being painful to lie on and often present with painful limited shoulder movement
- More likely in the presence of neck and shoulder blade symptoms, or even just a stiff neck or in the person with a previous history of neck pain
- Frequently they occur in those with sitting jobs, where a combination of frequent slouched sitting and looking down to read is the main cause of the problem developing
Shin Splints:
- In the person with shin splints who also has a sore or stiff back, or a history of back pain this is very likely spine referred
- Especially when the pain is in both shins, the likelihood of the spine being the origin of the problem increases
- Whilst being felt with activities like running, if the spine is implicated it is the slouched sitting at work that often causes the problem to develop
- A quick test of the spine as outlined earlier can help you determine if your shin splints are coming from a spine problem
Achilles pain:
- In the person with Achilles symptoms who also has a sore or stiff back, or a history of back pain this is very likely spine referred
- Especially when the pain is in both Achilles, the likelihood of the spine being the origin of the problem increases
- Whilst being felt with activities like running, if the spine is implicated it is the slouched sitting at work that often causes the problem to develop
- A quick test of the spine as outlined earlier can help you determine if your Achilles symptoms are coming from a spine problem
Plantar-fascia (heel pain):
- In the person with heel symptoms who also has a sore or stiff back, or a history of back pain this is very likely spine referred
- Especially when the pain is in both feet, the likelihood of the spine being the origin of the problem increases
- Whilst being felt with activities like walking, if the spine is implicated it is the slouched sitting at work that often causes the problem to develop
- A quick test of the spine as outlined earlier can help you determine if your heel symptoms are coming from a spine problem
Clear the spine, it only takes a few minutes!
Given how frequently the spine mimics other joint problems, it seems poor to me that is it missed in many people with joint problems. I see many patients that have been treated endlessly without benefit and then a quick screening of the spine reveals the source of the problem.
Assessing the spine by a qualified McKenzie practitioner should always be the starting point for any extremity joint problem or apparent lower limb or upper limb soft tissue complaint. In most cases the spine can be screened in 2-3 minutes, and when there is a high suspicion of a spinal source testing spine movements over 24-48 hours usually clarifies if it is indeed relevant.
Benefits:
- It takes only a few minutes and may save weeks and months targeting the wrong source
- It is a low cost, efficient way to rule in out rule out the spine as the source of your problem
- If the problem is from the spine, it can usually be rapidly reversed with simple direction specific exercises
- Expensive imaging is rarely required, and you may not be imaging the correct source if the problem is coming from the back or neck and not the local joint
Don’t forget, the spine is the master of disguise!
By Joel Laing
Melbourne CBD Physio and specialist in the McKenzie Method
To get an accurate diagnosis and quickly determine whether the solution to your problem lies in the spine or in the local joint/tissue come in and see our Melbourne CBD Physio Joel Laing, who has a Diploma in the effective, efficient McKenzie Method.
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References:
Abady, H. and Rosedale, R. (2016). Application of the MDT system in patients with shoulder pain (In press, presented in 2015 in Copenhagen at McKenzie International Conference).
Hirokado and Hashimoto. Clinical Usefulness of MDT Classification system in Japanese Knee pain patients (In press, presented in 2015 in Copenhagen at McKenzie International Conference).
Aytona, M. and Dudley, K. (2013). Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. Journal of Manual & Manipulative Therapy, 21(4), pp.207-212.
McKenzie, R. (1983). Treat your own neck. Waikanae, N.Z.: Spinal Publications.
