Big-Picture Practice: Thinking Outside the Painful Body Part
By Kevin M. Wong, DC
No matter what type(s) of technique(s) you practice, patients who come to see you can be broken down into presentation patterns. You have used your examination, diagnostic and treatment skills to know how to take care of people with success. In fact, the longer you are practicing, the easier it becomes to spot the type of presentation patterns our patients walk in with.
It is always encouraging when the patient who comes in with neck or upper back pain actually has the dysfunction contained within those areas. In other words, sometimes, "X" really does mark the spot, and if it walks like a duck and talks like a duck, it really is. Treating the area directly with your modalities and adjustments will work very efficiently within a few visits. Simple. Done. No problems.
Unfortunately, practice is not usually this easy. In fact, more often than not, the patient presents with pain in a particular location, but the major contributor comes from a related structure or structures located distally. It's the art of knowing when to look at body parts, even if they are not in pain. That's the big idea of this article. I want you to think outside the painful body part and see the big picture.
When It Seems Simpler Than It Really Is
1. A patient presents with classic, generalized lower back pain that can be chronic in nature and is usually located in the lower lumbar. This can occur to a male or female, young or old; anyone is susceptible. Pain is mostly localized, but it can be present in either sacroiliac joint and into the gluteal regions. The patient is either not sure how the pain began or was doing something mundane, like picking up a sock off the floor or making the bed.
The patient is astonished at how much pain he is in and how little he thought he did to cause it. Often the patient is confused and frustrated by having to take pain medication, anti-inflammatories or muscle relaxants. In some cases, the patient has had special imaging, which found mild to no arthritis and/or normal to slightly bulging lumbar discs.
2. A patient presents with knee pain on the anterior portion, medial portion or both. She describes the pain as sometimes being deep in the joint, almost "under" the kneecap. Most of the time, these patients have not had any traumatic cause of injury, and that is very perplexing to them.
The patient may have gone to the allopathic physician first, who told her nothing was wrong and that she should go see the physical therapist for help. She could be wearing an Ace bandage or a knee brace that may or may not be helping. She may have already had special imaging or even have had her knees scoped, ACLs replaced, or a total or partial knee surgery.
In both of these cases, the patient can report reduced or cessation of certain physical activities due to the increasing pain. Pain can also worsen with any type of weight-bearing activity.
Consider Patient Mindset
When these types of patients are coming in to you for help, try to remember their state of mind as they are sitting before you. Most of our patients have grown up going to traditional Western-medicine-type practitioners. They have been told to only go to the doctor when they are "sick." They have limited education of the body and are very focused on the painful area only.
You know better! You have the understanding that the biomechanics and the axial kinematic chain are vital components to a healthy body. It is our job to teach our patients how to understand their body and how the pain they are feeling is coming about. It could be a more widespread area that needs addressing, not just the one area that is painful. Here, "X" doesn't necessarily mark the spot.
Focus on the Big Picture
Of course, there is a portion or component of pain that actually comes from the lower back or the knees, depending on the case type as illustrated above. This is why some of these conditions remit rather quickly with good old-fashioned physiotherapy, adjustments and exercises at the targeted area.
But for many other types of pain that don't seem to remit in a timely fashion, I want to remind you of the axial kinematic chain and how it affects everything in the lower body. Whenever you have lower-back or any type of lower-extremity pain, please go right down to the feet and examine them. How do you do that? Let's recap.
For most patients, the three arches in the plantar vault of the foot collapse or fall toward the floor. This foot drop then puts pressure on the distal tibia, causing internal rotation. The inward rotation of the tibia creates a resultant inward rotation of the femur. Now the medial meniscus, medial collateral ligament and anterior cruciate ligament of the knee are stressed. This bony stress gives rise to soft-tissue strain in the anteromedial knee region.
Let's finish following the axial kinematic chain up to the pelvis. The inward rotation of the femur causes the pelvis to rotate anterior, translate forward and become unlevel, tipping down on the side of the inward femur rotation. Lateral curvature of the lumbar spine results, along with muscle hypertension, limited ROM and pain.
Thinking Outside the Spine
The following five indicators are quick ways of catching overpronation in your patients' feet. Foot flare, dropped medial arches, bowing Achilles tendons, lateral heel wear and medial patellae all reinforce the negative patterns that will put stress on the lower extremity and the lower back.
Not only do these indicators help you identify what types of stress or biomechanical patterns are present, but they also allow you to educate your patients so they understand them as well. These red flags are time tested and incredibly reliable instruments of arch collapse that I and many others use on almost every patient who walks in the office.
Back pain is one of the most common ailments we see in our office. Let your knowledge and skills with your lower extremities help you do a complete job in revealing all the factors that can be causing the patient's pain. After all, we are more than just back doctors. We are specialists in the spine and the articulations of the spine. Let's support our patients from the ground up.
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