Knee Pain: What’s Driving the Pain?

Published in the Massage & Myotherapy Journal, Volume 19, Issue 3, Spring 2021

Author, Rob Orr

Introduction

When a client presents with acute or chronic knee pain the first thing we need to consider is it the actual knee that’s driving the pain or is it coming from somewhere else. Also was it trauma or non-trauma related? If the knee pain coincided with a traumatic episode then more likely its coming from the knee, if its chronic is it altered biomechanics driving the pain? Is it a local knee obstruction that’s driving the pain (McKenzie & May 2003, Rosedale 2014)? Or is there nothing wrong with the knee and the pain is being created from a proximal region like the hip (Dr Bruce Mitchell), lumbar spine (Rosedale et al 2020) or SIJ (Dr Mark Laslett 2008). Is it a red flag masquerading as knee pain?

Why should you examine the lumbar spine, well there are two reasons why. First of all in 1991 Dr Kuslich and his colleague’s published a paper on the tissue origin of low back pain involving 193 patients. 17 different tissue types of the lower back was stimulated for a painful response through blunt force and electrical stimulation, the most common tissue type that caused pain was the disc (66-72%).

Secondly Richard Rosedale and his colleague’s published a paper in 2020 called EXPOSS (extremity pain of spinal source), this study comprised of 322 patients with isolated joint pain of the upper and lower body. Out of the 322 patients 181 of them there symptoms were spinal based and 81% had no spinal symptoms. So the moral of the story is clear the spine!

Summarising the above is it the knee? Lumbar spine? SIJ? Could it be a combination? Or is it a serious spinal pathology presenting as a mechanical source of pain (serious spinal pathology’s are out of the scope of this article as this article will focus on mechanical pain. But Ill quickly mention that serious spinal pathology presents >1.8% of the population (McKenzie & May 2004), even though this is a low statistic its always essential that you clear Red Flags by taking a thorough history. Is it a serious pathology involving a local tumour like a Osteosarcoma or a Ewing’s sarcoma in the distal femur or mid femur region? I think its important prior to continuing this article that we address the signs and symptoms and the most common age group that could present with an Osteosarcoma or a Ewing’s sarcoma presenting as knee pain. An Osteosarcoma is a bone cancer that most often presents in the long bones like the femur but can occur in any bone, it tends to occur in children and young adults and the symptoms are localised bone pain and inflammation. If this red flag is identified early and hasn’t spread the survival rate is high, so if your client in this age group presents with distal thigh pain with no history of trauma, no change or minimal change in range of motion, no position that eases the pain this needs to be ruled out via a plain film x-ray. Ewing’s sarcoma is an aggressive cancer that may spread to the lungs, other bones and bone marrow potentially causing life threatening complications, common age groups affected are children and young adults. So once again if the client presents with no history of trauma, no change or minimal change in range of motion, no position that eases the pain this needs to be ruled out via a plain film x-ray. The rest of this article will now focus on establishing whether the clients acute or chronic pain +/-  loss of motion is mechanical in nature, and whether it’s being produced by local structures of the knee, or proximal regions as in the lumbar spine or the SIJ.

Subjective Examination

Prior to the physical examination on questioning you should get clues from the client if there are any positions if that makes them better or worse. For example, better standing and walking (extension), worse sitting and bending forward (flexion). Or is the client worse standing  and walking, and better sitting. Even though this is only the start of the investigation these clues are important because your client is telling you what position makes them better or worse and its more likely mechanical pain! During the subjective examination I recommend that you change their posture while in a seated position by using a lumbar supporter or a towel rolled up into a sausage shape with a rubber band at each end to maintain the shape to promote a lordotic curve in their lumbar spine regardless of where the pain is presenting. This is a very important part of the examination as it will help you ascertain whether the spine is playing a role in the clients complaint regardless of where the symptoms are. I do this with every client and I’m still blown away with the results this achieves regarding establishing where the pain is coming from. Usually you will know if the spine is involved within 3 minutes or sooner as the clients symptoms will either improve or at times completely abolish, if the symptoms get worse this also informs you that the spine is involved.

Physical Examination

The first part of the physical examination will consist of a static postural check looking for signs of altered biomechanics then functional testing looking for altered movement patterns that could be contributing to the clients symptoms, this could be in the form of sit to stand, squats, lunges, single leg squat or other specific movements. From here it’s now time to isolate the knee and test active, passive and resisted (if applicable) range of motion in a supine position or whatever position you prefer. Is there pain during motion? End range pain only? Or is the motion obstructed and the client can’t get to end range +/- pain. The order of functional testing versus isolated testing doesn’t really matter unless the clients symptoms are highly irritable and if this is the case start with isolated testing and progress from there, orthopaedic testing would follow if applicable. Now you can’t examine everything in the first session as you need to treat as well but it is important that the knee, hip and lower back are all tested for a comprehensive examination. Also its important to note that If the pain is constant its more likely that the pain is chemically driven and If the pain is intermittent its more likely that the pain is being driven by mechanical sensitivity of that specific tissue/s, or coming from somewhere else like the lumbar spine.

Differential Diagnosis

The D/D’s will be based on all the information you have gathered so far from the medical history, subjective and objective examination. The most common D/D’s I come across are; (1) local knee obstruction (McKenzie & May 2003, Richard Rosedale 2014) (2) Discogenic +/- lower back pain (McKenzie & May 2003, Richard Rosedale et al 2020) (3) Patella Femoral Pain (Farina 2021) (4) Patella Tendinopathy (Rio 2017, 2019). In the past four to six months I have treated a lot of knee complaints with successful outcomes where the majority of the them were knee obstructions or lumbar spine related.

Discussion

The history of the client combined with the above physical examination should help you clinically assess: (1) Red and Yellow Flags. (2) Which structures are more likely involved. (3) Which structures are less likely involved. (4) Is there an injury leading to chemical sensitivity in the form of inflammation. (5) Is it more mechanical pain due to the tissue being structurally compromised. (6) Is there evidence of a joint obstruction. (7) Is it non mechanical in origin. If the clients history indicates that a sustained position or a repeated movement of the knee in a specific direction rapidly reduces their pain and significantly improves their range of motion this is more likely a local joint obstruction. If the client presents with knee pain in the clinic and you change their posture to more of a lordotic posture while seated and their knee pain subsides, abolishes or gets worse this is strong supportive evidence that the lumbar spine is involved, and the most common structure to cause this is the disc. If the client points directly to the tendon with a supporting history of the pain never changing locations and worse first thing in the morning this supports a patella tendon pathology.

Summary

If your client displays a rapid improvement in their knee with a sustained position or a repeated movement in a specific direction it is more likely that something is obstructing the knee joint leading to the pain. If the client displays a rapid improvement in their knee symptoms by performing repeated movements of the lumbar spine in a specific direction its more likely that the disc is involved. Always be aware that the hip and sinister pathologies can also cause knee pain.

Bibliography

1. McKenzie R, May S 2004, The Lumbar Spine Mechanical Diagnosis & Therapy volume one, Spinal publications Waikanae, New Zealand.

2. McKenzie R, May S 2004, The Lumbar Spine Mechanical Diagnosis & Therapy volume two, Spinal publications Waikanae, New Zealand.

3. Laslett M 2008, Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint, Journal Manual Man Therapy 16:3:142-152.

4. Kuslich et al 1991, The Tissue Origin of Low Back Pain and Sciatica: A report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia, Department of Orthopaedic Surgery, University of Minnesoda, America, Vol 22. No 2 April 1991.

5. Rosedale et al 2020, A Study Exploring the Prevalence of Extremity Pain of Spinal Source, J Man Manip Ther.

6. Farina et al 2021, Meniscal and Mechanical Symptoms Are Associated with Cartilage Damage, Not Meniscal Pathology, Journal of Bone Joint Surgery.

Posture vs Non Ideal Posture While Seated In Relation to Lower Back Pain, Does it Matter?

Published February 2021

AUTHOR, ROB ORR

Hello my name is Rob Orr I am a Clinical Myotherapist and a Credentialed McKenzie Therapist specialising in Mechanical Diagnosis and Therapy (MDT), and also the treatment of these conditions which includes hands on therapy and corrective exercises/stretches.

I have been a Clinical Myotherapist for 19 years, and a Credentialed MDT therapist for four years. I also have a sports science background and a postgraduate background in musculoskeltal pain management.

The topic I would like to talk about today is “posture versus non ideal posture when in a seated position”. My question to you is does it matter? Some people say yes and some people say no. I say yes it does matter, maybe not for everyone but the majority in my experience. Approximately 70% of the clients that I see in my clinic that present with lower back pain with/without radicular pain, neck pain with/without radicular pain display a rapid and significant difference for the better when changing their posture while in a seated position.

Over the past four years regardless of the clients complaint whether its spinal or non spinal based, I always change the load to their lower spine from a kyphotic siting posture (sitting in a slumped position) to a lordotic sitting posture (sitting upright) while I’m conducting the subjective examination during the initial consultation. I use an ergonomic aid in the form of a lumbar roll, or a rolled up towel in the shape of a sausage with a rubber band placed at each end so to maintain this shape, and believe it or not within one to three minutes 70% (approximately) of these clients pain/discomfort improves significantly, and at times within seconds! Also on occasions the clients pain/discomfort is completely abolished while maintaining this position. So you cant tell me that posture doesn't matter when sitting! Especially if you sit or long periods of time.

If your wandering why I do this with every client regardless of their signs and symptoms it is because 43.5% of extremity pain has shown to have a spinal source whether its primary or secondary (Rosedale et al 2020). This study exploring the prevalence of extremity pain of spinal source was conducted in 2017 and the results were published in the Journal of Manipulative Therapy in 2020.

Even though there has not been any specific scientific research on this exact topic there is certainly plenty of literature out there on ideal spinal biomechanics versus non ideal spinal biomechanics, regarding the load on the hard and soft musculoskeletal structures when sitting slouched  (kyhphotic posture) versus sitting in an erect (lordotic posture) concerning lower back pain with or without radicular pain. 

There is also electromyographic studies out there looking at the firing patterns of the trunk muscles when sitting in a slouched position versus sitting in an erect position. These results indicate that co-contraction of the trunk muscles during sitting with ideal posture could bring about the correct lumbar curvature, effectively stabilise the lumbopelvic region and decrease focal stress on passive structures.

Dr Andrea Bernini has shown that the thoracolumbar fascia is a sensory organ in the form of a 3D fascial webbing that is highly sensitive to chemical stimulation and is rich in nerve innervation consisting of mechanoreceptors and nociceptors. Now remember that there are a lot of soft tissue structures that join to the thoracolumbar fascia at different depths, so poor posture when seated could certainly alter the length tension relationship of this tissue that could also lead to pain. Bernini also believes that the thoracolumbar fascia is more responsible for lower back pain over muscle due to its rich innervation.

Also there is epidemiological data that link disc herniation with sedentary occupations and sitting posture (Videman, Nurminen, and Troup, 1990).

Further studies conducted by Professor Stuart McGill found that repeated lumbar flexion with simultaneous compression was the easiest way to herniate the disc. What was interesting it was the repeated lumbar flexion motion that was more damaging to the disc over the compression loads. So even though in a seated position you are not doing repeated lumbar flexion but you are placing your lower spine in sustained flexion (kyphotic posture) and at the same time sustained compression. Sustained lumbar flexion and repeated lumbar flexion can cause the nucleus pulposes (the substance inside the disc) to migrate posterior and posterior laterally leading to a disc bulge that can most definitely result in lower back pain and radicular pain. Kulish et al published a paper in 1991 on tissue origin of lower back pain and sciatica and their results clearly indicated that the disc was the most common source of lower back pain and sciatica out of 17 different tissue types tested.

In summary due to the evidence presented and in my clinical experience on this chosen topic “does ideal posture versus non ideal posture matter when in a seated position” I strongly believe it does.

Thank you

Rob Orr

BIBLIOGRAPHY

1. McKenzie R, May S 2004, The Lumbar Spine Mechanical Diagnosis & Therapy volume one, Spinal publications Waikanae, New Zealand.

2. Kuslich et al 1991, The Tissue Origin of Low Back Pain and Sciatica: A report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia, Department of Orthopaedic Surgery, University of Minnesoda, America, Vol 22. No 2 April 1991.

3. Donelson R,  Grant W, Kamps C, Medcalf R Spine 1991, Vol 16. Pain Responce to Sagittal End Range Spine Motion. A Multi-centered, Prospective, Randomized Trial; pp.S206-S212.

4. Watanabe S, Eguchi A, Kobara K, Ishia H, Influence of trunk muscle co-contraction on spinal curvature during sitting reclining against the backrest of a chair, Dpartment of rehabilitation, Faculty of Health Science and Technology, Kawasaki University of Medical Welfare.

5. McGill, S 2002, Low Back Disorders Evidenced based prevention and Rehabilitation, University of Waterloo, Canada.

6. Harrison DD, Harrison SO, Croft AC, Harrison DE, Troyanovich SJ, 1999,  Sitting Biomechanics Part 1: Review of the literature, J Manipulative Physiol Ther. USA.

7. Harrison DD, Harrison SO, Croft AC, Harrison DE, Troyanovich SJ, 2000, Sitting Biomechanics Part 2: Optimal Car Drivers Seat and Optimal Drivers Spinal Model, J Manipulative Physiol Ther. USA.

8. Makhsous M, Lin F, Hendrix RW, Hepler M, Zhang LQ, 2003, Sitting With Adjustable Ischial and Back Support: Biomechanical Changes, Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois 60611, USA.

9. Williams MM, Hawley JA, McKenzie RA, Van Wijmen PM, 1991, A Comparison of the Effects of Two Sitting Postures on Back and Refereed Pain, School of Physiotherapy, Faculty of Health Studies, Auckland Institute of Technology, New Zealand.

10. Videman, T, Nurminen, M, Troop, J.D.G, 1990, Lumbar Spinal Pathology in Cadaveric Material in Relation to History of Back P, Occupational and Physical Loading. Spine 15 (8): 728.

11. Rosedale, R, Rastogi, R, Kidd, J, Lynch, G, Supp, G, Robbins, SM 2020, Extremity Pain of Spinal Source, J Man Manip Ther, 2020.

12. Stecco, C, 2015, Functional Atlas of the Human Fascial System, University of Padua, Italy.

Lumbar Intervertebral Disc vs Sacroiliac Joint: Where is the pain coming from?

Published February 2020

Author, Rob Orr

Sometimes it can be confusing establishing whether it is a disc of the lumbar spine or the sacroiliac joint (SIJ) causing the client’s unilateral lower back pain, SIJ pain and associated buttock pain. What about when the client tells you that they also have referred pain into the groin and anterior thigh region, and on testing displays major losses in lumbar range of motion as well? There will of course be times where the client only presents with lower back pain and major losses of motion, or pain directly over the SIJ and nowhere else with major losses of motion.

Is it a lumbar disc? Is it the SIJ? Could it be a combination? Or is it a sinister pathology presenting as a mechanical source of pain? Sinister spinal pathologies (red flags) and psychosocial matters (yellow flags) are out of the scope of this article as it will focus on acute mechanical pain. ‘Serious spinal pathology presents in <1.8% of the population.’1 Even though this is a low statistic it is always essential that you clear ‘red flags’ by taking a thorough history! It is also important to clear yellow flags, especially if the pain has been chronic. The hip joint as a differential diagnosis hasn’t been included here as this article’s main focus is the lumbar spine and SIJ.

Theory

The focus of this article is to help the clinician establish whether the client’s acute pain and major losses of motion are mechanical in nature, and whether they are being produced by a lumbar disc or the SIJ.

An evidence-based and scientific approach will be applied in the form of the McKenzie Method (2) (repeated movement of the spine in a specific direction) to help the clinician to rule in/out a lumbar disc derangement (joint obstruction; also known as a posterior disc bulge, posterior lateral disc bulge, disc prolapse, disc protrusion or slipped disc). ‘Using the McKenzie system assessment for discogenic pain had a sensitivity of 94 per cent and specificity of 82 per cent.’(1) Kappa values measuring the reliability of the McKenzie Method when applying this assessment technique to the lumbar spine were measured at 0.70 and 0.84 (on a scale of 0.0 to 1.0).(1) Dr Mark Laslett’s protocol for testing the SIJ will also be covered. He found that the McKenzie Method combined with a specific cluster of SIJ provocation tests showed excellent sensitivity and specificity values for the diagnosis of SIJ related pain.(3)

Due to the high prevalence of positive SIJ pain provocation tests in clients with discogenic pain, Laslett used the McKenzie Method to rule in/out lumbar derangement. If the subject’s pain centralised or showed a clear direction preference during the spinal assessment they were eliminated from his study, and once eliminated the diagnostic accuracy of the SIJ pain provocation tests increased significantly.

Let’s quickly address why you should examine the lumbar spine first for any involvement during the physical examination. In 1991, Dr Kuslich et al published a paper on the tissue origin of low back pain involving 193 patients.(4) Each patient had 17 different tissue types in their lower back stimulated for a painful response through blunt force, and electrical stimulation. The most common tissue type that caused pain was the disc, and to be precise, it was the outer layer (annulus fibrosis) of the disc. Always clear the spine!

Note that the disc can be its own entity of local pain and can refer to multiple sites with no spinal nerve-root involvement. If there is associated pain below the knee it is more likely that the spinal nerve root is involved.(4) The most common source of a spinal nerve root compression is a bulging disc.

In regards to the SIJ, clients may say that they have been told they have SIJ instability; this is unlikely to be the case as the range of movement of the SIJ is ‘less than four degrees of rotation and up to 1.6mm of translation.’(3) Laslett cited the work of Sturesson, who found that in patients presumed to have an SIJ source of pain, there was no difference in range of motion between symptomatic and asymptomatic sides.(3) There is the exception of course with pregnancy-related SIJ pain, pregnancy-related pelvic girdle pain (PGP), and history of trauma.

When it comes to testing the SIJ, there are certain tests that have poor inter-examiner reliability and lack a reference standard for measuring SIJ dysfunction. So the ‘validity of these tests for this disorder is unknown.’(3) Additionally, asymmetry and fusion are common findings in those without pain. ‘Pain provocation tests have acceptable inter-examiner reliability with an acceptable reference standard.’(3) However, used in isolation they do not (Kappa values for three or more positive tests have proven to be higher than a single positive test). This article will focus on reliable and valid methods of testing the SIJ, and specifically which SIJ tests to combine to increase the sensitivity and specificity of the examination. The McKenzie Method will then be incorporated to rule in the lumbar spine (disc) or help clear the lumbar spine of any involvement.

Subjective examination

On questioning (after ruling out ‘red flags’, including fracture) you should get some clues from the client concerning what position, if any, makes them better. For example, better standing (extension) and walking (extension), worse sitting (flexion) and bending forward (flexion). Or is the client worse standing and walking, and better sitting. Even though this is only the start of the investigation these clues are important because your client is telling you what position makes them better!

Objective examination

The first part of a physical examination will consist of a postural check looking for any signs of a lateral shift, a lack of lumbar lordosis, or a kyphotic deformity of the lumbar spine.

The second part of the examination will focus on the client’s lumbar spine, looking at range of motion and associated pain/s.

The third part of the examination will focus on the SIJ. Four specific SIJ pain provocation tests will be applied consecutively:

(1) Iliac Distraction also known as the Gapping Test

(2) Posterior Shear also known as Posterior Thrust Test

(3) Side lying Compression Test

(4) Gaenslen’s Test also known as Pelvic Torsion Test.

If the client is positive with three out of the four SIJ pain provocation tests in the absence of the client’s pain centralising (distal pain moving towards the midline of the spine), the validity of the tests markedly increases.(3)

The fourth part of the examination is to apply the McKenzie Method, consisting of repeated movements in a specific direction aiming to get to end range. If the client’s pain does not centralise when applying the McKenzie Method, the probability of having SIJ pain increases.(3)

Now remember this is only the case if the client’s pain and symptoms do not centralise. To clarify, three out of four SIJ tests need to be positive, meaning that the client’s pain is reproduced during the examination. In conjunction with this the McKenzie Method needs to be included to rule out a lumbar derangement.(3)

The fifth and final part of the examination is re-testing the SIJ and lumbar spine with the same tests to establish if the condition is the same, better or worse after the McKenzie assessment. Prior to re-testing, ask the patient if their location of pain has moved towards the midline (centralising)? Has the pain disappeared from one area and gone to another? These are all important clues. When re-testing the client’s lumbar spine range of motion is there still pain associated with those movements? Can the client move further into range comfortably? When re-testing the SIJ are all three or four tests still positive? If unsure, repeat procedures two to five again.

If the client’s pain starts to centralise during the McKenzie Method, it is more likely that the pain is discogenic in nature and not the SIJ. If this is the case, you should also notice a significant improvement in lumbar range of motion. ‘Centralisation can be reliably evaluated and has been shown to be a significant prognostic factor; its presence is associated with good outcomes.’(1)

Discussion

The history of the client combined with the above objective examination should help you clinically assess: (1) red and yellow flags; (2) which structures are more likely involved; (3) which structures are less likely involved; (4) whether there is an injury leading to chemical sensitivity in the form of inflammation; (5) if the pain is mechanical due to the tissue being structurally compromised; (6) if there is evidence of a derangement (joint obstruction); (7) if the pain is non-mechanical in origin.

So in the history if the client displays either a sustained position or a repeated movement that rapidly reduces their pain, it is more likely a derangement of a lumbar disc or SIJ. Something is obstructing the joint leading to pain. If the pain is constant, it’s more likely that the pain is chemically driven. If the pain is intermittent, it’s more likely that the pain is being driven by mechanical sensitivity of that specific tissue/s. If the client displays a significant improvement in range of motion as well, this is more supporting evidence of a derangement. If the client’s pain shows signs of centralising, this is further evidence that a lumbar disc is involved.

Now if the client’s pain rapidly subsides with either repeated hip flexion (posterior torsion of the SIJ) or repeated hip extension (anterior torsion of the SIJ) without signs of centralising, it’s more likely that the SIJ has been deranged. This should also be supported by a significant improvement in lumbar range of motion on retesting. So once you have ruled out the lumbar spine it should be a lot clearer if the SIJ is involved. These are all clues that will help you with your working diagnosis supported by scientific evidence. Also please remember that the examination is not just about ruling in which structures are involved, but most importantly which structures are not involved.

Summary

If your client displays a rapid improvement in their symptoms with a sustained position or a repeated movement into a specific direction, it is more likely that something is obstructing (deranging) the joint leading to pain. Also, if the client’s symptoms centralise this is even more supporting evidence that a derangement (disc bulge) of the lumbar spine is more likely.

If the client’s symptoms rapidly improve with unilateral repeated movements of the hip with no signs of centralising, it is more likely to be a derangement of the SIJ.

It’s not always this straightforward, and you will get some complex cases, but this approach should help guide you through your investigation.

CASE STUDY

I would like to finish with an informal case study involving myself to give you an example of how this system works. On Sunday 2 February 2020 during a heavy weight training session I experienced sharp and dull left-sided lower back pain, pain over the sacroiliac region, sharp catching pain when getting up or down, left groin pain, and shooting pain into the left anterior thigh. The pain was constant and was rated 8/10 on the pain scale, and I was unable to walk or stand for two days due to the pain. No pain or altered sensation was felt below the knee at any point. Was it a lumbar disc or SIJ?

On day one of the injury I only felt a reduction in pain with sitting in flexion, and then a further reduction in my pain when placing my hip in maximal flexion. The 8/10 pain was rapidly reduced to 2/10 then 0/10 within 10 minutes of injuring myself, while in this position. With this rapid and significant reduction of pain I thought it was more likely to be a derangement of the lumbar spine or the SIJ. The chance of a serious spinal pathology like a fracture was unlikely due to these sudden changes for the better. It was less likely to be inflammation due to tissue damage because my constant pain changed to intermittent pain then completely disappeared as soon as I found a specific position.

On day two of the injury I used the McKenzie Method to help classify my condition so I could start my rehabilitation as soon as possible! I couldn’t use Laslett’s SIJ testing protocol as I was on my own, but I knew I could use the McKenzie Method to rule in/out other conditions. The clues at this point: I was worse with standing (extension) and walking (extension), and better with sitting (flexion) and my hip placed in end range flexion. Another important clue was that my pain didn’t centralise, it reduced, then just disappeared within 10 minutes.

So the evidence was strongly indicating that my SIJ was responding to a direction preference for flexion. The more ideal term for the SIJ would be posterior torsion, but let’s refer to this as flexion to keep it simple. From the evidence presented I proceeded with repeated supine bilateral hip flexion x 10–15.

On re-testing my pain had reduced and my range of motion also improved, not significantly but there was an improvement. This indicated to me that I was heading in the right direction. I then proceeded with supine unilateral hip flexion x 10–15 aiming to get to end range. During the last couple of repetitions the pain was minimal to none, and I was able to get my hip to end range. This made me believe it was more likely to be a derangement of my SIJ that was displaying a direction preference for repeated hip flexion.

My clinical reasoning for this was

(1) Repeated supine bilateral hip flexion reduced my pain and increased my mobility, but this was a minimal change (also I did not feel my pain centralise)

(2) Repeated supine unilateral hip flexion that involves more motion of the SIJ into flexion caused a rapid and significant reduction in pain, and a significant increase in lumbar range of motion.

(3) I was also able to stand and walk for a longer period of time with minimal pain.

So for the next three to four days I did 10–15 repetitions every 1–2 hours.

Within four days of the injury I was back to boxing, within six days I was back to modified weight training. Within eight days of the injury I was back to lifting heavy weights over my head again, including Olympic lifting!

This is an example of how efficient the McKenzie Method is in helping the therapist to establish where the main pain is coming from, and how fast I was able to get back into heavy lifting and training following the McKenzie protocol. This is a pretty good result after not being able to walk or stand for two days.

References

1. McKenzie R, May S. The Lumbar Spine Mechanical Diagnosis & Therapy volume one. Spinal publications Waikanae, New Zealand; 2004.

2. McKenzie R, May S. The Lumbar Spine Mechanical Diagnosis & Therapy volume two. Spinal publications Waikanae, New Zealand; 2004.

3. Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. Journal Manual Therapy. 2008; 16:3:142-152.

4. Kuslich et al. The Tissue Origin of Low Back Pain and Sciatica: A report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia. Orthopedic Clinics of North America. 1991, April;22(2):181-7.

Bibliography

Sturesson B 1999, Load and Movement of the Sacroiliac Joint, PhD thesis, Lund University, Malmo, Sweden.

Laslett M, Williams M 1994, The Reliability of Selected Pain Provocation Tests for Sacroiliac Joint Pathology. Spine 1994;19:1243-49.

Laslett M, Young SB, April CN, McDonald B 2003, Diagnosing Painful Sacroiliac Joints: A Validity Study of a McKenzie Evaluation and Sacroiliac Joint Provocation tests. Australia Journal Physiotherapy. 2003;49:89-97.

Aina A, May S, Clare H 2004, The Centralization Phenomenon of Spinal Symptoms: A Systematic Review. Man Ther. 2004;9:134-143.

Donelson R, April C, Medcalf R, Grant W 1997, A Prospective Study of Centralization of Lumbar and Referred Pan: A Predictor of Symptomatic Discs and Annular Competence. Spine. 1997;22:1115-1122.

Donelson R, Grant W, Kamps C, Medcalf R Spine 1991, Vol 16. Pain Responce to Sagittal End Range Spine Motion. A Multi-centered, Prospective, Randomized Trial; pp.S206-S212.

Wetzel FT, Donelson R 2003, The Role of Repeated End-Range/Pain Response Assessment in the Management of Symptomatic Lumbar Discs. Sopine J. 2003;3:146-154.

Dreyfuss P, Dryer S, Griffin J, Hoffman J, Walsh N 1994, Positive Sacroiliac Screening Tests in Asymptomatic Adults. Spine. 1994;19:1138-1143.

Sturesson B, Selvik G, Uden A 1989, Movements of the Sacroiliac Joints: A Roentgnen Strereophotogrammetric Analysis. Spine. 1989;14:162-165.

McKenzie RA 1981, The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, NZ: Spinal Publications Ltd; 1981.

May S, Aina A 2012, Centralisation and Direction Preference: A Systematic Review, Manual Therapy. Doi. 10.1016/j.math.2012.05.003.

About the Author

Rob Orr, Cred. Mechanical Diagnostic Therapy, Post. Grad. MSK, Adv. Dip. Myotherapy, Dip. App. Sports Studies, Cert IV Personal Training.

Rob is a Credentialed McKenzie Therapist & Clinical Myotherapist with 18 years clinical experience in private practice specializing in the diagnostics of musculoskeletal pain including sports injuries, spinal pain, disc pain and sciatica.

Rob also lectures at Victoria University and runs private workshops for other allied health professionals around Australia. If you would like to make an appointment to see Rob or have a query, please click this link