A basic history and exam allow us to determine WHAT tissue was injured, and possibly WHY that tissue was predisposed to injury. But we will be only able to determine HOW an injury occurred by carefully listening to our patients. Complete resolution of symptoms requires an understanding of the HOW, WHAT, and WHY.
Watch Dr. Steele explain this thought process, and why it’s necessary for long-term practice growth.
Recently, Foroughi et al. (1) published a paper on alleviating Patellofemoral Pain Syndrome (PFPS) with rehab that includes postural control strategies. But even randomized control studies have limitations; and this paper highlights a futile error. Using this paper as an illustration, we will discuss the Good, the Bad, and the Ugly aspects of evidence-based care.
“Whenever you find yourself on the side of the majority, it’s time to pause and reflect.”
– Mark Twain
Peer-reviewed research is necessary for evidence-based practice. This Foroughi paper is well-written and provides valuable insight into rehab for anterior knee pain. The author defines PFPS by what sometimes is referred to as the “WHAT”- or ICD-10 code. To be reimbursed by insurers, we need to know how to recognize the involved anatomical tissue.
The authors also go one step further to understand the “WHY” by suggesting that the “lumbopelvic-hip complex” may play a role in PFPS. We know that hip abductor weakness is common in patients with PFPS. Accordingly, the authors expand on traditional rehab with the inclusion of appropriate postural training. (2-8)
“Training on an unstable seat apparatus, which eliminates the influence of lower body movements on balance control, may have potential benefits for enhancing core muscle neuromotor control. The dynamic challenges of unstable sitting balance require a combined feedforward-feedback strategy in the trunk musculature to maintain spinal stability and postural equilibrium. Under such conditions, a strategy of spine stiffening through pre-activated, low-level muscle coactivation along with continuous trunk muscle adjustments in response to unstable sitting perturbations are needed to maintain trunk postural control.” (1)
Defining “WHY” means determining the causative factors behind a specific diagnosis—core instability, hip abductor weakness, scapular dyskinesis, etc. The ability to recognize the “WHY” is a skill that separates great clinicians from their mediocre peers.
This paper, sometimes mirroring our busy daily practice, forgets to ask HOW an injury happens. Most clinicians stop diagnosing after determining the WHAT and the WHY and begin treatment. The HOW is the etiology behind the WHAT and the WHY. The article by Foroughi did not consider the mechanism of injury within the inclusion and exclusion criteria.
Individuals damage tissue in many ways including posture, repetitive stress, developmental abnormalities, and trauma. PFPS is usually the result of repetitive activity such as running or jumping. While muscle strengthening and postural control are essential treatment components, there is no mention of why PFPS injuries happen in the first place. If the injuries are from running, then a gait analysis must be performed to address for dysfunctional movement patterns. If the patient is a weightlifter with poor squatting technique, then strengthening in isolation will provide lasting relief for PFPS.
Asking the right questions and listening during the initial visit will shed light on the mechanism of injury and complicating factors. For example, chronic reoccurring diagnoses are different than acute onset injuries. (To learn more, check out this related past blog on differences in treating tendinitis vs. tendinopathy) Short-term alleviation of symptoms is easy once you have the correct diagnosis. Long-term resolution of a diagnosis takes listening to why a tissue failed in the first place.
“Listening is about being present—not just being quiet.”
– Krista Tippett
Chiropractors suffer from the public perception of continued lifetime care. While there is a benefit to lifetime care, it should not be from a single nagging diagnosis. Our goal in practice must be to provide a solution to a problem that patients want to buy, not one that you need to sell. Transitioning patients into practice “promoters” comes from delivering greater value than expected. You can’t get better at selling a product people don’t want to buy.
I propose that all chiropractors seek to understand the HOW, WHAT, and WHY before determining how you will treat them. Only once all three questions are answered will you have a chance of exceeding patient expectations. Without knowing the etiology, it is impossible to understand the specific ADL advice, rehab exercises, postural re-education, or self-treatment needed to ensure long term success.
The one marketing system that is not for sale: Attention to detail!
The good news for you is that as a ChiroUp subscriber you have access to the tools you need to evaluate & treat your patients in the most evidence-based & effective way—the only thing you have to do is listen! We are ecstatic to have you in our community and look forward to continuing to promote chiropractic care as the undeniable best choice for patients & payors alike.
- Forouzan Foroughi, Sobhan Sobhani, Amin Kordi Yoosefinejad, Alireza Motealleh, Added Value of Isolated Core Postural Control Training on Knee Pain and Function in Women With Patellofemoral Pain Syndrome: A Randomized Controlled Trial, Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 2, 2019, Pages 220-229,
- Cowan SM, Crossley KM, Bennell KL. Altered hip and trunk muscle function in individuals with patellofemoral pain. Br J Sports Med 2009;43:584-8.
- Almeida GP, Carvalho E Silva AP, Franc ̧a FJ, Magalha ̃es MO, Burke TN, Marques AP. Does anterior knee pain severity and function relate to the frontal plane projection angle and trunk and hip strength in women with patellofemoral pain? J Bodyw Mov Ther 2015;19:558-64.
- Willson JD, Davis IS. Lower extremity strength and mechanics during jumping in women with patellofemoral pain. J Sport Rehabil 2009;18: 76-90.
- Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Phys- iother 2009;55:9-15.
- Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther 2011;41:560-70.
- Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med 2011;39:154-63.
- Chevidikunnan MF, Al Saif A, Gaowgzeh RA, Mamdouh KA. Effectiveness of core muscle strengthening for improving pain and dynamic balance among female patients with patellofemoral pain syndrome. J Phys Ther Sci 2016;28:1518-23.
About the Author
Dr. Brandon Steele
DC, DACODr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.