By Tom Fontana, MSPT
When something hurts or is “not right,” people want to know THE CAUSE and that often means (in musculoskeletal medicine) a bone, muscle, nerve, joint, tendon, etc. that you can name, see, or feel is broken, torn, degenerated, diseased or pinched. And people get frustrated when medicine can’t, or doesn’t, identify a particular structure.
When this occurs, is it simply that the right test wasn’t done? Did we not look in the right place? Certainly, there are times when this is the case. However, there are many other instances when THERE IS NO STRUCTURAL CAUSE.
This is hard to wrap one’s head around as we’ve been so conditioned in western society to reduce problems down to singular causes, but let’s see if this analogy helps.
We have all experienced a computer that is not working, correct? What percentage of the time is it that a component (i.e., hardware) is the problem? Infrequently. What percentage of the time is it that the hardware is fine but the SOFTWARE is to blame? Whoa!—just saw a bunch of hands shoot up. The instructions as to how the computer is supposed to work have been corrupted so that the hardware (i.e., capacitors, resistors, diodes, transistors, etc.)—all of which are OK!—is not producing the desired result.
So, too, can it be with the body. Your “hardware” (muscles, joints, nerves and bones) may be structurally sound but the neuromuscular system (instructions in HOW to use the muscles and bones—software) is faulty/underperforming. The following grid will be helpful in the following discussion:
How would you feel in each quadrant and can that help you/us figure out what’s causing your pain? Let’s start with the easy ones first.
How do you feel if you are in quadrant I? You have healthy tissue (hardware) and your movements are free and well-coordinated (you move efficiently and/or have good posture—software). You most likely have no musculoskeletal pain! Easy peasy.
How do you feel if you are in quadrant IV? You have injured/diseased tissue (perhaps from an accident, disease process, or age) and your movement is restricted and/or poorly coordinated. You likely have a lot of pain. This is also pretty easy to identify.
How do you feel if you are in quadrant II? You have injured/diseased tissue but overall move or hold yourself well. You also have pain.
Now comes the hard part.
How do you feel if you are in quadrant III? You have tissue that is healthy but you move or hold yourself poorly. You may have pain, especially if you have moved or held yourself poorly for a long time, but you might feel fine if you haven’t moved poorly or held yourself poorly for long (consider how a 70-year old with awful posture feels vs. a teenager). An instructor of mine once said, “If a person can’t
identify why they have musculoskeletal pain, chances are it is because of how they exist on the planet.” These people have no structural problems but how they hold themselves or move produces pain (perhaps because of excessive strain on joints, overuse of muscles/tendons, stress on soft tissue or nerves, etc.).
But if you’re just an average Jane walking on the street, how do you know which quadrant you are in based on how you feel?
If you have no pain, you must either be in quadrant I (and, if so, congratulations—you’re doing great, and keep doing what you’re doing!) or are in quadrant III but are a ticking time bomb—this is why it pays to prevent poor posture or movement quality.
If you have pain, though, how do you (or we?) know whether you’re in quadrant II, III, or IV (all of which have some level of pain)?
If you have been in an accident or have a chronic disease, it’s easy to see you are either in II or IV. We will help you recover from your accident or help you manage the effects of your chronic condition so you can live as pain-free as possible. How you hold yourself or move may make your condition worse.
But, if you weren’t in an accident and don’t have a chronic disease, you either have a new disease process, and are in quadrant II, or you are in quadrant III.
This distinction is often what we are trying to determine during a physical therapy evaluation. If we find no faults with your posture and you have sufficient strength, flexibility and coordination to move well, you are NOT from quadrant III and we would send you back to your doctor to look deeper for disease processes.
But, most often during the evaluation, we find poor posture, flexibility, strength or coordination that leads to poor movement though THERE IS NOTHING STRUCTURALLY WRONG WITH YOU! You are the definition of quadrant III—you have “normal” tissue that you are using “abnormally.” Still confused?
Try this experiment. Assuming your neck doesn’t hurt, turn it as far as you can to one side and hold it there. If held long enough, this will eventually lead to discomfort, even though the tissue is perfectly healthy. Another example is the person who falls asleep on the couch with their head held at a funny angle. When you wake up (usually at about 2:30 or 3:00 a.m.!) your neck hurts but the underlying tissue is every bit as healthy as prior to falling asleep on the couch—you just used it in a suboptimal way.
For those people, we help correct any hardware problems—short or weak muscles, inflexible joints, but more importantly the software problems—poor balance, habits or coordination of body parts, so the body moves more efficiently and with less pain.