Mechanical diagnosis and therapy and Morton's neuroma: a case-series.

Objectives: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and utility of physical therapy (PT) is unknown. Mechanical Diagnosis and Therapy (MDT) is a classification system utilizing direction-specific treatment for orthopedic conditions based on mechanical and symptomatic response to repeated end range movements. The purpose of this case series is to describe the management of three patients with a medical diagnosis of MN using the MDT classification system.Methods: Three female patients aged 54-75 years with unilateral plantar forefoot pain for 6 weeks to 8 years were referred by a podiatrist following positive clinically accepted diagnostic criteria for MN including radiological imaging and provocation testing. Patients were evaluated and treated utilizing MDT assessment and treatment principles. The intervention consisted of repeated movements matched to the patient's directional preference at either the lumbar spine (1 patient) or distal extremity (2 patients).Results: Immediate and one-year outcomes were excellent, demonstrating rapid and lasting improvement. Following discharge, the patients have been asymptomatic or able to self-manage without seeking additional medical intervention for this condition. Total visit frequency per patient averaged 2-3 visits total across 8-16 days.Discussion: Responses to repeated end range movements testing allowed for classification and prescription of exercise to rapidly improve symptoms and function in three patients referred to PT services with medically diagnosed MN. This series provides preliminary evidence that MDT may be effective in classifying and treating patients with MN.

The application of mechanical diagnosis and therapy on hip osteoarthritis: A case report.

Background: The prevalence and cost of hip osteoarthritis (OA) is rising. Mechanical diagnosis and therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movements. There has been no investigation of the association between MDT and patients diagnosed with hip OA. Case Description: This case report presents a 71-year-old female diagnosed with hip OA and matching the currently accepted clinical prediction rule (CPR) for symptomatic hip OA. The patient was classified and treated by a Diplomat of MDT and co-examiner using MDT. Outcomes: Short- and long-term (13 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and improvement in function in 5 visits over 21 days. The patient demonstrated the ability to prevent and manage reoccurrence of symptoms independently; nevertheless, she received a total hip replacement which was not in accordance with current guidelines and recommendations. Conclusion: This case report raises questions about whether or not pathologies traditionally associated with the etiology of hip OA are actually at fault. Moreover, it raises questions about the utility of special tests and CPRs typically utilized to identify those structures. The case report provides preliminary evidence from one patient that MDT may be capable of providing effective short- and long-term outcomes in the management of hip OA.

Directional preference of the extremity: a preliminary investigation.

Background: Mechanical diagnosis and therapy (MDT) is a specific classification-based musculoskeletal examination and intervention system that uses repeated end range and sustained movement to classify patients into mechanical syndromes. Research has recently demonstrated increased prevalence, reliability, and efficacy of MDT syndromes in varied peripheral musculoskeletal populations. There is currently no research analyzing if predictive variables exist for establishing directional preference in peripheral joints, other than the wrist. The aim of this study was to examine the clinical application of predictive variables for establishing directional preference and spinal referral in patients with isolated peripheral joint pain. Case Description: Thirty-seven consecutive patients with isolated peripheral pain were evaluated and classified using MDT assessment. Secondary analysis of predetermined variables was performed for association with directional preference and identification of spinal referral in Derangement syndrome. Results: All 37 patients were classified using MDT assessment. Thirty-three (89.2%) were classified as Derangement syndrome: 17 as spinal Derangement (45.9%) and 16 as peripheral Derangement (43.2%). One peripheral derangement also had an underlying Articular Dysfunction. Additionally, there were four patients classified as Other (10.8%). Discussion: Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference or spinal referral. Mechanical stress was found to be the most associated factor in predicting directional preference. No peripheral movement loss, paresthesia, and constant pain were more associated with spinal referral. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. Level of Evidence: 4.

The application of Mechanical Diagnosis and Therapy to the ankle-foot complex: a case series.

BACKGROUND: Pain at the ankle-foot complex is a common musculoskeletal condition that can lead to dysfunction. Mechanical Diagnosis and Therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained movement. There has been no investigation of the association between MDT and patients diagnosed with ankle-foot complex pain. CASE DESCRIPTION: This report presents four patients with a primary complaint of pain in the ankle-foot complex. Three patients had a medical diagnosis while the other was self-referred through direct access. All received classification and treatment by clinicians trained in MDT solely utilizing MDT principles. OUTCOMES: Short- and long-term (4-12 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in an average of six visits over 21 days (4-8 visits over 14-33 days) without the use of modalities, strength, or proprioceptive training. The patients demonstrated the ability to prevent and manage re-occurrence of symptoms independently without seeking further health care at long-term follow-up. DISCUSSION: The rapid speed of recovery and return to functional activities demonstrated in this case series, raises questions about whether or not the pathologies traditionally associated with the etiology of ankle-foot injuries are actually at fault or understood. Moreover, it demonstrates that specific movements can rapidly worsen or improve symptoms challenging the current generalized rehabilitation protocols. This report provides preliminary evidence that MDT may be capable of providing more effective short-term outcomes in the management of ankle-foot complex injuries. LEVEL OF EVIDENCE: 4.

Directional preference of the wrist: a preliminary investigation.

BACKGROUND: Directional preference is a phenomenon that occurs in musculoskeletal disorders. It is associated with improved symptomatic and functional outcomes. Research has shown a 90% increase in the identification of directional preference in the peripheral joints between 2006 and 2012. There is currently no research analyzing if predictive variables exist for establishing directional preference. CASE DESCRIPTION: This report presents 19 consecutive patients with wrist pain. These patients were evaluated using a mechanical diagnosis and therapy (MDT)-based assessment. Patients were classified into the mechanical syndromes Derangement, Dysfunction, Postural, and Other. Patients classified with wrist Derangement were assessed for the presence of directional preference. Secondary analysis of predetermined variables was performed for association with directional preference. One case description was included to demonstrate MDT assessment, treatment, and clinical reasoning. RESULTS: Of the 19 patients evaluated, 15 (79%) were classified as having wrist Derangement. All patients with wrist Derangement demonstrated directional preference. Eight movements were found to establish directional preference. Each was unique with varying degrees of direction, load, and force. DISCUSSION: This report found directional preference to be higher (79%) than previously reported values. Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference. Excessive mechanical stress was found to be the most associated factor in predicting directional preference. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. LEVEL OF EVIDENCE: 4.

The application of mechanical diagnosis and therapy in lateral epicondylalgia.

BACKGROUND: lateral epicondylalgia (LE) is a musculoskeletal diagnosis that causes pain and dysfunction in the lateral aspect of the elbow. Mechanical diagnosis and therapy (MDT) is an orthopaedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movement. There has been no investigation of the association between MDT and patients diagnosed with LE. CASE DESCRIPTION: this report presents three patients matching the currently accepted diagnostic criteria for LE, two with a diagnosis of lateral epicondylitis (tennis elbow) from a medical doctor. These patients were classified and treated by a diplomat of MDT and two third-year doctoral students of physical therapy using MDT. OUTCOMES: short- and long-term (one year) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in 3-6 visits between 11-59 days. Patients demonstrated the ability to prevent and manage reoccurrence of symptoms independently without seeking further health care. DISCUSSION: this case series raises questions about whether or not the pathologies traditionally associated with the aetiology of LE are actually at fault. Moreover, it raises questions about the utility of special tests typically utilized to identify those structures. The series provides preliminary evidence that MDT may be capable of providing effective short- and long-term outcomes in the management of LE. LEVEL OF EVIDENCE: 4.