Is MDT well-suited for athletes?

Article translated by Michael Dick (CAN)

This past weekend I had the opportunity to attend a McKenzie Institute Masterclass entitled « MDT & Athletes » taught by Greg Lynch (NZ) and Georg Supp (GER). What ensued were two days of classes taught within a great atmosphere for a course which was having its debut in France.

MDT and sports physio — are they compatible?

The image we have of the MDT

When we talk about the McKenzie Method (MDT: Mechanical Diagnosis and Therapy), we think of lumbar extension lying on one’s abdomen and self-treatment (see my article I did McKenzie Part A).

We can therefore legitimately ask ourselves: is MDT adapted to the pathologies of athletes? Is the McKenzie assessment and treatment specific enough to be effectively applied to high performance athletes?

The postulate of the athlete’s care

Concurrently, when we talk about sports physiotherapy, particularly the care of elite and professional athletes, we do not spontaneously think of McKenzie. We have in mind that after injury, the ideal would be:

• An assessment with
  well-conducted orthopedic tests,
• Fast and relevant imaging,
• A
  precise pathoanatomical diagnosis.

The objective of this triptych is to have a precise idea of the recovery time before return to sport and the care management protocols to be used.

Is it useful to have imaging done?

This is a subject on which I would like to write an article in the near future. Too much emphasis is currently placed on « abnormalities » found with imaging because a large proportion of « abnormal » imaging is found in asymptomatic patients, whether in the extremities or the spine, regardless of the age of the patients.

While waiting for an article on the subject, you can take a look at this graph from Adam Meakins’ blog The Sports Physio: 

Is it useful to make anatomical diagnoses?

Though even if the triptych (tests, imaging, patho-anatomical diagnosis) is attractive, it turns out that it is not particularly effective. Concerning the relevance of imaging, we are beginning to understand we are not treating images but rather patients. On the subject of tests, you can also take a look at the paper by Eric Hegedus and Chad Cook (2017) on the value of using specific orthopedic tests to make a precise diagnosis, which concludes that “they prove as diagnostic as a coin flip when examined by independent groups”, in other words, in many cases, the patho-anatomical diagnosis is « a house wine in fancy packaging”.  [image]

If you are not convinced of the problematic nature of making pathoanatomical diagnoses, I loved this reference to the Weir 2015 study on groin pain, where 2 case studies were presented to 23 international experts of these pathologies, and for clinical case n°1 this led to 18 different diagnoses. As for clinical case n°2, the 23 international experts in groin pain managed to agree on 22 different diagnoses!!!! WTF???????

Past priorities….

On the one hand, MDT is not just exercises to treat the spine.

On the other hand, the scientific literature does not support the relavance of pathoanatomical diagnoses as criteria for returning to sport or as management guidelines for sports injuries. The clinical response appears to be at least as reliable.

What MDT offers for athletes

As a McKenzieist (Part A, B and C for me, while my buddy Cyril has already done Part D, but I don’t blame him…), we have a certain confidence in our ability to exclude pain of spinal origin but also in our ability to restore joint function.

To convince you of this, I recommend you to look into the EXPOSS study (Exploring a Process for differentiating extremity pain of Spinal Source) conducted by Richard Rosedale and Georg Supp (awaiting publication, I believe) which explores the incidence of extremity pain that is referred from the spine.

Even if a good proportion of extremity pain can be modified by spinal movements, and that MDT also includes mechanical care pathways for the extremities, is this sufficient to attest that MDT can manage athletes and provide them with the opportunity to return quickly and effectively to their activity?

That was the whole purpose of this 2-day course about the role of MDT in the management of the athlete.

One can easily imagine that MDT, with its precise assessment based on symptomatic responses as well mechanical, functional and psycho-social markers, with its principles of self-treatment, with its progression of forces, perhaps has something to offer in terms of care management of athletes…

Yes, but…

If you have already started taking MDT courses, you might think the above statement is nice, but that apart from restoring joint mobility and abolishing pain, the MDT curriculum is a little light on sports physio, especially for Return to Sport (RTS) and recovery of muscle capacity.

This is somewhat true, especially if you have only taken parts A and B, and it is already a little less true if you have explored the pathologies of the extremities in parts C and D. Indeed, MDT involves the mechanical treatment of extremity pathologies but also strategies for muscle strengthening and for general physical activity, as well as the quick return to professional or sporting activity, and the progressive loading of structures, etc.

An assessment not very specific to athletes

The reality is that the McKenzie assessment form is insufficient to guide one’s management of an athlete through the course of care until he or she can resume sport. There is clearly a lack of space to record information about the athlete, their sport, their training, their level, their sporting goals and objectives, etc.

However, as we saw this weekend, it is up to us to collect relevant information from the patient and record it in addition to the MDT form. It is even highly recommended.

This is indeed what was taught during this MDT course, by supplementing our evaluations with a START-BACK, for example. The issue for me was that I tended to reduce the MDT evaluation to its singular form, yet when reviewing my course notes from parts A, B and C, I realized I had been told to adapt my assessment to my patient…

The course content of this Masterclass

Throughout the course, Greg Lynch and Georg Supp presented new management algorithms for musculoskeletal diseases, for example soft tissue disorders, stress fractures, etc. They also presented athlete-specific adaptations to the already-known management pathways of derangements and dysfunctions and the “Other” category.

By keeping our principles of taking baselines, exercise prescriptions, systematic reassessments, and patient education, McKenzieists are in fact already well equipped to adapt their care to athletes. One just has to think about going further than restoring joint function and adapting oneself to one’s patient.

« MDT is not only about reducing derangements.”

As a result, by respecting the MDT assessment, the care management algorithm and integrating the patient into their sport, Greg and Georg — through numerous clinical cases — pushed us to develop thorough, comprehensive treatment strategies adapted to competitive athletes of even the highest level.

Anything new under the sun?

I’m not saying that MDT is going to revolutionize the management of athletes because we always come back to « fundamental » principles, we must gradually increase the training load / rehabilitation load (notion of optimal loading) of our patients. What is true for a sedentary person who is given 6×10 lumbar flexions per day, is true for an athlete for whom we will integrate, for example, ballistic hip movements to solicit his proximal hamstring tendon perhaps 5 to 6x per day as well… It’s all a question of the right dosage…

Concerning optimal loading: during this course, we had a big session on tendinopathies (contractile dysfunction for McKenzieists — why not have the same name as everyone else? We are probably waiting for the scientific world to agree on a common name…). After a presentation of the state of the literature on the subject (Jill Cook, Ebony Rio, Alfredson protocol, HSR, isometric, combined, etc.), we experimented with the implementation of treatment strategies specific to our patient, and not the strict application of these protocols from the scientific literature.

As I pointed out in class, there is tendency to forget that the treatment protocols seen in the scientific literature are more suited to the design of the research protocol than to the clinical presentation of the patients in the study. As such, it is strongly recommended to understand the principles of the scientific literature and adapt them to one’s patient rather than strictly applying treatment plans!

Overall impression

I really appreciated the multiple clinical cases and especially the fact that this was a real masterclass and not a review of principles seen in other MDT courses. To put it differently, we didn’t focus on MDT assessment form and the McKenzie algorithm! We developed, reflected upon, criticized, and adapted clinical presentations, treatment plans and exercises programs.

What was missing was one or two live patient evaluations, and sometimes I would have liked the instructors to get a little more involved and push our thoughts and proposals further (surely Anglo-Saxon politeness…).

It is always a real pleasure to talk about athletes’ pathologies, to compare our ways of doing things with internationally-based therapists, and to accumulate new knowledge on these subjects.

Frankly, I recommend this course, which has allowed me to better understand the use of MDT for athletes by incorporating our experience and knowledge of musculoskeletal pathologies. Not that I thought it was incompatible. But the MDT curriculum is already very rich in new information, it takes time to integrate the MDT decision-making algorithm even just for joint derangement. This has resulted in my feeling almost obliged to abandon my usual tests (orthopaedic tests, evaluation of muscle function, evaluation of an athlete’s training load,…) for fear of losing time and the rigour of the MDT assessment. As a result, I have tended to oppose the MDT mechanical evaluation in search of a derangement against a musculoskeletal assessment for a sports patient. Which is certainly a mistake because when reviewing the MDT course manuals all this is already covered… It’s just that it probably takes some time for this to really become integrated into our practice as well as to quickly recognize clinical presentations.

In the context of athletes, I had a small intellectual conflict between my usual management of musculoskeletal pathologies and the need to exclude a spinal problem with MDT. I had trouble understanding how to exclude an issue of spinal origin without following a strict MDT evaluation. In other words, how to assess a musculoskeletal problem without wasting too much time with my MDT evaluation. This is something that was resolved for me during the course. All that is left to do now is  see real patients and see what happens.

The instructors’ « Take Home Message”

In the end, with athletes, who are human like everyone else (I think Georg said that; laughing; or not):

• It is necessary to be specific during our evaluation, towards the athlete, their training load,
  their sport, their environment, their
  objectives [all this is a large part of the course,
  very interesting]
• Our Mckenzieist habits,
  especially the use of the traffic light guide, are a good pedagogical way
  to manage patients.
• In MDT, we don’t just prescribe
  exercises!

A next course in France?

A little bird told me that there will soon be an “MDT & Athletes” Masterclass in France, and that it will be given by Florence MORISSEAU, who is always sharp and passionate about sport. There will surely be fewer clinical cases about soccer players and more with handball players or ultra-marathon runners…

Off the record

The course took place in a great atmosphere with various workshops and interactive sessions (Kahoot, quiz, etc.).

Moreover, it is extremely important to mention that I finished on the kahoot podium (3rd) behind Jordane (2nd) and Paul (The best).

The hotel recommended by Flo was top (and yours Flo?); Marie’s bathtub must have been top too; Jib is getting into great graphic designs (cf. infra); Jimmy doesn’t sleep enough and that we love beating the Blacks in rugby (that was before!) and that the Mannschaft does indeed have 4 stars on their jersey Georg!

You can also take a look at my other article in English : https://blogdukine.fr/mdt-prospects/

NB: A study would be needed, but MDT Dips (Georg, Flo) get up earlier than non-certified ones to do their jogging.

NB 2: Thank you for the proofreading Marie and JB,