McKenzie Approach Extremities

Original Editor - Matt Huey

Top Contributors - Matt Huey, Stacy Lawrence, Kim Jackson, Rucha Gadgil, Vidya Acharya and Alexandra Stead

Page Summary

• Mechanical Diagnosis and Therapy (MDT), also called the McKenzie Method, applies the same mechanical assessment and classification approach used for the spine to musculoskeletal disorders of the extremities.
• Extremity presentations are classified as Derangement, Dysfunction (Articular or Contractile), Postural, or Other/Non-mechanical syndromes, with directional preference central to derangement management.
• Management involves self-treatment exercises at regular intervals to load affected tissues, reduce or abolish symptoms, and restore normal joint function; dysfunction syndromes require several weeks of gradual remodelling.
• Up to 47.5% of extremity symptoms originate from the spine, so the spine must be ruled out when a patient fails to respond to extremity-focused treatment.

Introduction

Mechanical Diagnosis and Therapy (MDT), commonly referred to as the McKenzie Method or Approach, is well known for its relevance in treating conditions of the spine. Developed by Robin McKenzie, this method was first proposed in 1981 and later published in his 2000 book, which stated that "this method of assessment was equally applicable and effective for the assessment and treatment of mechanical musculoskeletal disorders of the human extremities."

The approach is commonly adopted for the spine, following first a mechancial assessment on the affected area. Following the assessment, a provisional classification is made along with a self-treatment manoeuvre. The reliability of MDT to classify extremity symptoms is good.

Classification

The classification syndromes are largely the same, with a few differences. The overall presentation is similar to spine symptoms.

Derangement Syndrome

• A mechanical obstruction of the joint resulting in a loss of normal joint motion
• Pain may be constant or intermittent
• Onset can be acute to chronic
• Directional preference is an essential feature
• Can improve rapidly
• Treatment involves a movement that reduces or abolishes the symptoms

Dysfunction Syndrome

Dysfunction syndrome has a clinical presentation of structurally shortened tissues. The symptoms can be classified as an Articular or Contractile Dysfunction

Articular Dysfunction

• Onset must have been at least 8 weeks prior
• Loss of end range movement
• Only produces symptoms at end range; even when moving passively, the symptoms will be produced at end range
• Treatment consists of remodelling the tissue at the end range.

Contractile Dysfunction

• May have come on in a shorter period of time
• Full end range movement
• Can produce pain during movement or at end range
• Will not produce symptoms if moved passively
• Treatment consists of remodelling tissue through the painful area

A hallmark of dysfunction syndrome is that symptoms do not improve rapidly. Changes happen slowly and gradually over time with proper loading.

Postural Syndrome

The patient has symptoms of soft tissue mechanical deformation from sustained positions or postures but no lasting effect on the contractile or articular structures.

The patient has no loss of motion, no pain with motion, no loss of strength or function. Very rarely seen in the clinic due to the resolution of symptoms with postural changes

Other or Non-mechanical symptoms

Some conditions can be non-mechanical. These include:

• Chronic pain syndrome
• Inflammatory
• Mechanically inconclusive
• Peripheral nerve entrapment
• Post-surgical
• Soft tissue disease process
• Structurally compromised
• Trauma/Recovering trauma
• Vascular

As with the spine, a patient initially classified as "other" may respond to mechanical loading.

Management

As with the spine, management consists of self-treatments performed at regular intervals to load the affected tissues. The exercises aim to reduce and abolish pain symptoms, and/or restore normal joint function.

Managing either articular or contractile dysfunctions may be more painful than for derangement classifications. This is due to the remodelling effect that is needed with proper loading. The therapist should instruct the patient in a proper loading strategy that does not underdose the tissue so remodelling does not occur, nor provide too much load to bring on an inflammatory response. Managing dysfunction syndrome takes several weeks as the tissue lengthens.

If a patient does not respond to treatment of the affected extremity, the spine must be ruled out as a source of symptoms. It has been found that up to 47.5% of people with extremity symptoms come from the spine.

Here is an example of someone with a shoulder derangement being treated using MDT:

Evidence for using MDT with Extremities

Several studies show the benefits of utilising MDT for extremity disorders.

Reliability

One systematic review compared the findings of 6 studies and found strong evidence of inter-examiner reliability in classifying extremity conditions.

Treatment Efficacy

This study found that patients with a diagnosis of knee OA were given exercises based on their MDT classification had better outcomes compared to controls in terms of pain and function.

Predicting Outcomes

A prospective observational cohort study examined the prevalence of shoulder impairments categorised into four MDT syndromes: Shoulder Derangement (44.3%), Shoulder Dysfunction (40.0%), Postural (0%), and Other (15.6%). All groups showed clinically significant improvements in pain intensity and disability at discharge. Notably, a significant difference in pain intensity at discharge was found between Shoulder Derangement and Shoulder Dysfunction (p = 0.01). Additionally, patients with Shoulder Derangement were discharged an average of 35.3 days earlier than those with Shoulder Dysfunction and 28.3 days earlier than those classified as Other.