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What can you do for your pain?

You have pain.

You may ache from sitting for work, or walking or moving from sitting to standing.

You may get headaches that creep from the back of your head to your eyes or wake up with your neck kinked and unable to move. 

The pain may start in the big toe or your thumb.Or for you it may be your back, elbow or shoulder. 

You struggle with activities you need to do and the pain has lasted long enough that you are looking for a solution.  

People have many options for rehab from physical therapy, injections, and surgery to massage therapy and chiropractic. 


Focusing on Treatments, instead of results (Mistake #2)

We often see people in pain who have been treated with a variety of new and cutting edge treatment methods. 

It goes something like, “I get cold laser and it feels great at the time, but the problem returns the next day.”

Or, “Dry needling feels great but the pain is back and I still can’t get through my workday without hurting.”

Or, “I have had a series of cortizone shots but it lasts a month and I’m worse than I was.”

Or, “I spent a few thousand dollars on stem cell injections but I am right where I started.”

The goal is to get the pain to go away. Pain is one of the most complex experiences a human encounters. We see it everyday in the clinic ranging from cervicogenic headaches and shoulder instabilities to knee osteoarthritis. Sometimes it seems as if the purpose of the rehab gets lost and people can go into an endless loop of treatment.

We create our process to avoid this loop by following a clear process.  If we get stuck at any point, we loop back to the previous step and start over.  

Smith Performance PT Solutions Process

Step 1: Understand the problem from your perspective

Step 2: Build a diagnosis from your medical history, subjective (your story), objective (physical exam)

Step 3: Test the diagnosis using your subjective and objective key sign 

Step 4. Retest in the same session until an effective treatment is found

Step 5: Develop home plan including recovery positions, exercises and activity, and trigger management strategies

Step 6: Create 3 Level Prognosis (Best Case, Worst Case, and Expected Outcomes)

Step 7: At follow up sessions, refine the diagnosis and the home plan

Step 8: At discharge, integrate home plan into normal daily routine

Step 9: Start Long Term Movement and Activity Plan


The majority of our patients have been treated somewhere else first without improvement. When we review their case, similar process mistakes happen over and over again. 

Lack of diagnosis (Mistake #1) or telling a patient to just stop the activity that hurts (Mistake #4) lead to more problems and eventually to a life of inactivity. Our passion as a company is to keep moving for a lifetime and the number one reason people stop or don’t even start an active lifestyle is pain and injury. 

Understanding these common mistakes can help you become a better consumer of rehab services and get better faster with longer lasting results. The end result is the ability to do the day you want.


What are the mistakes in rehab?

Mistake #1: Not Defining The Problem And Possible Problems Causing Pain

Mistake #2: Confusing a Single Treatment as the Solution

Mistake #3: Lack of Retesting

Mistake #4: Stopping the Activity

Mistake #5: Confusing Rehab with Long Term Programming (also known as the endless home exercise list)


You also need to know the solutions so you can respond and discuss the process with your provider:

Solution #1: Get a Diagnosis and Differential Diagnosis List

Solution #2: Get a Plan of Care with 3 Level Prognosis

Solution #3: Multiple Exams in the Same Session

Solution #4: Trigger Management Plan

Solution #5: PT Movement and Health and Human Performance

Let’s dive into the mistakes and solutions.


5 Rehab Mistakes and the Solutions

Mistake #1: Not Defining The Problem And Possible Problems Causing Pain

A diagnosis is a crucial first step in the rehab process. Imagine you have heel pain, a common injury that we see that does not normally have a diagnosis.  The following is a list of possible tissues that could cause the pain:

Flexor Digitorum Brevis

Abductor Hallucis

Abductor Digiti Minimi

Fat Pad Trauma or Atrophy

Calcaneal stress fracture

Lateral Plantar Nerve 

Medial Plantar Nerve

Tarsal Tunnel Syndrome

Low back referral

Hip joint referral

Plantar Fascia

Surgical Scars

Each of these structures requires different treatment methods.  Without knowing the problem, or what we call the pain generator, then we cannot be sure the painful tissue is getting targeted.


Solution #1: Get a Diagnosis and Differential Diagnosis List

While this seems simple, the majority of patients do not get a diagnosis or a differential diagnosis list from their provider. When we ask the patient with back pain, they typically say they were diagnosed with a slipped disc or ‘back pain’.  

Without a working diagnosis, how do you create a plan?

Without a working diagnosis, how do you know if you should expect improvement within a week?

Without a working diagnosis, how do you know what type of treatments to perform?  

How do you know if the plan is working?  Without a differential diagnosis list, how do you pivot to a new plan if the current one is not working?

The answer? 

You cannot.  This leads to a failed plan and eventually either you or the provider gets frustrated.  You now think you have genetics for a bad back or knees when really you just did not have a working diagnosis.

Mistake #2: Confusing a Single Treatment as the Solution

This mistake is almost as common as the lack of working diagnosis (Mistake #1).  When someone uses the same treatment on every person, there is an assumption on what is the problem.

The most common combination is a patient being told they have muscle tightness and scar tissue everywhere. 

The solution is vigorous massage or dry needling or active release or myofascial stretching or some variation of muscle treatment.

This could be the right answer for the occasional individuals with just a muscle injury, but often it becomes an endless treatment plan.

Solution #2: Get a Plan of Care with 3 Level Prognosis

Manual treatments are a great way to start getting people better, but for successful rehab there needs to be clear metrics that you as a patient can evaluate the progression of rehab.

We do this by getting a working diagnosis, laying out the components of treatment, and providing a range of possible outcomes. This is called the 3 Level Prognosis.

The 3 Level Prognosis makes the provider give you the best case scenario, worst case scenario, and expected outcomes to reach your goals. 

This combined with a working diagnosis and differential list (Solution #1), clear home plan (Solution #4) and retesting after providing treatments (Solution #3) leads the provider to use whatever combination of manual treatments, exercise, activity, and planning that makes you better.

Mistake #3: Lack of Retesting the Exam 

I find it insane, but some patients who walk in have never actually had testing to recreate the problem. The patients who have had an exam often never have it done again. 

When I first started practicing, I remember seeing patients who were impressed by a physician that could diagnose the problem within seconds.  The physician had seen this numerous times.  

It sounds cool until it became clear the diagnosis was not correct.  Now it sounds lazy. (Learn more about the diagnostic process HERE)

There are so many ways to mess up a diagnosis and the lack of an exam and retesting it for success means you are flying blind with rehab.

Solution #3: Multiple Exams in the Same Session

We do the exam numerous times.  Our team searches for things we call key signs that most effectively recreate the main symptom that brought you in.

We retest it over and over again to measure the success of our treatment within session.  This allows us to confirm our working diagnosis (Solution #1) and create an effective treatment strategy that you can do at home (Solution #4).



Mistake #4: Stopping the Activity

Imagine you are a runner. You go to the doctor and you tell them you have knee pain with running.

What do you think you will be diagnosed with and what you do you think the treatment will be?

My guess is you will be told you have Runners Knee and the solution is to stop running. And you had to pay for that!

So you stop running and like magic, the pain gets better.  You start running again a month or two later and the pain returns.  Our term for stopping the activity – Fake Improvement.  There are few situations where stopping the activity is helpful.


Solution #4: Clear Home Plan Including Trigger Management Plan 

A more effective solution is to understand all of the things contributing to the pain.  If a runner comes in with knee pain, this can be due to the patellar tendon, meniscus lesions, or irritation of the knee joint just to name a few.  Runner’s knee is a garbage, catch all term saying that you run and you have knee pain (Mistake #1). 

The pain could be due a lack of warm up or an inhibition problem that occurs with running that can be solved with banded side steps every couple miles.  The running itself is not the problem, rather a change in your neuromuscular system is.  When you stop running, you never get to test the solutions and you get stuck in an endless loop of starting and stopping.  

A home plan takes into account what works in a session as demonstrated by retesting (Solution #3) and gets you the tools to do it at home.  Trigger management plan helps you figure out what other things may be contributing, like sitting down right after a run may increase your knee pain.  To manage the trigger, you do not sit down within 30 minutes of running.


Mistake #5: Confusing Rehab with Long Term Programming (also known as the endless home exercise list)

While some people may disagree with us, the idea that the physical therapy exercise list is something you need to do for a lifetime is not sustainable for 99% of humans on planet earth.  It is time consuming, lacks a real plan, and uses exercises focused on rehabilitation. 


Solution #5: Recurrence Action Plan, PT Movement, and Health and Human Performance

No matter what you do, after you have an injury there is elevated risk it will come back.  All the information out there on preventing injury are typically a person peddling the next injury prevention cure. 

Once you are done with rehab, you need to get back to activity that maximizes your enjoyment and your health. 

We go after the problem of recurrence, chronicity, and supported active lifestyle in different ways.

If we are worried about pain returning, we develop an action plan that is used once the problem seems to return.  You apply the plan as soon as needed.

If there is a chronic condition that needs to always be addressed we use our program, PT Movement, to address it in a sustainable way.  Its a group class format specific to the body part and problem.  

For individuals who want to have a long term exercise plan with the support of a team including physical therapist, strength coaches, rehab coordinator, and exercise physiologist, we use our Health and Human Performance Program.

The point is that an endless exercise list does not prevent the problem from coming back.  The focus needs to be on lifelong activity and catching problems right when they start. 


What if you just go with whoever your insurance covers?

When you decide on where to go and what to do with your rehab, this list will help.  It does not matter if it is at a busy insurance based clinic, the chiro down the street, or a famous orthopedist that treats the best athletes in the world. 

Your case and your presentation is unique because you are unique. 

If you don’t consider the mistakes and solutions, you become a passive patient with no control in your rehab plan.

This is a big mistake and can lead to more visits, more pain, and reduced quality of life.  Even in busy clinics or intimidating office visits, make sure you get the care you want.  This list will help you ask questions and evaluate the plan you get.


What should you do next?

Pain is not fun and its something that every person will eventually deal with and for those unlucky enough to need help, there are common mistakes that you can guard against when you work with a practitioner.  

We would love the opportunity to discuss your problem and get you back to the life you love.  Click here to set up a phone call with one of our therapists and get back in control today.

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