Is “My knee hurts!” something you find yourself thinking daily? Medical care for your bones, joints, nerves, and muscles—what I call the neuromusculoskeletal (NMSK) system has always been fragmented and as a result, not nearly as good as it could be. Many years ago I wrote a book called Orthopedics 2.0 to try and help patients understand that there was a better way to view, diagnose, and treat NMSK injuries than through a little physical therapy strengthening or surgery. A very knowledgeable physical therapist in Canada just sent a nice unsolicited e-mail that I thought I would share.
Fragmented Diagnosis and Treatment
I’ll never forget my unbridled optimism coming out of residency training. I had spent several years reading every theory paper and newfangled approach to the NMSK system and believed that I would be able to heal patients with chronic back, neck, shoulder, knee, hip, and ankle pain. The problem, regrettably, was that reality didn’t cooperate. I soon found out that everything I had been taught or had read was mostly wrong, as few patients were responding. Thus began a career-long search for a better way.
Over the years I began accumulating various treatments and techniques as I noticed that they would help one type of patient or another. I would also notice what clearly didn’t work—traditional orthopedic surgery. I observed patient after patient after common spine, knee, and shoulder surgeries no better and often worse. Struggling for a way to put all of this together, I wrote a small book, which eventually was the birth of SANS.
What Is SANS?
SANS is the way I discovered I could push the reset button on NMSK care and conceptualize it in a way that would help patients and providers make sure that every aspect of the system got proper attention. So what is SANS?
Sans is obviously the Latin word for “without,” in this case referring to sans pain (“without pain”). Let’s look at the components of this program.
Stability is what it sounds like. Each joint and region of the NMSK system has to be stable in that it has to keep its alignment while it moves. When it fails to do that, the joint gets sloppy and more wear-and-tear forces ensue. The ligaments and the muscles work to provide stability, so they’re the focus here.
Articulation means joint. The joints need to be as healthy as possible to allow normal movement and function. While much of our focus on joint care has been surgical, the SANS program moves that forward from the 20th century to the 21st—less surgery cutting body parts out and more sophisticated and less invasive injections using your own stem cells and platelets.
Neuromuscular is the nerves and the muscles they drive. These are what provide stability and move the joints. All too often, small problems in nerves go unnoticed which then impacts muscles. Finding and treating these problems is often the missing piece preventing patients from improving.
Symmetry is the left/right and front/back balance of your body. Asymmetrical joints or areas place more stress on the parts, meaning earlier arthritis and other problems. Noticing whether the body is balanced and working to keep it that way are critical components for reducing pain.
To read more about SANS and how we conceptualize orthopedics, read the third addition of Orthopedics 2.0, our Amazon best seller:
Here’s the e-mail I received:
Dear Dr. Centeno,
I was recently given a link to your book Orthopedics 2.0 by one of my colleagues Dr. Victor Chan, an ND, who does some of the PRP injecting for my patients. Wow! Truly. This is the book I have been meaning to write for some time now. I am a sport physiotherapist who started his career as a registered massage therapist up here in Vancouver Canada. I also am licensed in acupuncture and IMS and have been tinkering with American muscle cars since I was 14 or so. I’m now 47 and have been practicing for 26 years.
SANS is the first time I have EVER heard another practitioner talk about this process never mind that it is the process I use: Alignment/Symmetry + Joint Mobility = Neuromuscular Conditioning = POWER! It’s on my website under Low Back Treatment. I use a ton of car and engineering analogies as well so to hear you reference the whole car symbiosis thing made me smile and shake my head. Very cool!
I own and am the clinical director of Performax Health Group, a team of PTs, RMTs, DCs, Kin and NDs. We are almost 8 years old and doing some pretty good work but if it were not for our ability to refer for PRP injection we would not be as efficient as we are. Joint stability is absolutely paramount when restoring human physical function as it is in most any other mechanical entity yet this concept eludes the vast majority of practitioners I have ever spoken with. They all seem to understand the concept. They nod their heads to say they agree yet most have no clue how to achieve this other than through strengthening and conditioning. Worse yet, a lot of them start with strengthening exercises in an attempt to “strengthen them strong” when they are ignorant of the fact (or just don’t care) that undiagnosed instability and asymmetry causes needless pain and endless visits to your local practitioner in a futile attempt to fix a symptom rather than a source of the problem at hand. I strongly believe asymmetry and instability are what lead to progressions of chronic states of dysfunction. Much like when I hear of other practitioners treating non-traumatic knee pain by treating the knee!
Once again, in my humble opinion, you have written an EXTREMELY, important piece of literature here. Not just because you have methodically outlined what I have come to understand as “the foundation of physical rehabilitation” but because you also understand the necessity for an integrated approach to restorative locomotion.
At any rate, from here forward I will be referencing Orthopedics 2.0 as I happen to think it beautifully outlines physical orthopedics, pitfalls of current thought and the fact that regenerative medicine is the wave of the future. I also am very familiar with Gracovetsky’s “The Spinal Engine” and Schamberger’s “The Malalignment Syndrome”. These, along with some other publications (Biotensegrity etc.) changed the way I approach and treat my patients.
I constantly state the dilemma surrounding the current physical treatment model like this: we are all taught the different parts of the vehicle, how it runs and what can cause it to break down. We graduate with our various degrees and set off into the world to start fixing cars. Only problem is some of us are given wrenches, some receive screw drivers and others allen keys or impact guns. Could you imagine if we had to rely on that system to fix our cars? Yet this system is what the general public is given to fix them! Not to mention the fact that I am taking quite a bit of grief from my medical counter-parts for referring for PRP/prolotherapy. Most say the research is just not there when I actually see it differently. “Not very wester medicine-ish of you don’t you think” is what I have heard from some MDs. Huh? As far as I know Hackett was an American no? …
Man alive I wish your clinic was in Vancouver! Sorry to seem so scattered I just am so grateful that I have come across another practitioner who sees this like I do and has taken the time to put it down so eloquently. Please thank your wife and kids for me too for putting up with you while you wrote this. It has made a big impact on at least one person over here on the West Coast!
Much thanks and respect,
The upshot? First, finding physical therapists who understand this stuff is rare, so if you’re in Vancouver, you definitely need to see Dan! If you’re not, read our book!
Download our free e-book “Orthopedics 2.0: How Regenerative Medicine and Interventional Orthopedics Will Change Everything” by Dr. Chris Centeno.