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Monday, January 28, 2013

1/22/13 Sports Medicine Lecture at Samuel Merritt University

Sports Medicine is great fun and great challenge. With 99% of all sports injuries non-surgical, it is primarily a discipline in rehabilitation. Getting the athletes back to full activity as soon as possible, and with a minimum of re-occurrences of the original symptoms, is the goal of a Sports Medicine practice. It is a world of medicine practiced by many different professions, podiatry being only one. No profession holds more than 50% of the answers to the many challenges facing the provider, so the discipline of sports medicine is humbling at times, and truly team focused.

Who are the members of that team? The discipline of sports medicine is very unique in medicine since it has the PATIENT as the primary member of the team not the health care provider. You and the patient work together as a team to work through the challenges from injury to health. This Patient-focused approach can be intimidating to the health care provider and the patient, so it is not right for every patient and every health care provider to practice. Patients may want to go to a sports medicine clinic, but will not have the mind set to do the hours of stretching, icing, physical therapy, etc required. Doctors/therapists may want to practice sports medicine, but really truly focus on giving shots, doing surgery, doing procedures, with no real understanding of rehabilitation. 

So, how does the student of sports medicine begin to learn the discipline of sports medicine. I will try and put together in these next 2 weeks, the general principles to live by with your own unique spin. Everyone will practice differently thankfully. Yet, there are some basic rules to live by that we will explore together in our limited time.

General Principles for a SPORTS MEDICINE PRACTICE:

  1. Listen, Listen, Listen
  2. Perfect, Perfect, Perfect
  3. Podiatry Owns Biomechanics--listen and watch for the clues
  4. KISS Principle when appropriate, full court press when not (How disabled?)
  5. The Magical 80%
  6. What Phase of Rehabilitation is the Patient In at any visit
  7. Do Not Limit Yourself to What You are Taught (Grow!!!)
  8. The Foot Bone is Connected to The Ankle Bone....
  9. Gait Evaluation is A Key to Diagnosis
  10. Learn from Patients First, Books Second
  11. Progress From Simple to Complex, as needed, by layering
  12. Partner with Your Patient, Not control
  13. Learn the complexities of various Treatment Modalities and master the sutleties
  14. What are the Common Causes of Injuries?
  15. Be a Teacher and Friend, as well as a Doctor
  16. Do Not Give Control of Treatments Completely over to Anyone?
  17. Understand Foot Inserts and Be An Expert in their Design
  18. Listen for your Mentors--they are out there
  19. Learn from your followup visits, see patients often (Develop Your Flow Charts)
  20. Use email, etc to develop good followup (keep in touch)
  21. Find Ways of being Involved, do not be Detached (cry, celebrate, laugh, admit mistakes, work hard for your patients).

Listen, Listen, Listen

This skill is first since it is the basis of our treatments and our human interaction with the patient. But, with the time restraints for modern day medicine, with less time mandated by many factors being spent with patients, it needs to be addressed. How do we hold on to the skill that defines being a good doctor/therapist, as it is eroding from the culture? Doctors/therapists have many chances to hold on to this skill--limited time in the actual visit, email correspondence, patient questionnaires that can be filled out, telephone followups even for more information, the use of medical assistants/physician assistants/nurse practitioners/athletic trainors, can all increase our knowledge base on that particular patient.

Perfect, Perfect, Perfect

The 3 Perfects stand for:

  1. You as an individual health care provider continue to strive to get better throughout your career
  2. While treating a patient, always try to make the treatment as perfect as possible--do not keep settling for less than ideal treatments (the good enough syndrome) especially if the symptoms warrant that the treatment be improved
  3. Try to perfect the intangibles: your online education presence, the handouts in your office, the doctors you refer to, etc.

Podiatry Owns Biomechanics--listen and watch for the clues

Almost every lower extremity injury, most back problems, and some upper extremity problems, has a possible solution in Biomechanics. The solution may make a chronic disabling injury disappear, or merely change bad pain into more manageable pain. With 33 common lower extremity injuries produced or aggravated by the foot over pronating, it is easy to see how studying the biomechanics of patients can produce wonderful clues for us. Much of this science is tried into gait evaluation and by muscular, ligamentous, or structural evaluations. The common areas that a biomechanical trained health care provider will look into are:

  1. Over Pronation
  2. Over Supination (aka Under Pronation)
  3. Leg Length Differences
  4. Inadequate Shock Absorption
  5. Tight or Weak Muscles
  6. Tight or Loose Ligaments
  7. Neurological Problems
  8. Compensatory Problems from perhaps old injuries

KISS Principle when appropriate, full court press when not 
(How Disabled?)

It is a world of modern medicine is a world of procedures. This is what pays the bills, and can be the fun stuff we do. Insurance companies pay more for more elaborate tests and modalities. But, armed with all this great medical training, you must ask at each patient visit what is really needed to get the job done with the least risk to the patient. This is influenced greatly by the patient. Can their needs be addressed simply (KISS--Keep It Simple Stupid), or should there be a full court press (throwing in the kitchen sink if necessary). For most day to day patient visit, KISS is perfect. But, simple problems can be very significant to the patient, or may turn for the worst, needing more complexity. And complex problems can be the other side of the coin. Healthy looking patients can come into the office with negative findings, and an attitude reflective that everything is okay, but in deeper probing and listening, are completely disabled. I am standing here at class (at least while I type this) looking well, but due to my back problem, totally disabled from playing basketball, sitting, driving, putting on my pants, shoes, and socks. My ability to minimize my symptoms, to work as well as possible around them, would make my back doctor mis-interpret the level of my disability. This is done every day in every clinic. Symptoms are either over treated (where KISS was more appropriate) or under treated (see post on Good Looking Syndrome).

The Magical 80%

When rehabbing patients, you have 2 scales that you will use consistently to access progress. The pain scale is 0 (no pain) to 10 (most severe pain) is the most common one of the measures used. The functional scale from bedrest (0% functional) to full activities/no symptoms (100% functional) is a lesser used, but vital part of a sports medicine practice. As you treat patients, each visit you will need to assess where the pain and function are at. The goal for most injuries is to attain 80% plus pain relief (pain scale not over level 2 in function) and 80% plus function (full activities with 0-2 pain). For 0-2 pain, can take years to completely go away, and to have an athlete only perform when there is no pain, would be unnecessary. This is considered "Good Pain". It is common for both of these scales to be mis-interpreted. Commonly, the athlete is told to wait on functioning (their sport) while they undergo a treatment to drive the pain down to 0. The treatment is considered successful, until the pain returns with a vengeance as they resume their sport. It is best in most cases to treat while allowing restricted function which you gradually increase while maintaining pain level to 0-2. I always say that I would rather a runner run 1 second per day, then not at all. And if they run 1 second, can they do 2, etc.

What Phase of Rehabilitation is the Patient in at Any Visit?

What are the 3 Phases of Athletic Rehabilitation?

  1. Immobilization/Anti-Inflammatory Phase
  2. Re-Strengthening Phase
  3. Return to Activity Phase
With being said, patients (if they had 3 feet it would be perfect) can be solidly in one phase at one time, or be stradeling all 3 phases at once. It is a goal to work patients as quickly as possible through the phases, but at times, they have to be placed (with imaginary handcuffs to the bedpost) in one phase for an finite period of time. I love to start strengthening as early as possible, and even allow some current activities to continue if I can keep the pain level between 0-2. The daily onslaught of patients I see that should be in Phase 1 but are running with pain 4-7 since they went from Phase 1 to Phase 2 and now should be in Phase 3 with other provider is very common. You just have to start over and re-establish what it takes to maintain Phase 1 pain levels (0-2). Or, the patients that were never placed into Phase 1 and have been painful for years, is another common variation of the same scenario.

Do Not Limit Yourself, but continue to grow in Knowledge and Experiences

There is such a plethora of resources out there to grow your sports medicine. Be open minded. Learn from everyone. Definitely, become a member of the American Academy of Podiatric Sports Medicine. Learn mainly from your patients. They live with their pain. They have seen others to seek help. What has worked and not worked. What is the new stretching device you never heard of? When a physical therapist sends you a report on the treatment, go over with your patient anything you do not understand. Be a constant learner, it makes this fun!!

The Foot Bone is Connected to the Ankle Bone...

Being in a sports medicine and biomechanics practice, you will begin to understand how the body is so interconnected. What I do affects the rest of the body both positively and negatively. I remember my first patient with runner's knee pain coming in for his first orthotic device check. I asked him how his knee was doing, he said okay (not convincing me that the orthotics were helping him), but then a big smile and he said 20 years of shoulder pain while running was gone completely. If I knew more back then, maybe I could have figured out why. Dr Merton Root, modern day founder of Foot Biomechanics, and inventor of the principles behind modern day foot orthotics, once got a big laugh from his students when he said he could tell after his evaluation which of his patients with neck pain would get relief from his orthotic devices. Yes, the foot bone is connected above, and if you seek to understand how someone should walk or run that is stable for their body, and you can help get them there, you may be surprised at your results.

Gait Evaluation is Key to Diagnosis

We will spend some time in class reviewing some of the basics of gait evaluation. Of course, it applies to more than one activity. It is truly an evaluation of the technique involved with walking, running, race walking, figure skating, ballet, etc. But, since we all walk, and it can be done right in your office, and it seems to reveal a part of the soul of the human body involved with motion. Being able to continue to move, walk, stay active is one of the secrets to great happiness to the human spirit. And, being good at evaluating walking gait, will key you into problems that the patient may have with their running, backpacking, etc. I remember one of my greatest gait evaluation success stories. Ben was a golfer with back pain, not a good combination. 4 years of treatment from various specialities were not helpful. When he came into my office, I watched him walk to see if that would give me you could tell he had either a functional or structural short leg--correcting that is back pain 101 for me. He did have a short leg on xray and he did great, but the main point I want to make is that after I watched him walk and pointed out some things he said in 4 years no one had ever watched him walk! Gait evaluation may be the key to helping thousands of your patients.

Learn from Patients First, Books and Seminars Second

Weekly I learn something new from some patient that affects my medical practice, but you must be on their level. You must be considered a Teammate that shares info, not the All Knowing Doctor/Therapist that only gives it out. Sports Medicine is a team approach between you and the patient. When you give the patient options, ask what they would like to try first. Guide them but not totally dictate. When treatments are not working, it will be easier from them to tell you if they consider you on their side, and more of an equal.

Progress from Simple to Complex, as needed, by Layering

When coming up with a treatment plan, and when your judgment and/or the judgment of the patient does feel that a full court press is needed, the KISS is commonly used. The KISS principle is far from a watered down non-thoughtful approach however. It assumes that the patient will get somewhat to completely better with less than the most sophisticated approaches available. Plus, and not to be under-estimated, it grants you followup visits with the patient to see how motivated they are to do the program, or what findings did they make that may change initial assumptions. If the First Visit was the ground breaker, the followup visits can tell you a lot more about this patient. A common problem with KISS philosophy is that you may know you are following it, but the patient must also know. Many patients leave their doctor's appt with a simple plan, when only partially successful, may feel it is all the doctor/therapist had to offer. So, explain the layering, educate a little from the beginning what the next steps will be. Suggest a routine followup in a short period of time either in person, phone, or email, to make sure both of you are on the same page. Increase the complexity of each treatment modality as you learn what the patient can or can not do.

Partner with your Patient, not control them

As you can tell this is a big theme of my practice. It works for me, but definitely not with all of my patients. Many patients do just want to be told what to do. Many patients just want to tell you what they expect you to do. One small example is with the barefoot runners. Many times in the last year with this barefoot running craze patients who I think need orthotic devices tell me that they will try anything but orthotics since they want to keep their feet strong, even when I think orthotics used in the short term would speed up their progress. They are being honest with me, and I try to be honest with them.  Try always to work around differing opinions, and you may be surprised you are not always right. Take your patients as they come. Most very different but very much the same as you. Individual needs should replace protocols unless you feel that their safety is in jeopardy. This rarely occurs. For those of you who want to read some fascinating, and eye opening personality categories, read a book on the Enneagram. It means 9 Personality Types. It means that 9 people could sit in a room with a problem and come up with 9 very different solutions. Always consider that your patient will look at the problem different than you and just needs your guidance on good sound options for them.

Learn the Complexities of Various Treatment Modalities, and Master the Subtleties

Every treatment modality you use, can be modified. Every treatment modality, has multiple layers of complexity. Learning and mastering the modalities you use daily will bring you great success as a health care provider. If I ask a patient what they are doing to help their injury, a generic response may be icing, better shoes, strengthening exercises, and physical therapy. Most health care providers would leave it that since it sounded very well thought out---anti-inflammatory, mechanical changes, strengthening and expert help. But, it is fun to probe into each modality, and you definitely have to if they are not improving or getting worse. How are they icing? Can you recommend any changes, or should we switch to contrast bathing for the swelling problem you can see? How did they select their shoes? Do they feel better in the shoes, but only walk 30 minutes per day in them? Are the strengthening exercises hurting them? Are they the right exercises? A blatant example I commonly see is patients with posterior tibial tendinitis strengthening the anterior tibial tendon and not engaging the posterior tibial tendon. What is the physical therapist doing for them? What are the good aspects of the treatment, and what should be modified? Be curious, and keep learning.

What are the Common Causes of Injuries?

The most common causes of injuries include:

  1. Structural Problems---commonly seen in gait evaluation
  2. Muscle/Tendon Problems---commonly seen in gait evaluation
  3. Ligamentous Issues----sometimes seen in gait evaluation
  4. Dietary 
  5. Internal Medical
  6. Training Errors
  7. Equipment Errors---commonly seen in gait evaluation
  8. Neurological---sometimes seen in gait evaluation

Be A Teacher and Friend, as well as a Doctor

The emphasis here is on teaching. Some of you will be natural teachers, others not. But, that is what staff is for. Train your staff well in areas you are lacking, we all lack something vital and need help. Delegate, but remain committed to this education. This blog is to educate my patients and others. Our physical therapists helping me can take more time than I to educate. The running shoe stores you refer to must be known to give good advice---teach all your patients at least to Power Lace. Make handouts. Write Lists. Remember the average patient only remembers 30% of what is told in a medical office visit. Give them your email to ask more questions. Be Friend them, if they want, and most do. If you have ever visited Dr Richard Green's office in San Diego, you would know what I mean. His patients were all his friends. Quite impressive role model for me.

Do Not Give Control of Treatments Completely over to Anyone

I make a lot of referrals. Modern medicine is getting away from the concept of primary care giver who knows all--except in the concierge practices now growing. I do only a mediocre job at followup. I am always striving to be better. I want to know what others are saying and doing for my patients. Do not be embarrassed to disagree with another. If the patient is doing better with a referral and trusts that individual, great news. If things are rocky, and improvement slow, analyze what is going on closer for your patient. Help them as much as possible. Be a loyal teammate who has their back.

Understand Foot Inserts and be an Expert in their Design

Podiatrists are foot people. We dedicate our whole lives to make feet happier. Understand all the functions of foot inserts, both custom made and over the counter. I have never found an insert that did not have some value. Some patients need fairly generic inserts to support and cushion, others need very specific support, and others need only cushion. Know what is readily available. Think outside the box and modify inserts for even better symptom improvement.

Listen for Your Mentors, they are out there

What powerful mentors you have here in Drs Dutra and Choate. Go seek out the local podiatrists in your area, and the current members, fellows, and board members of the American Academy of Podiatric Sports Medicine.

Learn from your FollowUp Visits, and Develop Flow Charts

I think we are all pretty smart sounding when we first meet a patient. The first visit, with questionnaires, a lot of action, gait exams, initial prescriptions, etc, is pretty easy for most health care providers. You learn a little about the patient, and you start action. But, it is the followup visits that the true art of medicine is practiced. You learn more about the patient, and them about you. Your listening skills, their response to treatment, your problem solving if there is problems or no improvement, their willingness to do all the treatments you outlined (like ice 3 times per day), and back and forth your team is made.

I love flow charts to organize treatment for patients. One of doctors is a master at it. I have the natural rhythm of an injury rehab flowing in my head so that I can evaluate each patient's progress with it.

Use Email to Develop Good Followup

Find Ways to be Involved, Do Not Be Detached!!

Quiz Questions For 1/29/13

  1. What are the five common biomechanical problems normally treated in a sports medicine practice?
  2. Explain the 80/20 rule in athletic rehabilitation and how it correlates to the pain cycle.
  3. What are the three classic phases of athletic rehabilitation and explain how they can blend together?
  4. Explain what tissues at the knee are stressed when a patient excessively supinates.
  5. For every treatment modality, there are many layers of treatment going from simple to complex.  Explain how this can be applied in a case of a patient with achilles tendonitis.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.