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Thursday, June 27, 2013

Golden Rule of Foot: Keep It Simple Stupid

Golden Rule of Foot: Keep It Simple Stupid

     Yes, the famous KISS principle applies here as in most aspects of life. So, it is a great start to the Golden Rules of Foot that podiatrists live by. For every treatment plan, there are simpler and more complex modalities. Patients can help you decide if you go for the big guns or start slowly. I make mistakes all the time being too simple when more complexity is needed, and too complex when simple will do. So, I allow my patients a vital role as we discuss options. It is the nature of a sports medicine practice anyway for the doctor/therapist and patient to team up to work together on the problem(s) at hand.

     One of my patients today just injured her posterior tibial tendon. Because of many factors, including the fact that she ruptured the other posterior tibial tendon 15 years ago, I immediately ordered an MRI to know what direction to go towards. This would be considered a more complex approach, instead of a more simple xray, with course of icing, anti-inflammatory medication, and ankle brace. But, the seriousness of possible missing a tear and immediately treatment thus I could not take a chance. The more one uses an MRI you see when and where it really makes a difference. No KISS Principle today.

     One of my new patients today was in for a second opinion regarding big toe joint surgery. Very serious stuff, but her conservative care was very lacking, and the surgery suggested very complex with joint replacement. I started her icing 3 times daily, spica taping to hold the joint still, Cluffy wedge to place weight on the first toe, and dancer's pads to further off weight the big toe joint. Simple stuff to start for a serious problem. She is to call or email in a month and also send me her MRI done 6 months ago. Here I am starting with the KISS principle since it seems helpful and direct.

     One of the interesting factoids I have learned is that complex is exciting, interesting, and seemingly professional to most doctors, therapists, and doctors. They expect treatments to be something the patient do not do on their own. Add a laser into the discussion and everyone gets excited. Medical schools and seminars emphasize complex treatments and testing. And this is how the KISS Principle gets ignored, violated, battered, and destroyed daily in most medical practices. Students who rotate occasionally through our office seem bored with simple solutions and definitely are not taught this stuff. I rarely see a bunion patient with toe separators by their podiatrist as an example.

     I am internationally known for my orthotic designs, yet I use OTC orthotics routinely when KISS applies. I always prefer icing and contrasts to oral medications or injections. If a patient said that they would rather have surgery than to ice 2 times a day for the rest of their life, I would have a vigorous discussion of why that may not be prudent. The KISS principle can be boring, time consuming, and non-flashy, but 90% of the chronic pain patients I see have a very inadequate KISS based conservative program of treatment when I first see them. These are patients that have seen up to a dozen of health care providers. I also give credit for this dilemma to the patients for not following through on simple treatments, or implying to the health care provider that it sounds too simple (the provider hears that as an attack that they are "simple minded.") How often are simple treatments ended because they only gave 20% pain relief when 5 simple treatments additively could give 100% pain relief.

     When you are going through treatments, find what works even partially, and stick to them for 2 months longer than you need to due to pain. Make your treatments additive (One from Column A, One from Column B, etc). Add complexity when needed, but if the treatment complexity seems more than the seriousness of the injury, ask questions. And if the treatment simplicity seems not enough for the seriousness of the problem, ask more questions. I sure hope this thought process is helpful. Dr Blake

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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.