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Friday, December 13, 2019

Philosophy of Treating Athletic Injuries (Part 1)

Philosophy of Treating Athletic Injuries (Part 1)

The treatment of athletic injuries is based on many principles that must be applied to the individual with his/her injury. Of course, the same principles that are used on athletic injuries can be applied to non-athletic injuries and pain syndromes as well. The experience and knowledge base of the doctor and therapist become very important to the patient. The decisions of diagnosis, cause, when to cast, when to X-ray, when to inject, and when to stop all activity must be carefully thought out. This is why this is not a cookbook lesson plan to be easily followed by any doctor or therapist. Understanding the individuality among athletes is the key to understanding the complexity of treatment of athletic injuries. Each similar injury has a different set of circumstances associated with it. There may be differences in, among other things:

·       severity of injury
·       severity of the cause
·       length of time that the injury has been present
·       amount of residual weakness, swelling, scar tissue accumulation, or stiffness
·       suddenness of the injury
·       individual’s sport
·       individual’s physical, psychological, or emotional need to return to activity
·       previous treatment
·       speed of return to activity
·       pain tolerance
·       multiplicity of the problem(s)

Does this give you a hint of the complexity? The patient is a stranger to the doctor or therapist on the first visit. There is sometimes a limited amount of time to sense the patient’s problem, frustration, cause or causes, and possible treatment plans, etc. Many decisions are then made. The patient’s main goal is to rid himself or herself from the problem as soon as possible, with no recurrence. The health care provider’s main goal is to safely rid the patient of the problem with no recurrence. Should the patient rest a day, two days, two weeks, three months? Should the patient self-treat the problem at home to save expenses, or be seen in therapy daily, weekly? Should an elaborate work-up on the cause be pursued? Should every ache and pain be X-rayed, bone scanned, MRI’d, casted, or injected? Should every possible cause be treated, even if this would entail months of treatment and huge expense to the patient? The purpose of this conversation is to bring the patient closer to the doctor/therapist in making decisions on treatment care. It is a joint venture, and both must know what the other is thinking. This TEAM approach is unique to sports medicine, but slowly spreading to other disciplines as well.

There are a few common athletic injuries where the doctor or therapist must immediately realize that the patient’s problem is very serious. The crack or snap that is heard, the amount of sudden swelling, the severe intense pain, the total inability to walk without pain, the inability to bend a joint without severe pain, the history of years of pain without relief, can all signal the doctor/therapist to regard this injury as special and definitely serious. Complete investigation should be performed in all of these cases. Fortunately, these are the rare injuries. Definitely, five percent or less of all athletic injuries fall into this category. Most of the time, the injury was gradual, with no to minimal swelling, only moderate aches (level 5 pain at most), with no limping when walking, running, skating, dancing, etc. All body parts are freely movable. The symptoms have existed for three months maximum. Should be easy to treat, right? Sometimes that is the case; but there are so many variables that play a role in the difficulty or ease of treatment.
     The doctor or therapist must have basic rules that guide them in their treatment of  injuries or pain syndromes. A starting place for the treatment of most injuries develops from there. For each doctor or therapist, these basic rules are very different. Hence, the reason that some are successful at treating sports injuries, while others are not.
But even the best doctor/therapist cannot put all the pieces together all the time for every patient. And, of course, the patient feels let down, misdiagnosed, ripped off, etc. Can this be prevented? Sometimes it can. If the basic trust in the doctor and therapist is there, the patient will communicate his or her frustrations. This forces the health care provider to re-evaluate the course of action and accept failure, change direction, etc. Usually the doctor/therapist is busy actively treating many patients at any one time, all in different stages of healing, without the ability to individually check on the progress of each patient. The patient must follow up, inform if there is no change for the better, and positively help in the healing. There can be physical reasons a treatment regimen fails.
We must avoid failure from patient frustration and lack of communication and distrust in the doctor/therapist and patient relationship. Fortunately, 90 percent or more of patients get better when communication is free flowing.

Here are some basic principles in the treatment of athletic injuries. The first priority right at the initial visit is to decide on the severity of the problem. The two important categories are major and minor. A major injury needs no guesswork in treatment philosophy. The patient may develop permanent injury if not treated quickly, accurately, and intensely. This is the first type of injury we discussed, when there is the inability to walk, severe and intense pain are present, etc. Diagnosis is important. X-rays are taken, and MRIs or other tests are considered quickly. Physical therapy is initiated. Expense, time, and risk of radiation become minor concerns or no concern of all. These, in a way, are easier to initially treat. Cookbook teaching is present for most. Follow the book and success in treatment is usually obtained. It may take months or even years to rehabilitate, and the patient may never run or ski or dance again, but the doctor is the hero. He/She prevented it from getting worse, taking longer, etc. Hopefully, you are completely cured in the process and can resume all activities.

Fortunately, most athletic injuries do completely recover!!!
And, fortunately, few injuries are considered in this major category.
The patient's outlook on their injury varies according to:
·       outlook on severity: major or minor problem to them
·       expense of possible treatment
·       time and energy of possible treatment
·       speed of recovery desired
Therefore, with 95 percent of all injuries considered minor in consequences, the doctor/therapist must come to grips with the patient's perspective. The doctor or therapist then maps out a plan of attack after the initial evaluation. Always important to have, this plan of attack has different variables. These are:
·       Further diagnostic testingnow, or only if not getting better
·       What type of pain is the primary source at present: mechanically induced, inflammatory, or neuropathic?
·       Initial treatment planphysical therapy, home exercises, medications, casts, lifts or other shoe inserts, training adjustments (i.e., rest, alternative exercise), taping and other treatment modalities
·       Back-up treatment planif patient does not get better, if patient is better but wants faster relief, and if patient wants insurance to prevent re-flares (Golden Rule of Foot: Always Have a Plan B)

Patient Education Advice—the patient needs to know how to prevent recurrence of injuries by knowing the cause of a particular injury (and the causes of most injuries). This is so crucial in preventing the same injury from just coming back. It is one of the key reasons podiatry is so successful with athletics because we can find a cause to reverse. As the doctor or therapist maps out the proposed treatment plan, it is based on what the majority of patients with the same or similar problem became better with. I try to point out all the possibilities of diagnosis, cause, and treatment, and then allow the patient to decide how much expense, time, and energy he or she wants to build into the rehabilitation plan. Most patients are started on a home exercise program and other self-help ideas. X-rays are not routinely performed, since 90 percent of the time the injury is limited to soft tissue. Casting is done when walking is difficult, but removable casts/boots have revolutionized the process (if you have to get one, look into the Ovation Medical ones). Much less muscle atrophy is seen with removable casts/boots than the traditional permanent casts. Cortisone shots should be limited to only mandatory situations due to their possible weakening effects on the soft tissues. Never have tendons injected with long-acting cortisone since possible ruptures can occur. 
Patients are advised what the next step would be if the injury is not responding to treatment. Sometimes there are so many possibilities of treatment that they all cannot be covered in the initial visit. Surgery rarely is needed for a particular problem, so it is not normally mentioned at the initial visit. The doctor or therapist tries to discuss with the patient:
·       His/Her immediate concerns at the full diagnostic examination (if the diagnosis is still questionable, does the patient want/need X-rays, MRIs, etc.)
·       The patient's ability to begin therapy now, speeding up the process of healing (I can think of very few injuries, primarily neuropathic pain syndromes, which would not be helped by therapy)
·       Their concerns for a rapid (as fast as possible) recovery
For some health care providers, it will seem strange that some patients do not want the "best" fastest care. The problem is that with this "fast" care comes expense, time, and energy. These are commodities some patientsmost patientsare short on. Most of the time we settle on slower, but still effective, courses of action.
Problems arise when the doctor treats the patient on a slow course, cutting expenses, when the patient wants to be cured today, or even yesterday. Some patients must face reality. If they want the best, more effective treatment of their problem, they must give the time and energy and expense to accomplish it. Medical care costs are getting out of control, and paying for it more of a burden.

It is important to minimize the amount of patients going elsewhere when their treatment is slow or recurring. Again, communication is the key. The doctor or therapist must respect the patient as a person, and the patient must view the doctor/therapist as someone truly concerned. Sometimes, there are no good answers to a problem. I try to limit those to a small percentage. I find that if I can communicate with a patient, treatment goes well. If the patient never trusts me, communication will not go well, and the treatment will be shaky, with constant problems. Broken trust between doctor/therapist and patient is rarely fixable.
To be continued (this was an excerpt from my book "Secrets to Keep Moving").

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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.