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Saturday, January 2, 2021

Rules Guiding Treatment: Excerpt from upcoming book entitled "Practical Biomechanics for the Podiatrist"

The following excerpt is from my upcoming book entitled "Practical Biomechanics for the Podiatrist" which should be released at the end of 2021 or summer 2022. I hope that there is wisdom in these words. 
And, as a patient, when it is obvious the rules being followed are not helping, speak up about a possible change of course or in some modality. 

More About Rules

Many rules in medicine are just guidelines. You need to learn that there are general rules of a profession or discipline and there are golden rules (some that you will need to create) that will guide your practice. A general rule is a guideline whereas a golden rule should not be broken, at least by you.  For example, the general rule is that lateral foot pain is from over supination and medial foot pain is from over pronation syndromes. The exceptions to this general rule are numerous like lateral ankle or subtalar joint impingement from over pronation or posterior tibial tendon strain from over supination. Therefore, general rules are guidelines with exceptions. An example of a golden rule is that if we help the patient create a 0-2 pain level for all phases of rehabilitation and all activities the patient will be given the opportunity to get better.  Learn the general rules of your profession, but create your own golden rules. Write them down, say them out loud, and to others, and do not vary. The next few paragraphs include a couple of my many golden rules that help me practice, and as a podiatrist you may agree or have your own golden rules. 

      Golden Rule: All bone pain can be caused by poor bone health. Seems very simple written that way. A patient presented with severe bone pain causing shin pain for 2 years. I was the 8th doctor he consulted. He was 27 years old. At the first visit, with none of his previous records yet to go on, I applied my golden rule due to his palpable shin bone pain and ordered a bone density test. It came back that he had severe osteoporosis with the bones of an 83 year old. He is gradually improving with the help of an endocrinologist. This had been missed at a major university hospital.

      Golden Rule: Medial meniscal pain is either helped with valgus wedges or varus wedges. It took me a while to learn this one practicing in an orthopedic clinic. The general rule is for valgus wedges to be used with medial meniscal pain to attempt to open up the medial knee joint line. If that did not work, meniscal surgery was done. But, I remembered that Dr. Root had taught that pronation caused tibial inversion which can crowd the medial compartment. When patients did not respond to valgus wedging, I just flipped them over to give them a varus wedge. It proved to be around 45% of the patients responded to varus wedging and 45% of the patients responded to valgus wedging, with 10% still needing imminent surgery. In the long run, some of those patients did require surgery but some 40 years later are still coming in for their wedges to be made.

      Golden Rule: Low Back Pain that feels worse with walking or standing or moving may be helped with foot biomechanical corrections. A 24 year old patient with golf related low back pain was referred to me after 2 years of physical therapy, micro-disc surgery, and then 2 years of chiropractic treatments. He experienced no pain sitting or lying, only walking and after one hole of golf (many attempts in those 4 years). When I performed my initial cursory gait evaluation, I noticed a lean to one side (many causes of that), and he commented I was the first person to watch him walk in 4 years. Osteopathic evaluation noted a possible ½ inch short leg and some foot pronation. Due to the length of his disability, immediate AP Pelvic Standing X Rays in Normal Stance Barefoot were taken documenting 7/8th inch short leg. Within months after correcting all his shoes, he was back playing full rounds of golf with no problem. We never got around to correcting the pronation part of the picture. Years later I met his dad who informed me that he was doing great, and only asked if I felt the back surgery had been necessary. Oh well for my $200 treatment!

      Golden Rule: Always Treat all 3 causes of pain in patients presenting in pain (this is a tie in to my last blog post). Those are mechanical causes and their treatments, inflammatory causes and their treatments, and neuropathic causes and their treatments. A problem can be caused by one source, but need to be treated by all three. A problem can start mechanical, and then have the inflammation and nerve hypersensitivity develop days and weeks or months afterwards. I find that body reactions to a problem are like a bell shaped curve with an average reaction and people on either side of average. It does not matter what response you are talking about (swelling, pain level, scarring, nerve hypersensitivity, muscle atrophy, etc.) there are those that hardly have any reaction, or a more normal reaction, or an exaggerated reaction. The wonders of the human body are on full display at times. Almost daily I see patients for 2nd opinions with heel pain treated with orthotic devices that are not improving. The orthotic devices are typically well constructed, but create too much heel pressure. The general rule with heel pain and orthotic devices is that the devices should soften the heel and transfer the weight to the arch. It is typically easy for me to adjust their current insert. Yet this is only the mechanical treatment of the heel pain, with the inflammatory and nerve aspects of treatment normally needing more options. It can be tricky since what helps inflammation does not normally help nerves, and vice versa. Nerves hate ice, love heat. Inflammation loves ice and heat can make them worse. Sometimes finding out how a patient responds to ice or heat can help guide the treatment of what is most important at that time.

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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.