Taking A Good Biomechanical History: Excerpt from "Secrets to Keep Moving"

 Biomechanical Approaches to Treating Pain

 This is the start of Chapter 1 from the book "Secrets to Keep Moving" about taking a good history (or giving one).

Golden Rule of Foot:  With so many pain syndromes having a mechanical component, it is important to treat painful areas with mechanics in mind.

The topics included in this chapter are:

1. Taking a Good Biomechanics History (which is the topic of this blog post)
2. Understand the symptoms related to pain syndromes of 5 Common Mechanical Problems
3. General Principles for Foot Orthotic Devices
4. Treatment of Short Leg Syndrome
5. Hannaford Devices for Shock Absorption and Memory Foam Accommodation
6. Common Shoe Modifications
7. Running Shoe Choices, Evaluation, and Orthotics
8. Right Handed vs Left Handed
9. Taping Techniques

1. Taking a Good Biomechanics History

    This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Follow up visits work off the success or failure of the treatment plan set on that first visit (it is why I am anal with staff to allow that patient ample time, and allow me to see them on time). If the information collected is inadequate, the entire sequence of events following may be subpar. Please review Chapter 3 on History Taking now before we go further.

    The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

 

1. Do you know if you have a short leg?
2. Do you believe you have weak or tight muscles in general, or around the injured part?
3. Do you have loose ligaments in general?
4. Are you right or left handed?
5. When you were a child did you have to wear braces or shoe inserts?

6.            Have you ever been prescribed shoe inserts?

7.            Have people told you that you walk or run funny?

8.            What has your history been of overuse injuries (non traumatic)?

9.            Have all or most of your injuries been to one side of your body?

10.         Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?

                                                   High Arches or Pes Cavus

    

11.         Do you have any arthritis from your hips downward and where?

12.         Do you feel unstable in any joints? 

    A skilled practitioner knows the relevancy of the answers to your problem. The answers will help point the course of treatment in the right direction. I sure hope it helps you.

 

Preparing for Upcoming Medical Visit: Key Factors in HIstorical Review

I   How Intense (use Pain Scale) is the pain? What Irritates (makes it

worse)?

     Patients present all the time to my office with injuries or pain syndromes. The patient may tell me that they have pain somewhere, but the intensity of the pain at various times of the day are crucial. Sometimes, the physical examination completely matches the level of pain and other times not. When not, the examination is much worse than the pain that the patient complains of, or the examination is fairly negative while the patient complains of much more pain than expected. This all means something, but it can take time figuring that out. 

     When a patient has had pain for awhile, they have normally tried various treatments (including rest). It is important for me to know what helps them, and equally important what irritates them. Sometimes the description of what irritates them separates the probable diagnoses (from nerve to bone to tendon). Some generalizations would be: Bone injuries are sensitive to impact, nerves are sensitive to positions, and tendons are irritated by motion only. 

Historical Review: Helps You Organize for an Upcoming Visit, and Helps the Health Provider Immensely!

A   What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?

     When you are seeing a healthcare provider about your symptoms, try to be organized in your thoughts. Standardized questions that you will be asked may not hit on the individual issue you are facing. Perhaps, boring to some who want to have full faith that the medical people will ask the key questions, this self examination that I have started several posts ago may hone in on your injury right from the start. 

     Of these self examination questions, your Assessment of the Problem may be the most important. I have so many patients tell me that they knew the diagnosis was not what the doctor or therapist came up with and stuck with for the year of unsuccessful treatment, but for some reason never spoke about what they thought was going on. Get it out on the first visit.

     This also applies to patient's fears that they need alleviated. The two common fears are cancer when a mass or growth is on the foot, or that the diagnosis will mean they will never walk again. If you have a concern like this, the question can be phrased simply "could be cancer, or will this mean I will have permanent problems?" 

    And lastly, the Anatomy involved should really be honed in before your appointment. Foot and ankle pain that I deal with can be very vague and that works against our finding some answers. At least if the problem involves a big area try to focus on what hurts the most. And, don't be like some of my patients who put their foot up and say it hurts, but can not really advance the discovery from there. In their defense, sometimes feet or ankles only hurt when you are doing something (running, hiking, dance, etc), and stop hurting completely when you stop. But, the more help I can get from the patient's self examination of the problem, usually the better. 

     

F: Family History of similar problem? Frequency of pain (how often)?

F Family History of similar problem? Frequency of pain (how often)?

     When patients get a problem, one area to review is family history. In my family, my mom and brother both had knee replacements, and my dad and sister have had serious GI problems. Things do run in families. 

     The second F concerns frequency of pain (how often). A patient can present with pain that only occurs at 5 miles into a run, or with each step. Just because a patient presents with pain, really understanding how disabling it is to a patient is easily misunderstood. 

Treating Foot Pain: General Discussion

     So your foot hurts!  Where do you go from here? Probably stay off your foot as much as you can. Probably take 2-3 advils, once or even twice a day. Maybe alittle better, but its is not really getting better. 

Was there an incident that happened, or did the pain come out of the blue? One place to start is in self examination. Pretend the doctor or nurse is asking the questions. I like this order of questioning. If you do see a doctor, I love when patients come in prepared like this. 

The mnemonic goes like this---

F Family History of similar problem? Frequency of pain (how often)?


A What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?


I How Intense (use Pain Scale) is the pain? What Irritates (makes it

worse)?


L With one finger, point to the exact Location of the worse pain?


E What Eases the Pain? Does the pain have an Electric sensation with it?

D What has been it’s Duration (how long has it been going on)?



O What were all the events surrounding the Onset of Pain? Are there

any Observable skin changes?


P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?


Q What is the Quality of Pain (burning, tingling, dull ache, sharp,

numbness, throbbing, pulsating, etc)?


R Is there Redness? Does the pain Radiate and where to?


S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?


T What have you done to Treat the problem? What Treatment has

helped? What Treatment has made it worse?


U Are there Underlying Health Issues (diabetes, osteoporosis,

arthritis, poor circulation, etc.)?


V Does the pain Vary (better at different times, worse at other times)?


W Can you Work? Were you injured at Work? Does this affect your Work

shoes?

Tomorrow, I will add to this discussion, but I wish all my patients would present with the answers to these questions.