Is Diagnosis an Important Part of Assessment?

Members do not see these Ads. Sign Up.

I am grateful to Podiatry Now for permission to reproduce a recent Biomechanics Corner column.

To this I would add the following, by means of stimulating a debate.

There are many shake and bake models for biomechanical assessment. Root (or perhaps we should call it Langerroot) is the classic. Dennis has his. The talar made protocol which bases the prescription on the supranavicular angle (feiss line) is gaining a following (free DVD available on request). One poster who's identity slips my mind often talks of Biomechanics needing to look past the patients pain, and assess the success of the outcome on how much we can improve the patient's gait.

I am suspicious of all of these, and any which looks entirely on optimising function over resolution of pathology, or even ignores the specific pathology altogether.

What say you? What is the most important part of an assessment? Is it the nature of the patient's function, or the nature of the patients presenting pathology?

Regards
Robert

 

Robert,

I'll play Devil's advocate, if I may. Lets say we have a patient presenting with pain in the region of the 2nd MTPJ:

1) List the pathologies that might be included in a differential diagnosis?

2) For how many of these pathologies would the treatment be the same?

 

BTW, Devil's advocate a side, assessment is carried out in order to make a diagnosis.

 

Ive been having a bit of a think about similar question over the last couple of days at work.

say we take 10 patients from the country nnnnn. They go to an orthopeadic surgeon for pain who may not even look at the patients feet they gets a diagnosis of 1 of the following

1 all heel pain heel spur
2 90% of forefoot pain is a collapse of the front foot valve
3 10% of forefoot pain is Morton´s toe

The patient feels great they go of to a orthopeadic tech who makes them an orthotic which if the patients all have the same size feet no one could tell them apart.

7/10 get better

Why ? is what Ive been asking as all the diagnosis are not even diagnosis one of them is a myth, the orthotics are not customized apart from the size.

This country of course does not exist :bang: and these example would not happen :craig:

 

Good man.

Oky doky.

Some possibilities without heading into zebra territory or writing a treatise on FF pain.

Plantar plate rupture / tear
Stress fracture
Capsulitis
Neuroma :butcher:



How I would treat if I suspected

Plantar plate, Possibly refer for ultrasound / MRI / surgical opinion. possibly strap toe. possibly seek to dorsiflex met

Stress fracture, possibly refer for xray, Possibly seek to exclude osteoporosis (being all holistic and ****). Possibly seek to support the met evenly along its length.

Capsulitis, Try to establish why it is present, is the 1st met incompetent? Tx might involve working more on other structures to increase their load bearing capability.

Neuroma, Try to increase IM space, decrease impulse.


The same treatment? No. Possibly the same INSOLE in places but as we know the TREATMENT is much more than the INSOLE.

A big ole met dome might spread the mets nicely for a neuroma but I suspect a patient with a stress fracture in the shaft of the met might not thank you for increasing 2nd met dorsiflexion moments. The capsulitis might breath a big sigh of relief if you give it a nice cavity to sit in but if that involves more dorsiflexion of the toe the plantar plate would like it not at all!

And what of prognosis? Failing to give a patient an accurateish (sic like parrot) idea of how long before they start feeling better is not the path to joy!

I've been there on my darker days. The "sod it, give em all an interpod and pick up the pieces of the ones who get worse" days.

I console myself thus. If we took 20 visits to a gp on a given day and gave them all pain killers, I'd bet 15 of them would feel better. But we don't go to our medics for a best guess and a % shot at improvement. And how many of your foot pain patients will still be better in summer when they go into sandles? Because your ortho tech won't have told them what to stretch, or exercise, or what to do if they have a flare up, or how to self manage, or given them advice on what footwear when, or what strapping would help that they could do at home, or whether its something they are stuck with for life or just the next 6 months. Etc. Lets remember we do more than give insoles.

And of course there is the patient I saw today who has been round dozens of such "have a stab" treatments in the last 5 years for idiopathic motor neuropathy. 5 years, and nobody has bothered to test which muscles work just fine and which have completely given up and vanished. 5 years of variations on AFOs which could never have worked. 5 years without know what was wrong or why.

Ask HIM if a diagnosis was important.

Regards
Robert

 

Surprised you didn't mention Friebergs infarction, you being a paediatric specialist and all

Personally, I'd go through every tissue from superficial to deep. It could be a corn-right? Pass them through the pathological sieve- superficial to deep- what is there? Then ask: is it really coming from "there"?

The point being that the treatment of several condition's that may produce pain in the region of the 2nd MTPJ should include mechanical rest of the area. So even without a firm diagnosis, one may begin to relieve the patients symptoms while follow up studies are performed. Given the current waiting times in the NHS for "follow-up" studies, you may even have "cured" the patient by the time they get their appointment for the x-ray, ct, mri , ultrasound etc... viz efficacious treatment may be obtained without a firm diagnosis.

So, if we had better imaging (your treatments seemed to depend on these) at the point of assessment, would more efficacious treatment ensue? Or, would you still off-load the area?

 

My original list was longer. Then I realised I'd have to write about all of em!

HEY YOU NICKED THAT!!! (para 6 of that article).

By that logic ALL problems which produce pain in the area can have the symptoms releived with paracetamol and lots get better by themselves with time. Seems a little unambitious to me though.

Although I conceed we can cure patients by working through the treatment options based on % success rate (assuming we don't make it worse of course), Its possibly not the BEST way to find out what they need.

Ah, in the utopian world. Actually only one of those examples calls for more than a simple 50 year old tech x ray.

But yes, I think more effective treatment WOULD ensue with better diagnostics.

For example. In another thread we talked about plantar plate repair surgery. Done a fair bit in the colonies I understand, and in SOME clinics here. I presume the operation must have some merit (or why would it be done?)

In 10 years in the NHS, seeing almost entirely biomechanics for the last 7, i've seen approximately zero patients diagnosed with PPR or PPT and zero patients who've had repairs.

Now it COULD be that PPR has a demographic spread peculiar to areas with access to MRI scanners, but I suspect not. So where are all those ruptured or torn plantar plates in kent? Limping around with undiagnosed, or worse MISdiagnosed forefoot pain I suspect.

And when they roll up at the surgery office with forefoot pain or dorsally subluxed toes they get told they have... well obviously not PPR/PPT. And we shan't dwell on whether the surgery they have is optimal. But I see a LOT of unsuccessful neuroma excisions! (in met spaces 1-4 inclusive)

Whereas since I've been looking for it, I've started finding it. And its changed my treatment approaches based on what I'm trying to achieve.

DCIS, another example. The "mechanical rest" bit of the treatment (different lacing on the shoes) I was doing before. But now I know what I'm looking at I can do other stuff as well.

Regards
Robert

 

Actually, I got that several years ago from a podiatrist / osteopath, roger2shirts- I think. Sage advice, don't you think? What article are you talking about?

 

Here's something else that I've "nicked": "it's no secret that ambition bites the nails of success"- as the American's say, "go figure"

 

The one at the top of the thread.

I nicked the "skin down" approach off my first mentor, Steve Lassiter. Great guy you'd have liked him. BIG into his foot anatomy. His theory was that when a patient put their finger somewhere and said "it hurts here" you had to know what was under their finger.

As we say in Kent, "I guess". Do the nails of success have an alternative means of keeping short enough to stop them breaking? I may be stretching the analogy too far. Do the clippers of pragmatism or the file of honest self appraisal come into play? Does the mycosis of selection bias or the subungal corn of the take-the-best heuristic affect them? Are the aforementioned covered by the nail varnish of the placebo effect.

Sorry. Got allegory all down me.

Joking aside, I think one also needs a backup plan for when a diagnosis is not apparent. And in honesty I still see feet with the "it hurts all over, all the time" or Untheir syndrome in which I do have to take my best guess at a prescription or protocol based on trying to optimise function or assessing in gross terms what movements are painful. Better that than try to cram the patient into a diagnosis which does not fit. But I think that has to be plan B.

Regards
Robert

 

Nice thread Robert
It is a question which I have thought about quite a lot over the years.
I do not always have a firm diagnosis before manufacturing orthoses.
I guess I always take the approach that I need a reasonable theory why a particular area of the foot is painful and that there is a pattern suggesting a mechanical link. This can be confirmed via relatively simple interventions such as taping and padding-
I will seek a more certain diagnosis if the the pattern is unclear.

Example- athlete with 6 week history of achilles pain, bilateral. Referred by orthopod for an assessment and he has poor foot structure. Also notes some forefoot pain has been increasing over the past few weeks.
So far alll sounding like problems which may be mechanical...
'So what level of sport are you doing now/ what is different that you are getting this forefoot pain?'
'Nothing- no sport- I have been decreasing my sport because of my achilles- I am doing less, but I have new pain and my old pain is not better'
Examionation showed swollen 2-4 toes.
Off to see the physician again to find out there is a seronegative arthropathy.
Up to the point where the history was unusual, I would have been comfortable with a treatment plan which addresses his biomechanics.

On the flip side I have seen many people who have been passed from Xray to MRI to CT between practitioners seeking a diagnosis of a problem which can be explained by mechanical overload.
Treating biomechanics can be diagnostic also...


As for this...

I believe Julie Gregg- a Sonographer from Melbourne- as part of her studies found that there was a high number of PPR (over 50%?) in people over 60- perhaps Craig P can clarify this- suggesting that they are not neceassarily symptomatic or possibly that they have a limited time they are symptomatic.

 

I think the real issue here is that of "what a diagnosis is, and what a diagnosis isn't". "Pronated feet" is not a diagnosis.

I am reminded of Morgan''s meat pie paradigm though. If the patients gets pretty much the same foot orthoses regardless of their pathology, why bother with a diagnosis? Which brings us nicely around to prefabricated devices....

 

Love that meat pie story. Perhaps its worth telling again Simon? For the newcomers?

This contention leans on two premises I feel are erroneus.

One, that the patient gets the same orthoses regardless. Which they don't (not from me at least).

Two, that the orthotic is the only or most important part of the treatment. Which it isn't.

Consider Craig's patient. If we had not bothered with a diagnosis and just given him his meat pie, he would not have found out about his Seronegative arthropathy. Which means he would not have been able to also explore the other TX options, the DMARDs etc, without which his meat pie would only have helped his feet. And they might not have been enough to do that!

Given the choice between being able to do everything in my treatment arsenal BUT the orthotic, or the orthotic and nothing else... Tricky choice. Depends on the patient. I saw 5 new Biomech patients today. 2 I cast for orthotics, one a plasterzote over EVA laminate and the other a high density EVA shank dependant. One got a pre fab and a bunch of advice, the other two got advice and no orthoses.

Are you still devils advocating BTW or are the views expressed now those of the author?

Regards

 

Tell the new kids the meat pie story !!!!!! cause more meat pies in a post than Roberst and I´ll get confused.

 

Are you the exception or the norm? I would contend, having recently visited a commercial lab here in the UK, that there are still an awful lot of practitioners prescribing devices who: a, can't cast a foot for toffee and b, can't write a prescription for toffee. It reminded me of my time in a commercial lab where we would frequently get a form saying "labs discretion". How many people regularly prescribe a 4 degree / 4 degree device AKA a meat pie regardless of the diagnosis?

Here's the rub, Rob. If we take a patient centred approach and make prescription devices based on our best current knowledge for a group of them with pathology x and then take another group of patients with the same pathology and give them prefabricated devices, which ones get the better outcomes? What does the literature tell us?

While orthoses are not the only fruit, they are, in my opinion, a very powerful tool in the treatment of pathologies that have mechanical origins when employed correctly- see above. What do you think is the most important part of the treatment?

What do you think?

 

These are not my ideas, they are those of Gary Morgan who, as the legend goes, was returning home following his attendance of a course run by a large international orthotic lab and stopped off to buy some supper from his local fish and chip shop. Perusing the menu our hero noticed that you could have meat-pie with chips, meat pie with mushy peas, meat pie with potato fritters, meat-pie with gravy, meat pie with curry sauce, meat pie with.... the list went on (classy joint). He then reflected upon his days learning in which it seemed to him that despite the presenting pathology, the course leaders were advocating that patients should pretty much all receive a foot orthoses manufactured from a neutral suspension cast with a 4 degree/ 4 degree rearfoot post. Gary reasoned that this prescription was the "meat-pie"; that you could dress it up with different top-covers, or met domes etc., but at the end of the day it was still a meat pie just with a different a side order.


Something like that anyway.

If anyone knows what Mr Morgan is up to these days, get him to recount this, I'm sure he'll make a better job than I.

 

I like the meat pie story..........

If we just consider the orthotic section of a treatment plan

What sort of success rate does the meat pie device have though in treatment plans. If we consider Root/Langer combo with your 4/4 ( a little rave base)?

You have a moslty failed method for determining why your prescribe your device, ie you pronate too much, diagnosis become 2nd in importance , you then prescribe your ´meat pie´device .Compair this to now where diagnosis of problem is key, use physics and knowledge of biomechanics to prescribe a device to take load from stressed tissues.

are success rates of patients outcomes better now or then in the general podiatry world?. Maybe there is still 100´s or 1000´s of people using the 4/4 method today

and then why did/does the old method get +ve results ?

 

Is it only me who goes through some kind of Pavlovian response when I hear that story? Every time I have read it I uncontrollably salivate and reach for the car keys...

 

I love a good pie, me. But to be honest I'm more sophisticated these days and prefer the doner- it's exotic. Tell the truth the story works just as well with the doner: doner and salad, doner and chilli sauce, doner and chips, doner meat and chips....... Back in half an hour- nipping to the kebab shop.

In fact, last weekend I went to back to Northampton, hadn't been there for at least a decade and went into Buddies- a burger joint based on a New York diner, long story short- at least 50 different burgers on the menu.... all of them based on a meat beef burger, each with different embellishments. If you live near Northampton, Buddies is cool.

P.S. Lawrence Bevan- the Istanbul slug is still in operation...

 

Istanbul slug...good times...however a classic lesson in the need to thoroughly wash lettuce.
;-)

Re "diagnosis". These days in the NHS at least the emphasis is on using Podiatrists to replace the traditional diagnostic role of the Orthopaedic Surgeon. In that setting the "diagnosis" is paramount, whilst you may hit a 7/10 strike rate with empirical treatment it's the one who says "why wasn't this condition x found earlier" thats going to give you the problem.

Re "meat pies" - they should be on prescription, world would be a better place

 

By law I can not Diagnose. Therefore I concentrate on the latter.
Aetiology
• noun 1 the cause of a disease or condition.
Then I use my tool box to try to relieve the cause.
Hans Albert Quistorff, LMP
Antalgic Posture Pain Specialist

 

Huh??

 

This is not as unusual as it sounds, Ian. However, we have in Hans post something of a paradox, if he cannot diagnose, how can he seek the aetiology of an unknown condition? Answer: someone has to tell him what the diagnosis is!

 

Originally Posted by HansMassage
By law I can not Diagnose.
Huh??
__________________
My location

For those not in the USA It may seem confusing but each state has its own set of practice laws and each field of health care providers tries to carve out their exclusive niche that the other can not invade by lobbying the state legislature.
Massage is within the scope of practice of most of them but they don't want to work but they also don't want to lose the profit so the "doctor" provides the diagnosis [translate what the patient says into medicaleze] sends them to us with a prescription; we do the assessment , treatment and plan and send it back to the "doctor"
Then the insurance adjuster goes over all this hoping to find a missing digit in the coding so that they don't have to pay.
Did somebody mention health care reform in the USA?

 

Simon/Hans,

This is completely new information to me - I was unaware of such legalities. Guess I can tick off my something new learnt for today, and its only 9.30am. Result.

Ian

 

Whole medical systems are set up on this type of idea.

In Sweden the governement pays for a lot of the health care by huge tax bills on everyone and anything sometimes 2 or with petrol 3 taxes. Anyway .....

The person feels some pain say in the knee, goes to GP who then refers to an orthtopeadic surg who then may or may not refer for x-ray, MRI or perform an artroscope straight away to ´have a look inside´ They then make a diagnosis are refer to P & O, Physio etc. The diagnosis follows the patient and treatment is ment to be built around that Diagnosis, it can not be challenged by the P & O etc only by another orthopeadic surg.

EDIT. Podiatry does not move in this system it´s in the private medical section

 

This new hand held ultrasound should help with diagnostics.
Not as yet available in the UK and still waiting to find out the cost.

Signostics Personal Ultrasound

Justin Blake

Dundalk Foot Clinic

 

What say I!! Unfortunatley Robert sometimes it seems the most important part of an assessment is for Practitioners to look good and to be seen doing something. Or maybe the morgage repayments go better with orthotics for everyone! When I get patients in with three or four sets of orthotics it can be a challenge. It can be hard to maintain the integrity of the Podiatry profession as the patients bull **** radar is in full swing and any time taken to diagnose and think and talk things through is clouded over with past statements and variations.

The nature of the presenting pathology though and then how it affects function is the way I like to go, in most cases.

 

Sorry to pour water on anybodies bonfire, but the Royal College of Radiologists take a very dim view of Clinicians using Dx US without the proper training! many enthusiastic folk are using this kit rightly or wrongly, but many will need a Radiologist behind them in case of mis diagnosis and potential litigation.

 

Apologies for not reading in detail the above posts. "Is diagnosis an important part of assessment"?

We have missed the point, big time. Assessment is a critical part of diagnosis. I apologise if this glaringly obvious point has been made earlier. Rob