The Framework for musculoskeletal conditions in the UK

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This is worthy of posting here. It was picked up from a post by Tony Redmond to the jiscmail list:

Download PDF file of report

 

Musculoskeletal Framework

The Department of Health has published a Musculoskeletal Framework, which outlines the configuration of musculoskeletal services. The significant role of podiatrists within these services is well recognised in the Framework, which also includes guidance and advice on setting up and running Clinical Assessment and Treatment Services (CATS).

http://www.18weeks.nhs.uk/cms/ArticleFiles/gm5hdlexqmhakbqwzzxfb32t19102005124130/Files/MSF.pdf

 

"Podiatrists can be of great assistance in the management of low back pain and hip and knee problems"



Knee problems?
Unquestionably.

Hip problems?
OK?

Low back pain?
Other than identifying LLDs and correcting them....how?

 

See:
Gait style as an etiology to chronic postural pain. Part I. Functional hallux limitus.Dananberg HJ.
A common, but locally asymptomatic and therefore rarely recognized functional inability of the first metatarsophalangeal joint to dorsiflex strictly during gait is described. Normal motion is present in this joint during nonweight-bearing examination; therefore this is referred to as functional hallux limitus. Since this joint forms the pivot about which the entire body advances during each step, this disturbance in function, when repeated thousands of times on a daily basis, can alter foot and postural biomechanics. It can cause and perpetuate many chronic postural ailments, including lower back pain. When functional hallux limitus is specifically addressed in an orthotic treatment plan, 77% of long-term chronic postural pain patients exhibit 50% to 100% improvement in their overall condition, in spite of failing previous therapy on their specific site of pain and never exhibiting any foot symptomatology.

Gait style as an etiology to chronic postural pain. Part II. Postural compensatory process
HJ Dananberg


The body is designed to pull the center of mass over a single pivotal site formed by dorsiflexion of the first metatarsophalangeal joint. If this response dorsiflexion motion is blocked by functional hallux limitus, then the kinetic energy, which is created for this motion, must somehow be dissipated. The process by which this dissipation occurs creates a specific pattern of compensations which, in the past, has been seen as primary motions unrelated to sagittal plane blockade. These compensatory motions are described along with a brief section concerning the methods of treatment.

Gracovetsky SA. Linking the spinal engine with the legs: a theory
of human gait. In: Vleeming A, Mooney V, Dorman T, Snijders
C, Stoeckart R, editors. Movement, Stability and Low
Back Pain: The Essential Role of the Pelvis. New York:
Churchill Livingstone, 1997:243–51.

 

Achilles.

If one walks in with chronic anterior knee pain, and ipsilateral pathomechanics displayed statically/dynamically, I think we would be confident that addressing distal foot function would have a beneficial effect on knee pain.


But if one walks in with chronic LBP, and any pathomechanical display caudally, could you or anyone else here be confident that addressing a FHL for instance would work that far up the chain? I doubt it. Unless we observe a significant LLD and then address it, I doubt it.

 

Atlas,
Where do you think that the effect of foot function stops in relation to the kinetic chain??
regards
Tony Achilles

 

I am not sure it really matters as to were it stops (we have all seen the arguments re TMJ pain and headache), but maybe its more a matter of how much good data we have and how much of a good understanding we have ... ie the further we go up the kinetic chain the less good data we have.

 

and the more sceptism we are greeted with...

 

which is why we urengtly need more good data (one way or the other)

 

My rope/chain analogy best answers this for you.


If you have a rope/chain from your house to a place one block away, and you swing it violently, where is the main distruption and disturbance in the chain? It won't be a block away will it.

There are variables that I have spoken to pgcarter about, in relation to stiffness up the chain, but my analogy puts grave doubt in my mind that fixing something caudally can have a significant impact high up.

(LLD is different. Any 1cm difference will have a 1-to-1 impact at least at the lumbo-sacral/pelvic region. Whether this is relevant to the patient's condition is another thing.)

 

I take on board the lack of evidence available, however, as far as I was aware, the jury is still out regarding foot function and all associated pathologies ??!!

HTML:

If you have a rope/chain from your house to a place one block away, and you swing it violently, where is the main distruption and disturbance in the chain? It won't be a block away will it.

There are variables that I have spoken to pgcarter about, in relation to stiffness up the chain, but my analogy puts grave doubt in my mind that fixing something caudally can have a significant impact high up.

(LLD is different. Any 1cm difference will have a 1-to-1 impact at least at the lumbo-sacral/pelvic region. Whether this is relevant to the patient's condition is another thing.)

Have to disagree here, your assumption relies on gait functioning purely as a pendulum.
Think you would also find it extremely difficult to map your 1cm LLD to 1-1 ratio at the lumbo-sacral/ pelvic region??

Determining the effect of foot function on the spine is difficult, due to the number of variables present, but to dismiss it appears foolhardy
regards
Tony

 

Tony, lets assume you have equal leg length. Take one shoe off. Stand. Do you think your ipsilateral ilac-crest or PSIS is at the same height as it would be with your shoe on?


As for the rope analogy, it perfectly explains why, in the absence of LLD, why foot dysfunction manifests closer the the dysfunction itself. Pendulum or no pendulum.

 

The other point I would add Tony, is that look what moves with STJ motion in weightbearing. Go from full inversion to full eversion, and continute this. With the former, you knee heads laterally into varus. With the latter, your knee heads medially into valgus.

Can you fully invert/evert your ankle/foot complex (WB) without moving your knee? No.

Can you fully invert/evert your ankle/foot complex (WB) without without moving your neck? I would say almost yes...overtly anyway.

The further you are away from the rope/chain, the lesser is the influence and disturbance.


Ron

 

wow chaps -its the biomechanics stuff again!

Getting back to the point, the document is one of the first times we see podiatry in a positive light from the DoH- lets make use of it. Diseminate it to ALL the appropriate people in your NHS trust or for those of you in independant practice, to your local PCT as a marketing package.

Lets see it for what it is - an opportunity!

Do we really have to get bogged down in this forum once again with semantics of angles and angles and motions!!

 

agreed

I concur with footfixer, a positive for NHS Podiatry for a change

With regards to LBP, I am happy to try and resolve this for a patient if it is something they complain of in conjunction with other lower limb problems


However, I am careful to inform the patient that they should seek assistance from a Physio, osteopath or chiropractor alongside anything that I as a Podiatrist can do as there maybe upper body issues which would may also need addressing to correct any problem.

 

My rigid orthoses, alleviate my lower back symptoms, my medial knee pain, my 1mpj pain and plantar fasciitis. As a former elite athlete they resolved my medial shin splints and the above pain. ( The many $'s of soft tissue Tx, massage and gait training certainly made it harder to fund the International Competitions but did nothing to get me mobile.) I guess they are only masking my pain, must be all in the head of myself and all the other lower back pts I have dealt with?? Anecdotal?? My fave word.
a ver ex-elite athlete

 

Don't doubt you for one minute. All I am saying is that one would be much more confident about alleviating symptoms closer to the foot (ankle, knee) with an appropriate pair of devices; in contrast to symptoms above the hip.

 

The main point with the MSK framework is the in the change of approach; a new paradigm for Podiatry ( or a forgotten one ) a biopsychosocial approach,which will provide a higher quality of service to our patients.We have to consider the wider perspectives, not just the position specific biomechanics.As practitioners we need to develop,and even cross professional boundaries. This will produce practitioners with exteded roles and special interests,to offer greater service and outcomes to patients who present with pain.
In regard to the rope/chain analogy, if I stick a pin in your foot your brain quickly knows about it,neuorlogical changes as a result of foot position pathologies may well arise to pain further up the chain.One only has to look at trigger point therapy to see that.Therefore LBP can quiet easily become part of the Podiatrists remit.

 

I just want to say that I'm delighted with the publication of the MSK framework, not least because it adds further weight to my argument for greater integration between pods and physios. My current clinical activities in joint working with physio is not directly funded as such (we just do it by mutual agreement), but we are working on auditing outcomes so that we can demonstrate our feelings that the joint approach yields better outcomes in a shorter space of time than was the case before we set up the clinic. So far we've used a combined approach to treat both lower limb and back pathology, and it gives really good results for most patients. I'm hoping that I will be able to successfully argue for greater collaboration, including neuro and rheumatology, and the more 'official' publicity for podiatry the better, as far as I'm concerned!