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Prescribe orthotics for 'biomechanical dysfunctions' when the patient isn't suffering from any sympt

Discussion in 'General Issues and Discussion Forum' started by Meanderthal, Mar 10, 2010.

  1. Meanderthal

    Meanderthal Member


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    I write for a hillwalking magazine, and I recently received an email from someone I've never met (much less had a consultation with) who claims to be a podiatrist. After viewing a 10 second clip of me walking, this podiatrist concluded that I suffered from knee pain resulting from a biomechanical dysfunction of my lower limb. He suggested that I would benefit from a pair of orthotics to correct my foot posture.

    All very helpful of him. Except for one thing: I don't suffer from knee pain and to the best of my knowledge have never suffered from any biomechanical dysfunction of my lower limbs, or any part of any of my limbs for that matter.

    To be fair to this podiatrist, making a correct diagnosis would have been very difficult owing to the fact that throughout the short video clip I was a long way away from the camera, and so appeared very small on the screen. It was also a foggy day, so visibility wasn't particularly good. Besides which, I was wearing baggy trousers and the wind was blowing them all over the place, making it impossible to accurately analyse my gait. His expert analysis was probably further hampered by the fact that I was walking downhill towards the camera and using trekking poles at the time.

    Still, it's the thought that counts, eh?

    Needless to say, I'm not taking this 'podiatrist's' email too seriously.

    However, it did make me wonder whether it's accepted podiatric practice to prescribe orthotics for 'biomechanical dysfunctions' when the patient isn't suffering from any symptoms.
     
  2. Griff

    Griff Moderator

    Re: Phantom knee pain

    Hi Meanderthal,

    Well that would depend on what paradigm they subscribe to. (Very little within podiatric biomechanics is accepted by all sadly). Generally there are those who believe in criteria of normalcy, and therefore seek to 're-align' people irrespective of the prescence or absence of symptoms. Then there are those who generally treat symptoms, and look to reduce the damaging stresses on the injured tissues - irrespective of whether in 're-aligns' people (it usually doesn't). Sounds like you met a subscriber to the former school of thought.

    A more pertinent question for me is whether it is accepted practice to contact someone you have never spoken to or even met, and off of the back of seeing 10 seconds of video footage (and poor quality from an analysing point of view by the sounds of it) then hit them with a sales pitch for orthoses. This is bad form in my opinion. Steer clear.

    Ian.
     
  3. Graham

    Graham RIP

    Agreed. If it ain't broke don't fix it!
     
  4. peter96

    peter96 Member

    What would you do if a patient had some kind of biomechanical dysfunction present that was likely to cause pathology after a period of time. Would you advise them to watch out for certain symptoms, and seek appropriate treatment if they occurred.


    I know every patient is different, and some cope with minor dysfunctions or function that is not ideal very well, but then there are others who are probably going to develop secondary problems to certain biomechanical dysfunctions doesn't the saying a stitch in time will save nine apply to them.
     
  5. Andrea Castello

    Andrea Castello Active Member

    In short...yes I would treat.

    Let me preface this by saying that I would not consider myself a heavy prescriber of devices.

    I know there is much debate at the moment with regard to the issue of treating or not treating, but in my mind, if I have a client with a foot type that in my opinion, will cause issues later on, I will treat it. I would consider it negligent not to. If I were not to treat, and the client came back later with an issue I could have prevented or at least reduced the risk of occurring and I had done nothing, I would be deeply ashamed.

    A peer put it to me this way (and yes I know there is no proof to show that devices prevent problems, but there is no evidence that I am aware of that shows they don't)..."Would you tell someone to stop smoking when they developed lung cancer or intervene earlier to prevent the cancer in the first place"

    Regards
    A
     
  6. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    The answer lies in the principle of intervening to treat those who are asymptomatic if they have a risk profile that they have a high probability of developing symptoms.

    How do you determine that? - I have no idea!
     
  7. Ian Linane

    Ian Linane Well-Known Member

    I suppose we might want to ask what we mean by symptoms as well.

    Ian
     
  8. Tkemp

    Tkemp Active Member

    Hiya Meanderthal,

    Was the "Podiatrist" offering a free set of steak knives or a new travelling case or radio alarm clock with the orthotics?!!? :D
     
  9. stevewells

    stevewells Active Member

    I think it would be very difficult to prove negligence in that situation. I think if someone were thinking of severely increasing activity you may have a point (eg. "my feet roll in, I have no symptoms but I wanna do the marathon for the first time at 55")
    It would be interesting to know how you would defend yourself if you prescibed to a patient who is asymptomatic and they subsequently developed problems- regardless of whether they were caused by the devices.
     
  10. ROFLMFAO!!!

    Sorry meandertal, local joke at the expense of dodgy insole marketing.

    I saw an info pack on the new Talar made Functional foot typing system yesterday. 6 foot types with a different pre fab for each.

    Thing was, like the previous system (the one which hung on the Feiss line), there was no slot for "no your feet are mechanically sound so far as we know, we don't think you need an insole"

    Its a strange concept when you think of it. We're happy to describe all the situations you should move away from, but not the one you should be in. We're happy to move people towards an arbitary ideal but not to say what we think that is!

    Hammer nail syndrome. Its a killer.
     
  11. Graham

    Graham RIP

    What is a "biomechanical dysfunction"? If the individuals foot and leg mechanics appears to be dealing with our artificail world, ie, no symptoms, we have no way to determine if they ever will!
     
  12. Joe

    Joe Member

    How common is it for patients to come to a podiatrist who are asymptomatic?



    Joe Eads, C.Ped
     
  13. In the NHS its as common as dirt.

    And of course you have all those pathologies which owe little to biomechanical dysfunction (or at least little in the sense of what we can do with it) who get referred because nobody else knows what to do with them.
     
  14. Andrea Castello

    Andrea Castello Active Member

    Evidence based practice would suffice I would suggest. A large part of evidence based practice (as pointed out by an expert in the field at State Conference 2 weeks ago) is one's clinical expertise and knowledge, not solely systematic reviews or RCTs. Ultimately we have a responsibility to do no harm and as long as the treatment does not make things worse (and can be clinically justified), I believe I would be safe. I think Craig's point with regard to risk profile is a very valid one, and this is where I believe one's clinical experience plays a large part in deciding what to do. I have many asymptomatic patients (in particular children) whom I monitor, however there are those cases where I believe intervention is indicated. I feel I need to point out I never force clients or parents of clients to undergo therapy. I advise them of the options, costs, and risks and allow them to make the decision. Isn't that what "informed consent" is all about??

    I am confident enough in my own ability to make a decision on a client with regard to future outcomes based on anecdotal evidence. I wouldn't have been in my first year of practice, but over time I believe we all have an appreciation of what could happen to a foot in certain circumstances.

    I appreciate the question Steve. It made me think which is why we are on here after all!!

    Regards
    A
     
  15. Meanderthal

    Meanderthal Member

    Although the email contained no mention of a free set of steak knives or a travelling case or a radio alarm clock, I'm quite tempted to reply to it just to find out whether it would lead to this type of scam (and because I could do with a new radio alarm clock).

    For the sake of argument, though, let's suppose this alleged podiatrist is not a scammer but is a genuine podiatrist who was merely seeking to help me. I think we'd all agree that he chose a dodgy means of attempting to do this, but was his intention of offering unbidden advice acceptable? Would you ever offer podiatric advice to someone who hadn't asked for it, or would you think it was none of your business?
     
  16. Andrea Castello

    Andrea Castello Active Member

    I would say...none of my business.
     
  17. Peter

    Peter Well-Known Member

    Other than when shoe-fitters start pestering my kids when we buy shoes for them, I try and keep my opinions firmly to myself, unless asked.

    IF (Big IF), the podiatrist was genuinely trying to help you, you would have received a polite email with an offer to examine you free of charge, and IF needed, provide orthoses at cost only.

    Im quite disgusted that someone has contacted you this way, but thanks for bringing it to our attention:drinks
     
  18. peter96

    peter96 Member


    A biomechanical dysfunction could be defined in a number of different ways. I would describe a biomechanical dysfunction as an alteration in the normal mechanics of a person's musculoskeletal system.

    That's the easy bit the tricky part is defining normal. If you just consider gait then i think symmetry is a requirement for normal gait, but then no ones gait is exactly symmetrical different people would have different opinions as what degree of asymmetry would constitute a dysfunction then there is the question of what degree, and what type of dysfunction could cause pathology. So i concede that the definition of a biomechanical dysfunction is a bit fuzzy.


    I know its a bit of minefield to treat people who have no symptoms but in some cases it may be worthwhile.


    DON
     
    Last edited: Mar 17, 2010
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