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MRI required to prescribe Orthotics says Orthopaedic Surgeon

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  #1  
Old 24th February 2011, 01:18 AM
PodAus PodAus is offline
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Default MRI required to prescribe Orthotics says Orthopaedic Surgeon

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Question: Can a patient be treated for obvious mechanical discrepancies contributing to mild midfoot pain post running, without an MRI?

A runner /patient with a prominent navicular and os navicularis was informed by an orthopaedic surgeon that an orthotic could only be prescribed with an MRI (and only by using the MRI), and that only 'soft' insoles could be of benefit. Any 'hard' orthotic was 'wrong' and could not help (All in the absence of indicated clinical assessment such as Sagittal plane function (Windlass / Lunge) or supination resistance / navicular drop:drift / gait, or footwear / WB activity / and no consideration of Tissue Stress Theory nor SALRE).

More Questions:
Is the dismissal of external forces and subsequent mechanical stresses as major causative factors for midfoot discomfort a common approach by orthopods?

Does anyone advise, or had patients whom have been advised that an orthotic can only be designed with an MRI (or XRay even...???)

How can diagnostics address forces contributing to tissue stress? Especially when the patient persists with WB activity (runners just wont stop running some times).

How can an orthotic be designed using an MRI or XR?

How many Pods get an MRI prior to orthotic prescription???
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  #2  
Old 24th February 2011, 01:23 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

This is absolute nonsense.

Does this surgeon live in a cave, have a long unkept beard and wear a loin cloth to work? Because his thought processes about orthoses 'hardness' are certainly from the stone age...
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Old 24th February 2011, 01:28 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by PodAus View Post
Question: Can a patient be treated for obvious mechanical discrepancies contributing to mild midfoot pain post running, without an MRI?

A runner /patient with a prominent navicular and os navicularis was informed by an orthopaedic surgeon that an orthotic could only be prescribed with an MRI (and only by using the MRI), and that only 'soft' insoles could be of benefit. Any 'hard' orthotic was 'wrong' and could not help (All in the absence of indicated clinical assessment such as Sagittal plane function (Windlass / Lunge) or supination resistance / navicular drop:drift / gait, or footwear / WB activity / and no consideration of Tissue Stress Theory nor SALRE).

More Questions:
Is the dismissal of external forces and subsequent mechanical stresses as major causative factors for midfoot discomfort a common approach by orthopods?

Does anyone advise, or had patients whom have been advised that an orthotic can only be designed with an MRI (or XRay even...???)

How can diagnostics address forces contributing to tissue stress? Especially when the patient persists with WB activity (runners just wont stop running some times).

How can an orthotic be designed using an MRI or XR?

How many Pods get an MRI prior to orthotic prescription???
The orthopedic got no idea, you don´t need a MRI to prescribe a device.
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Old 24th February 2011, 02:24 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by PodAus View Post
Question: Can a patient be treated for obvious mechanical discrepancies contributing to mild midfoot pain post running, without an MRI?

A runner /patient with a prominent navicular and os navicularis was informed by an orthopaedic surgeon that an orthotic could only be prescribed with an MRI (and only by using the MRI), and that only 'soft' insoles could be of benefit. Any 'hard' orthotic was 'wrong' and could not help (All in the absence of indicated clinical assessment such as Sagittal plane function (Windlass / Lunge) or supination resistance / navicular drop:drift / gait, or footwear / WB activity / and no consideration of Tissue Stress Theory nor SALRE).

More Questions:
Is the dismissal of external forces and subsequent mechanical stresses as major causative factors for midfoot discomfort a common approach by orthopods?

Does anyone advise, or had patients whom have been advised that an orthotic can only be designed with an MRI (or XRay even...???)

How can diagnostics address forces contributing to tissue stress? Especially when the patient persists with WB activity (runners just wont stop running some times).

How can an orthotic be designed using an MRI or XR?

How many Pods get an MRI prior to orthotic prescription???
Was this direct from the Orthopod, or from the patient?
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Old 24th February 2011, 02:53 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by davidh View Post
Was this direct from the Orthopod, or from the patient?
Good point well made.
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Old 24th February 2011, 10:28 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Hi PosAus

The frequency of my putting in a good word for an Orthopod varies between blue moons and man landing on an Extrasolar planet. However, DH and RIs words are wise. I hate to think how many misconstruction's of my advice have been passed on to others. Maybe the Orthopod recommended an MRI for something non-associated. Might be worth writing nicely (something I find difficult) to him or her and asking their opinion or for a copy of their notes. You never know, might make a friend. I won't speak to them if you do though!

Cheers

Bill
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Old 24th February 2011, 11:18 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by PodAus View Post
Question: Can a patient be treated for obvious mechanical discrepancies contributing to mild midfoot pain post running, without an MRI?

A runner /patient with a prominent navicular and os navicularis was informed by an orthopaedic surgeon that an orthotic could only be prescribed with an MRI (and only by using the MRI), and that only 'soft' insoles could be of benefit. Any 'hard' orthotic was 'wrong' and could not help (All in the absence of indicated clinical assessment such as Sagittal plane function (Windlass / Lunge) or supination resistance / navicular drop:drift / gait, or footwear / WB activity / and no consideration of Tissue Stress Theory nor SALRE).
My first thought was that the orthopod had an economic interest in the local MRI. Talk about medical inflation. MRI's for everyone.

Radiographs are a more interesting question. So, you have someone with typical heel pain. How often will you see something that can be diagnosed with an x-ray when you get one for typical heel pain? Atypical heel pain? Would medical expenditures be less if you just treated it as plantar fasciitis and then got the x-ray if the pain did not go away?

In the above case, was it bone pain? What diagnosis in that situation would need to be confirmed with an MRI?

Quote:
Originally Posted by PodAus View Post
More Questions:
Is the dismissal of external forces and subsequent mechanical stresses as major causative factors for midfoot discomfort a common approach by orthopods?
That's a question for the orthopods.

Quote:
Originally Posted by PodAus View Post
[
How can diagnostics address forces contributing to tissue stress? Especially when the patient persists with WB activity (runners just wont stop running some times).

How can an orthotic be designed using an MRI or XR?
I had a patient with a calcaneal fracture that had a fragment that projected plantarly. Without the x ray I would not have been as agressive with off weighting the callused area. So, some of the time the x-rays will tell you where the calluses are.

Also a good point about the difference between what was said and what the patient heard.

Eric
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Old 24th February 2011, 12:48 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Rediculous comment. Maybe the orthopedist has part ownership in the MRI unit is looking for alternative means of repaying the purchase price.
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  #9  
Old 24th February 2011, 04:16 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Until we hear back from Paul, this could be the patient getting their "wires crossed"; could be that the orthopedic surgeon simply wanted an MRI to check things before going ahead with the orthotics.

If that is not the case, then of course its ridiculous. I would really like to know what he expected a soft orthotic to actually do if the patient just flattened it.
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Old 24th February 2011, 05:49 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Direct from PATIENT... However patient was very specific in their communication and their understanding is now very firmly - "I needed an MRI for an orthotic to be made, so you (Podiatrists) are wrong". The Surgeon allegedly expressed this to the patient in a way it would be difficult to mis-interpret (and this surgeon has a reputation for bagging Podiatrists and other health professionals).

Of course non-respondent cases where ortho-mechanical intervention is not successful may require diagnostics to assist in forcing patient to rest. But as a first line of defense for all patients.

The Sx's alleged first words to the patient were "You may need surgery, but I'm going on holidays for 3 weeks so stop using your 'hard' orthotics as they will be doing you damage and orthotics can NOT HELP. You need an MRI." Next consult, according to the patient, the surgeon then advised, as an Os Navicular was "detected", "Yes you do need an orthotic, but it must be a soft one. But you may need surgery later".
{why did the Pt go to the Surgeon? Because the GP suggested so}.

What is the Patient supposed to think about Podiatrists?
When does this unprofessional behaviour warrant an official complaint?
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  #11  
Old 24th February 2011, 05:54 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

In that case, I find there is no point arguing. I just tell them if that is the course of action they want to follow, then fine. I then tell them to come back and see if if/when that course of action does not work. Its often remarkable how many choose not to pursue that course of action or come back embarrased as it did not work.

Quite simply if the forces producing the symptoms are low, then a soft orthotic will work really well. If the forces are high, then the chances are it will not. It is easy to demonstrate that to them. Let them make their own choice.
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Old 24th February 2011, 06:18 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

The forces are very high with highly medially deviated STJ axis/FHL/vhigh SR/ lunge mild restriction. Pt works standing on concrete floor all day in own small business and is addicted jogger. Forces = tissue stress; 1st line defense = relative rest but pt non-compliant with WB activity reduction for more than a few days here and there. Ortho-mechanical intervention indicated asap. Pt responded well to semi-flexible prescription device (accounting SALRE with design), but Pt would not change work footwear to accommodate orthoses. Thus had habit of being "sore" after 8 hours standing!
DMICS Dx involving medial footwear compression @ navicular.

Cant see any "MRI required before anything can do done" in Kevins work below, which is completely relevant to this case:

Quote:
Upon taking the history, patients with DMICS point to the area of the metatarsal-cuneiform joints, navicular-cuneiform joints, and sometimes to the area of the metatarsal-cuboid joint as the source of most of their pain. Much less frequently, the pain is noted more proximally, in the dorsal aspects of either the talo-navicular or calcaneo-cuboid joints. The pain generally worsens with increased weight-bearing activities and patients report the pain from DMICS will either occur just before heel off and/or during propulsion of walking gait. Walking barefoot or in low-heeled shoes usually exacerbate the pain, while walking in shoes with an increased heel height usually eases the pain. There is usually no history of trauma even though patients with blunt trauma to the dorsal midfoot have very similar symptoms.


On physical examination, there is discrete tenderness along the dorsal joint lines of the affected midfoot joints but no tenderness along the dorsal aspects of the extensor tendons with dorsiflexion resistance applied at the digits. Edema is never present plantarly and minimal edema is only detected dorsally in the most painful cases. There is no pain with forceful manual dorsiflexion of the forefoot on the rearfoot. The hallmark in the physical examination of patients with DMICS is that they all have very significant pain with plantarflexion of the forefoot on the rearfoot. This test of plantarflexion of the forefoot on the rearfoot is a remarkably sensitive indicator of the level of severity of DMICS.

The reason that manual plantarflexion of the forefoot on the rearfoot during the clinical examination causes such significant and consistent pain in patients with DMICS is that the dorsal capsular ligaments along the joints of the midfoot are inflamed. The cause of the inflammation in the dorsal capsule of the joints of the midfoot is the chronic excessive interosseous compression force (ICF) in these joints during weightbearing activities.

Figure 1. An increase in either the ground reaction force (GRF) on the forefoot, the force of body weight and/or Achilles tendon tension will lead to an increase in the interosseous compression forces in the dorsal midfoot which increases the likelihood of dorsal midfoot interosseous compression syndrome (DMICS).

The combination of three forces act together on the foot during late midstance to cause an increase in the ICF across the dorsal joint surfaces of the midfoot (Fig. 1). First, the weight of the body exerts a plantarly directed force through the tibia onto the talar dome. Second, due to the requirements of the gastrocnemius and soleus muscles to be active during late midstance, the Achilles tendon in under great tension causing a plantarflexion moment on the rearfoot. Lastly, since the center of mass of the body is over the metatarsal heads during late midstance, ground reaction force (GRF) is at its peak on the metatarsal heads which causes a dorsiflexion moment on the forefoot.

The net result of these three forces acting together is a very strong flattening force or moment on both the medial and lateral longitudinal arches of the foot. The stronger the flattening moments on the medial and lateral longitudinal arches, the greater is the ICF across the dorsal joint surfaces of the midfoot. The flattening moments on both the medial and lateral longitudinal arches are increased by such factors as increased body weight, low heeled shoes and a tight Achilles tendon. Weak plantar ligaments and weak plantar intrinsic and plantar extrinsic muscles also increase the dorsal ICF at the midfoot since these ligaments and muscles help prevent medial and lateral longitudinal arch collapse.

It is the repetitive trauma at these dorsal midfoot joint surfaces with each step which causes the pain from DMICS. Treatment revolves around both reducing the inflammation to the dorsal midfoot joints and trying to eliminate the mechanical factors causing the increased flattening moments on the medial and lateral longitudinal arches. Local treatment to reduce inflammation may include icing and non-steroidal anti-inflammatory drugs and even cortisone injections in resistant cases.

Mechanical treatment involves, first of all, having the patient stretch their Achilles tendons and either adding a heel lift to their shoes or getting them into a slightly higher heeled shoe. Most helpful is to prevent the medial and lateral longitudinal arches from collapsing during gait as much as possible with either padding, strapping or generic or prescription foot orthoses. The foot orthoses must be stiff enough to support the medial and lateral longitudinal arches and should be well contoured to the foot. I find that if the initial treatment of the patient with temporary insoles or padding is helpful, the patient is very happy to proceed further with the more corrective and much more beneficial prescription foot orthoses since DMICS can be quite a painful and debilitating condition.

Foot orthoses must be made of a relatively rigid material which will not flatten significantly during late midstance. I recommend a 3/16” polypropylene plate with a 40 /40 rearfoot post, the heel contact point made to a 1/8” thickness, a 2-3 mm medial heel skive, a 16-18 mm heel cup, balanced 2-40 inverted with or without a valgus forefoot extension. I may also add a 1/8” to 1/4” heel lift under the orthosis and/or get the patient into a shoe with increased heel height differential and relatively firm, stable sole such as a running shoe and/or hiking boot to decrease the excessive GRF on the metatarsal heads during the late midstance phase of gait which may be caused by even a mild equinus deformity.
When a case is clear as to Tx protocol (as in this case), are diagnostics / MRI required before Tx begins... I thought not.

Am I missing something??
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Old 24th February 2011, 08:57 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by PodAus View Post
The forces are very high with highly medially deviated STJ axis/FHL/vhigh SR/ lunge mild restriction. Pt works standing on concrete floor all day in own small business and is addicted jogger. Forces = tissue stress; 1st line defense = relative rest but pt non-compliant with WB activity reduction for more than a few days here and there. Ortho-mechanical intervention indicated asap. Pt responded well to semi-flexible prescription device (accounting SALRE with design), but Pt would not change work footwear to accommodate orthoses. Thus had habit of being "sore" after 8 hours standing!
DMICS Dx involving medial footwear compression @ navicular.

Cant see any "MRI required before anything can do done" in Kevins work below, which is completely relevant to this case:



When a case is clear as to Tx protocol (as in this case), are diagnostics / MRI required before Tx begins... I thought not.

Am I missing something??
Paul:

An MRI is not necessary to properly prescribe custom foot orthoses. In fact, in most instances, plain film radiographs aren't necessary to properly prescribe custom foot orthoses. The orthopedic surgeons I know think that MRI scans are overutilized since they often don't pick up on pathology that are obvious on surgical/arthroscopic/clinical examination. I tend to agree with them. Proper clinical examination is often much more helpful than MRI scan at establishing the proper diagnosis.

I tend to doubt any halfway-intelligent orthopedic surgeon would say that an MRI is necessary before custom foot orthoses can be properly prescribed. Of course, in your case, the orthopedic surgeon may not meet the "halfway-intelligent test". My guess is that the patient is confused or in error about what the orthopedic surgeon actually said or that this orthopedic surgeon doesn't have the slightest clue about how foot orthoses work and about what they are capable of. I would love to have a chat with this orthopedic surgeon and set him on a proper course of continued education about how the foot works and about how foot orthoses work if he continues to insist that MRI scans are necessary to prescribe foot orthoses.

Maybe you should offer to send the orthopedic surgeon some scientific literature on the clinical effectiveness of foot orthoses and on their kinetic and kinematic effects on foot and lower extremity function and pathologies.
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Old 24th February 2011, 09:14 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

PodAus

After reading your initial post all I could think of was how many times I've heard things from patients that supposedly were said by other doctors. Some unbelievable (the roots of your wart are wrapped around your knee joint; bunion surgery is never successful; too much milk causes bone spurs; on and on.....)

Unless you heard this first hand, from the orthopedic, I would suggest that "something" got lost in the translation.

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Old 24th February 2011, 09:52 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Craig you said, "Quite simply if the forces producing the symptoms are low, then a soft orthotic will work really well. If the forces are high, then the chances are it will not. It is easy to demonstrate that to them. Let them make their own choice."

Do you use this in clinical practice? i.e. soft orthos = low force, hard orthos = high force. I'm not asking for a formula & I realize there are other factors that affect these decisions.
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Old 25th February 2011, 12:52 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

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PodAus

After reading your initial post all I could think of was how many times I've heard things from patients that supposedly were said by other doctors. Some unbelievable (the roots of your wart are wrapped around your knee joint; bunion surgery is never successful; too much milk causes bone spurs; on and on.....)

Unless you heard this first hand, from the orthopedic, I would suggest that "something" got lost in the translation.

Steve
I go along with this. Hearsay is hearsay.
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Old 25th February 2011, 01:02 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Quote:
Originally Posted by PodAus View Post
The forces are very high with highly medially deviated STJ axis/FHL/vhigh SR/ lunge mild restriction. Pt works standing on concrete floor all day in own small business and is addicted jogger. Forces = tissue stress; 1st line defense = relative rest but pt non-compliant with WB activity reduction for more than a few days here and there. Ortho-mechanical intervention indicated asap. Pt responded well to semi-flexible prescription device (accounting SALRE with design), but Pt would not change work footwear to accommodate orthoses. Thus had habit of being "sore" after 8 hours standing!
DMICS Dx involving medial footwear compression @ navicular.

Cant see any "MRI required before anything can do done" in Kevins work below, which is completely relevant to this case:



When a case is clear as to Tx protocol (as in this case), are diagnostics / MRI required before Tx begins... I thought not.

Am I missing something??
No Paul, the best thing you can do is to say to the patient in situations like this

Decide where you want treatment from, If we follow my treatment path then, I will design the orthotic device as I see will work best for your situation, but you must realize the onus is on you as a patient to help with treatment, if that includes icing, resting, stretching etc then you must follow the treatment program.

If they decide the orthopedic surgeon was the treatment path they want to follow, I always say good luck and if they are not getting positive results to come back and we can start over.

No point getting stressed by it all. As my 1st Pod boss used to say, Podiatry be a great job without the patients.

Also if the patient is unwilling to rest from running make it clear that the results may not be as good as hoped due to the increase force running places on the foot.
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Old 25th February 2011, 02:56 AM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

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Originally Posted by markleigh View Post
Craig you said, "Quite simply if the forces producing the symptoms are low, then a soft orthotic will work really well. If the forces are high, then the chances are it will not. It is easy to demonstrate that to them. Let them make their own choice."

Do you use this in clinical practice? i.e. soft orthos = low force, hard orthos = high force. I'm not asking for a formula & I realize there are other factors that affect these decisions.
Off course. I use a lot of soft orthotics and I use a lot of hard orthotics. You use what is indicated. If the forces that need to be changed are low, then a soft device will change it. If the forces that need to be changed are high, then you have no choice, you need a device that provides high forces.

The easy way to show the patients is to use the supination resistance test. If I need 2 hands and 2 fingers to supinate a foot and lift the arch, how useless is a soft orthotic going to be? Patients can see how hard or easy it is.
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DTT (27th February 2011)
  #19  
Old 25th February 2011, 03:44 PM
PodAus PodAus is offline
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Thanks everyone - a great forum to be able to vent my frustrations
Problem is this patient thinks the surgeon has to be right because "they are a surgeon with much more training..."
I am suspect on this particular surgeons approach, because I have had at least a dozen patients whom have consulted with this surgeon and have relayed feedback in a very similar theme. Other Pods have had a similar experience with this person also... I suspect they may feel threatened professionally.

Moral of the story; it is all about expectation, both from the patients' and practitioners' perspective. Communication breakdown on lots of levels helps us refocus on our priority of clear and concise communication in our quest to become better Practioners.

All have a great day
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Old 26th February 2011, 10:56 PM
CraigT CraigT is offline
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Hi Paul
You might want to also point out that non-compliance in surgical cases often is much more disastrous than non compliance with orthoses.
Also if they are not happy with orthoses then they can take them out of their shoes. Not happy with the surgery... well.... um...

As for feeling threatened professionally... I think it would be more accurate to say they are ignorant and, more disconcertingly, have no idea that there are.
I remember meeting an Orthopod who was very pro Podiatry and hearing him say 'I don't understand why this person would need orthoses- they have a good arch' and he said it in a way that suggested that he thought the Pod was clearly ignorant- and this was someone who did believe in Podiatry...
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Old 27th February 2011, 09:07 AM
efuller efuller is offline
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Assuming the Orthopod is an idiot... What is your goal? If the goal is to convince the patient that the orthopod is wrong. Tell the patient to go back and ask why they need an MRI to get an orthotic. And tell the patient to be skeptical. People with a lot of training can still be wrong.

Eric
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Old 27th February 2011, 04:35 PM
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Default Re: MRI required to prescribe Orthotics says Orthopaedic Surgeon

Goal here is to have the patient understand that the medical protocols we follow as Podiatrists are valid. The patient still insists an Xray or MRi was required for an orthotic to be prescribed. Why - because "the surgeon told me".

...It's impossible to please everyone, all the time...
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