Are You On Board With High-Resolution Diagnostic Ultrasound?

Stephen Barrett DPM FACFAS

The dawn of Man, as illustrated by the genius film director Stanley Kubrick in his 1968 film, 2001: A Space Odyssey, shows a tribal ape picking up a large animal femur from a bony carcass and staring at it inquisitively. Almost serendipitously, the primate smashes the bone to the ground, pulverizing the remainder of the animal skeleton. With the shrapnel of bony particles exploding in every direction, it suddenly occurs to the ape that he has discovered a very powerful tool: the club. Equipped with this new instrument, the innovative ape and those in his troop are able to literally whip the butt of the unequipped, provocative primates who were sitting on the other side of the mud hole. Bottom line: the development and use of tools leads to the emergence of a superior group in society, who can literally (or figuratively) crush the competition. Failure to adapt will eventually lead to irrelevance and subsequent extinction.. Fast forward now a couple of million years and there are two troops of homo sapiens known as homo podrilosauri. Anthropologists have studied these two groups and have found many similarities in these complete bipeds. However, there is one major difference: what they do with new tools at their disposal. These scientists have named the two groups the “pollicus profundi” and the “illuminati.” Members within the pollicus profundi tribe, in comparison to the illuminati, are stuck in this dogmatic fog and illusion. “But the old ways have worked for hundreds of years,” they proclaim. Anthropologists have nicknamed them the “thumbs.” In contradistinction to the bands of “thumbs” running around out there, the illuminati are not shrouded by dogmatic fog and have seen farther in more profoundity, simply because they have embraced the power of innovation and use it judiciously. By the way, the anthropologists have seen small factions of “thumbs” wiped out by a single illuminati who stole all the new patients from them. Now you are asking your self: “What in the hell is he talking about?” Well, the “club” is high-resolution diagnostic ultrasound. The illuminati have taken their “club," embraced it and, in fact, expanded the use of it to the betterment of their patients. The “thumbs” on the other hand are violently and vociferously beating on their hirsute chests, belying that the “illuminati” are just exploiting their “clubs” as a money making tool! They contend that there is no value in using the “club” as they can press on the patient with their thumb and know not only what the level of the pathology is but how to perfectly place another instrument, namely the "needle," into that tissue to deliver their medication of choice, and do it better than the well equipped illuminati. In anthropology, there is a well-known law termed, “the delusion of primitivity,” which they have ascribed to the “thumbs." “The delusion of primitivity” stems from three things according to these erudite Anthro boys (they could be female but for storytelling purposes, please allow and indulge me this very slight gender insensitivity). These things are: 1. Penuriousness 2. Arrogance/Ego 3. “I was trained that way and I’ll be damned if I’m going to read anything new or allow myself to learn something new.” There has been a lot of psychobabble banter spewed across the medium of the podiatry Internet chat arenas about this topic. Let us see if we can use the example of plantar fasciopathy to illustrate how badly the illuminati are whipping the “thumbs.” Nearly every practitioner who considers him- or herself an expert in heel pain (and if you are a podiatrist, you better include yourself in that category or seek other employment), will have to agree that not all heel pain is caused by the plantar fascia, and not all plantar fasciopathy has the same degree of disease. If you don’t agree with that, then stop reading right now, run down to your travel agent and try to get a ticket back to planet Earth. So what happens here? The “thumbs” see their patient, press on the bottom of the heel with their — you guessed it — thumb and when the patient jumps or says “ouch," they make a concrete diagnosis of “plantar fasciitis.” (Note the use of fasciitis here to illuminate that many of this tribe have still not read the plethora of journal articles that have proved this is a degenerative condition and not inflammatory in the least). Next step? “Let’s shoot it up with a steroid.” And that they do! Where are they really depositing the medicament? Certainly, it must be exactly where they envision with their 3D brain. Now what does one of the illuminati do? She (note that I corrected for that previous gender insensitivity) pulls out her “club,” which happens to be equipped with a 15 MHz transducer, looks at the true condition of the plantar fascia in high resolution definition on the monitor, and then designs a treatment plan which is based on severity of disease rather than “thumbness.” And oh, by the way, if it really needs to be injected, she is able to pinpoint exactly where her medicament is deposited. (Hopefully, it is not a steroid but that is another blog all together.) When is the last time you heard this report on the nightly news: “The military decided to not use missile guidance systems for the planned strike as the general in charge has launched plenty of missiles before and usually gets close enough. The mission was a partial success;. Half the objective was destroyed and there were only a few peripheral causalities due to the imprecise nature of the approach recorded.” The illuminati know that high resolution diagnostic ultrasound is the gold standard for diagnosis and determination of the severity of plantar fasciopathy. Heck, in many cases of heel pain that present to the clinic, upon peering into the tissue with this most modern of “clubs,” we determine very quickly that the plantar fascia is in fact in perfect shape and not the culprit at all. So here is a huge difference for the patient as well as the expenditure of costly resources by treatment from a “thumb” versus illuminati. The illuminati treat a defined, objective diagnosis. If it is not fasciopathy, they look for other etiologies such as neurogenic ones. On the other hand (or should I say thumb), the “thumb” throws them into an off-the-shelf orthotic until the custom one comes in, fits the patient with a night splint and blasts him or her with a steroid. Usually, this process includes multiple office visits and long courses of time. This is not horrible if the patient really does have a fasciopathy but it is truly horrible if the patient doesn't have a fasciopathy. Even if the patient does have plantar fasciopathy, the illuminati will have effectively treated it much more quickly and effectively because the power of knowing the degree or severity of any condition allows for tailored effective treatment. The anthropologists are seriously concerned that the illuminati are so overpowered compared to the “thumbs” that over a short evolutionary time, they will have captured all the patients that used to be seen by the “thumbs” and the “thumbs” will have nothing but the finger of the illuminati pointing at them. (You guess which finger.) “Adapt or perish, now as ever, is nature's inexorable imperative.” ― H.G. Wells

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