There are several common steps I use in a general biomechanical assessment when I am evaluating patients with injuries or pain. I recently shared these principles during a remote lecture I gave to students at the California School of Podiatric Medicine at Samuel Merritt University. However, in a time when traditional office visits are limited due to the COVID-19 pandemic, I thought some of these steps may be adaptable to a telemedicine-type of encounter.
- Obtain a thorough history of the injury including why the patient thinks the or she is injured.
- Evaluate the patient’s gait during walking or running if possible. Under normal circumstances, this is crucial to decide on gait patterns and if the patient’s complaint matches. It could be possible to gain some of this information through the video feature of teleconferencing.
- Physical examination of the injured extremity then helps us to begin to separate out the three source of pain: mechanical, inflammatory and neuropathic. This part is challenging remotely but some visual observation and direction from you to the patient may help in obtaining the best information you can.
- Physical examination of the possible biomechanics involved in the patient’s pain or injury. Again, this is a challenge at present but certain aspects are still possible. Have the patient sit back from the screen enough so you can see both sides. Notice if there is swelling, have him or her move the ankle and foot around. Have him or her use one finger to point to the area maximal tenderness. See if the patient has a floor lamp to shine on his or her feet.
- Is there biomechanical asymmetry?
- Make a tentative working diagnosis with the information obtained.
- Compile the common differential diagnoses applicable to the case, focusing on common, not rare, options.
- Incorporate the concepts of Occam’s Razor and the Rule of Three into the initial treatment decision-making.
- Determine what phase of rehabilitation the patient is currently in at this visit.
- Determine if imaging is necessary at this point. Under current circumstances, this will more limited than usual but if imaging is truly necessary, this could be reason to authorize an in-office visit.
- First decision: What do I have to do get this patient’s pain consistently between zero and two on a visual analog scale? This is the realm where injuries can heal and the real reason to put the patient in phase 1 of rehabilitation, which emphasizes protection, rest, ice, compression and elevation (PRICE) rules.
- Second decision: How much inflammation do I need to address?
- Third decision: Is there any neurological component to treat?
- Fourth decision: What mechanical changes can I make in the next few visits that may help relieve pain, improve biomechanics and facilitate the patient’s full return to daily activities?
I hope my algorithm is helpful in organizing your own approaches to diagnosis and treatment, and may help in formulating an outlook on steps that might be effective in remote patient evaluation.
Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com.
Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.