Each week, I have patients who present with their first foot or ankle injury, and I wonder whether I am looking at the tip of the iceberg of this and other future injuries. No matter how minor the injury appears, I wonder if it will be followed by another and another and another.
What can I do as a healthcare provider to eliminate or at least minimize the onslaught of future injuries? How seriously should I take these initial injuries, which will heal relatively quickly? Should I always follow the KISS principle and Keep It Simple, Stupid when I think some of these injuries are definitely the tip of the iceberg? More pain is on the way. What goes into the thought process of deciding who should get more treatment when patients present to my office with relatively simple injuries?
Always direct the treatment of any overuse injury (without an acute single episode) at the one or two common causes or the several possible causes for this individual patient. Take Achilles tendonitis for example. There are a number of common causes of Achilles tendonitis …
1. Straight overuse situation in which the Achilles tendon is in major stress (i.e. stair running for the first time or working out too many days in a row, etc.)
2. Very tight Achilles tendons
3. Worn out shoe gear with lack of stability or cushion at impact
4. Unstable shoes or excessive wearing of shoe gear with inadequate support (i.e. too much time in flip flops, etc.)
5. Short leg with compensation of early heel lift
6. Excessive pronation of the foot/ankle with excessive torque on the Achilles
7. Excessive supination of the foot/ankle with lateral instability and overfiring of the Achilles tendon to stabilize the ankle joint complex
8. Very loose Achilles tendons from over stretching or patients with loose ligaments in general, which produces a weakness in the tendon
9. Weak Achilles tendons from many reasons (just returning to regular exercise program, following prolonged casting, aging process, genetics, dietary, etc.)
10. Achilles tendonitis secondary to another problem (heel spurs, ankle injuries, sciatica, tibial stress fractures, etc.)
After performing an initial physical examination, obtaining the patient history and making the diagnosis if possible, the clinician will try to assess the reasons this individual patient developed the injury. It is the experience of clinicians that separates them from other healthcare providers in getting to the cause(s) of some injuries. Some “reversal of cause” treatment must begin in all cases. But for some patients, looking below the surface level of water, below the tip of the iceberg, is really what is crucial. What factors could lead, if not addressed, to either prolonged injury/treatment or frequent recurrence of the symptoms? This is so crucial but in a busy medical practice, we often do not proactively explore these factors. The patient and clinician only stumble into the discoveries.
When a ship’s captain looks at the iceberg approaching, the captain scrutinizes the situation, assesses the severity and then makes an appropriate plan. Healthcare providers and proactive patients can be slower than the sea captain at finally making these decisions but we must look at the possible severity of the injury and the severity of the cause of injury in order to come up with an appropriate plan. Since we can grade the severity of anything three typical ways (mild, moderate and complex), let us look at these two factors in injury treatment from this angle. Perhaps then you can understand when under the tip of the iceberg danger may be lurking in the forms of prolonged treatment, possible incomplete healing and frequent recurrence of the symptoms.
After the initial assessment (history and physical) and perhaps after several follow-up visits, the clinician will place the patient in one of nine categories. These categories are:
1. Mild injury/mild severity of cause
2. Mild injury/moderate severity of cause
3. Mild injury/complex severity of cause
4. Moderate injury/mild severity of cause
5. Moderate injury/moderate severity of cause
6. Moderate injury/complex severity of cause
7. Severe injury/mild severity of cause
8. Severe injury/moderate severity of cause
9. Severe injury/complex severity of cause
Do We Relax Too Much As Docs When Assessing Mild And Moderate Athletic Injuries?
With the severe injuries, the treatment is usually prolonged enough that the patient and doctor/physical therapist gradually work at recognizing and correcting all possible causes of the injury along the way. It is in the assessment and treatment of the mild and moderate injuries that one must reconcile the KISS principle and the tip of the iceberg principles. It is when the injury is classified as mild or moderate that the healthcare provider must decide when to look under the tip of the iceberg and explore the depths of moderate to complex causes. It is in the four categories below that I find the most problems in dealing with these injuries. These categories are:
1. Mild injury/moderate severity of cause
2. Mild injury/complex severity of cause
3. Moderate injury/moderate severity of cause
4. Moderate injury/complex severity of cause
In these cases, I see the most patients for second opinions. Why is the injury not healing? Why does the injury keep coming back? The mild and moderate nature of the initial injury makes the healthcare system relax and not look too deeply into the cause of injury.
Treating A Patients With Chronic Achilles Pain
I will end this discussion with one example of this dilemma. Since I already used Achilles tendonitis above, I will finish using an example of Achilles tendonitis. The patient had pain in the Achilles for three months prior to seeing the initial doctor. The patient was a runner who pronated too much and rarely stretched the Achilles. When he did stretch, he only did negative stretching off a curb (which I do not encourage). The patient was a vegetarian (not to pick on you guys too much) but ate well. He ran a lot of hills after moving from Dallas to San Francisco. The patient learned he had one leg shorter than the other but never did anything about it.
The initial treatment addressing the possible causes of the injury were orthotic devices for the pronation, new motion control running shoes, power lacing, Achilles stretching three to five times a day and running on flat ground (not hills) until the symptoms got better. The doctor had categorized the patient with a mild injury/moderate cause of injury and had addressed the causes on the surface well.
Was the doctor just looking at the tip of the iceberg? What was below the surface that he needed to address? After six months of treatment, the patient was still not much better in terms of function. Running was still very limited. The initial treating doctor told him to stretch more and give it more time at their last visit (of six visits overall). This patient then sought a second opinion.
Upon review of the injury itself, the previous physician made the right diagnosis. Even though the initial treatments were good, they never improved when the lack of improvement called for this, thus making these treatments overall subpar.
Each of the treatments the previous physician initiated were subpar in retrospect. There was only partial correction of the pronation with the new orthotic devices but they were easy to modify to greatly improve their function. The running shoe store had convinced the patient to not get a motion control shoe since he had orthotic devices and the doctor never evaluated his running after the first visit. The power lacing was incorrect and we subsequently modified this. Diet counseling came up with non-optimal protein intake, an assessment that will help the patient forever. Measurement of the patient’s flexibility showed him off the charts in over-flexibility. Too flexible means too weak and this improved with six weeks of no stretching at all. The patient thought I was crazy when I proposed that one. Exact measurement of his legs showed over ½-inch short leg on the injured side. Subsequent treatment with heel lifts helped him immensely.
Within several weeks, he was feeling much better. By eight weeks, the patient resumed running regularly with a better diet, a heel lift for the short leg, a sensible stretching routine before and after exercise, no negative Achilles stretching, stable orthotic devices, stable shoes, proper power lacing, and a gradual restrengthening home program under a physical therapist with six once-a-month visits to up the ante.
Yes, under the tip of the iceberg for this athlete was a considerable short leg, a considerable dietary problem, slightly harder to treat pronation and an Achilles that could become over-flexible too easily. His mild injury did not initially respond since the doctor misread the cause of injury as moderate when it really was complex.
The Golden Rule of Foot: When treating athletic injuries, if the symptoms and function plateau, look under the tip of the iceberg to a deeper level of possible answers.