Biomechanics are foundational to podiatry, physiotherapy, and the study of orthotics and prosthetics. Here we provide an excerpt from the author’s recently released Book 1 of the 4-part series, Practical Biomechanics for the Podiatrist.
By Richard Blake, DPM, MS
What is it to say you use a biomechanical approach for your patients? Biomechanics means the functional mechanics of the body. Our bodies are unbelievable. They are very powerful, and fairly resilient. Why do they get injured? What systems or other body parts affect the injured body part? The patient is coming to you for help. There is the immediate implied need in the doctor/therapist–patient relationship to make an injury feel better. Probably some version of PRICE (protection, rest, ice, compression, and elevation) will help them along if biomechanics is not your strength. X-ray imaging can also be crucial to rule out significant problems. Yet, with every patient with an injury, there is also an implied need to make this injury never happen again. At least, they need to know why it happened, simply to make sense of it. This is truly where podiatry–and those who practice clinical biomechanics–reign. The biomechanical understanding of why an injury happened, how the cause can be corrected, and therefore, how to prevent it from ever happening again is crucial. This understanding can be what allows the athlete to run for years, dance for years, hike for years. This understanding can be what allows a good athlete to become great by avoiding or minimizing injuries during their competitive years. I take equal pride in my athletes running their first 5K, qualifying for the Olympic Trials, or walking their first steps after a serious injury caused months of immobilization.
When the patient comes into the office as a new patient or just a new injury, the questions asked should be directed to help understand the cause. Was it acute like a fall or twist, or just overuse? You find out where the injury is and what exactly happened. You have a list of differentials roaming around your head. You then watch the patient walk if they can, and run if they run. You watch their biomechanics and try to make a correlation. This book will help you with the correlations, like how a short leg can cause iliotibial band syndrome, or how excessive pronation can cause lateral foot pain. Some injuries require some sort of images before an accurate diagnosis can be made. But, most problems are overuse, soft tissue, and have predictable patterns.
As you learn these patterns, the predictability will be easier. Yet, sometimes the pain patterns do not make sense. Or, your treatment is not working when it should, so you must look deeper. You must have Plan B.
Practical Biomechanics Question #51: Finding the weak link or links in the patient’s chain of armor, and correcting those, can help the patient for many, many years. It can be simple or a great detective game with many pieces. What is a far too common cause of bone pain that always needs to be evaluated?
Common Steps in General Biomechanical Approach
Learning biomechanics goes much further than helping a runner complete a marathon, although that can be a fantastic adventure and success! Learning biomechanics will help every bunion surgery you do, every knee replacement you do or help rehabilitate, and maybe every patient with chronic low back pain. It is only in knowing which problems are mechanically induced or aggravated, that you can know what is not mechanical and more neurological or inflammatory. The world needs better doctors that can help mechanics. It is a great and rewarding world.
These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:
- History of the injury and the patient’s reason why they were injured.
- Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches)
- Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic)
- Physical examination of possible biomechanics involved
- Is there biomechanical asymmetry?
- Tentative working diagnosis made
- Common Differential Diagnosis: common not rare
- Occam’s Razor and the Rule of 3 for initial treatment help
- What Phase of Rehabilitation is the patient in at this visit?
- Should we do Imaging at this point?
- First Decision: What do I have to do to get the pain consistently between 0-2? This is the real reason that the patient has to be put into Phase 1 of Rehabilitation where PRICE rules. The 0-2 pain level realm is where injuries can heal.
- Second Decision: How much inflammation needs to be addressed?
- Third Decision: Is there any neurological component that should be treated?
- Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal?
Practical Biomechanics Question #52: The above thought process is probably a new way of looking at a patient for most, except the podiatry students just learning, but it has helped me for years. When dealing with mechanics, what is the importance of taking a pause of reflection for the Second and Third Decision listed above?
History of the Injury and the Patient’s Own Reason Why They Were Injured
There are so many types of injuries, but we have to start putting together a good picture of what happened and can it be prevented in the future. You can actually have a positive impact on all the different types of injuries, at least in the rehabilitation, by knowing the most you can. I will start this discussion with the mnemonic that always runs through my head when I am taking a history (also included in Chapter 17).
Common Historical Questions:
- F (pain frequency, are there important family history findings?)
- A (patient’s own assessment, what activities produce pain, what activities are okay)
- I (pain intensity, is there a lot of inflammation?)
- L (pain location, how long does the pain last?)
- E (what eases pain?)
- D (what is the duration of pain?)
- N (does this problem feel like nerves, like numbness, etc?)
- O (what are the events concerning at the onset of pain?)
- P (what produces the pain, past injuries involved?)
- Q (what is the quality of the pain?)
- R (does the pain radiate, is there redness, originally it was the result of what?)
- S (how do shoes help or produce pain, is there swelling, is there stiffness, are there previous surgeries that may play a role?)
- T (what treatments done, what treatments helped and hurt, any tingling?)
- U (does the patient have underlying problems?)
- V (how does the pain vary?)
- W (has it affected work, is there weakness?)
Most injuries are either acute (sudden onset of pain) or chronic (gradual buildup of pain). It is important with acute injuries to learn if there were circumstances that led to the injury, like generalized weakness from an illness leading to a fall. It could just be their 3rd or 4th ankle sprain with each one causing the ankle to get weaker and more unstable. The more you can make sense of the period surrounding the acute injury, the more you can help the patient rehabilitate fully and prevent the problem from occurring again.
I spend the most of my time dealing with either acute injuries from overuse (like a Jones fracture secondary to 10 days of basketball in 12 days), or just straight overuse where the weakest link in the chain starts complaining. Acute injury from overuse is where the athlete was overdoing activities and finally something (like a tear in the plantar fascia) started complaining.
The patient can tell you exactly when they felt pain that has not gone away. Straight overuse typically presents as a gradual onset of pain that slowly worsens over time until it finally forces the patient to accept some restriction in activities and start some treatment. This is where an understanding of the weakest link in the chain concept is important. When we overdo activities, and our bodies start complaining in an area, something is making that area a weak link. Our job is to find out why.
Practical Biomechanics Question #53: In a busy medical practice, an extensive history is normally done by a pre-visit questionnaire, with the provider glancing at the answers before delving more deeply with their own questions. In our mnemonic, what does the letter “F” stand for?
Richard Blake, DPM, MS, is adjunct faculty at the California School of Podiatric Medicine. He has practiced podiatry at the Sports and Orthopedic Institute of St. Francis Memorial Hospital in San Francisco, CA. Dr. Blake is Past President of the American Academy of Podiatric Sport Medicine. His book, Practical Biomechanics for the Podiatrist, Book 1, is available from Amazon.com and Barnesandnoble.com.
