Outside of post-surgical scenarios and fractures, it’s rare an orthopedic boot is necessary. I’ve seen them prescribed inappropriately many times. Severely restricting or eliminating movement to that extent with an immobilization boot is the last option for orthopedic disorders. For example, you don’t want to boot a tendinopathy! As I always say, it comes down to competent diagnosing.
Not only are patients often getting incorrect treatment for their ankle/foot complaints, but walking around on an uneven surface can disrupt other parts of the body. A boot can jack you up both literally (by an inch or more) and figuratively. It’s common for people to complain of knee, hip, or back symptoms because of walking around in a boot. For those who do need to wear a walking boot, I usually recommend buying something to attach to the other foot (such as an “Evenup Shoe Leveler”) to level the feet or simply wearing a higher shoe on the unaffected foot. -- Laura
How do I increase a person's ankle dorsiflexion range of motion? There is no one way to fix a sign/symptom. I can name ten possible things I would do to increase a person's dorsiflexion depending on the source of the deficit. A sign or symptom is not a diagnosis. You diagnose the problem that causes the sign/symptom and provide the appropriate treatment for that diagnosis. It’s the same as with other medical problems. There’s not one way to relieve head pain nor one way to increase low blood pressure. You figure out the reason (the diagnosis) and address that.
I know I sound like a broken record, but people want to oversimplify orthopedics when it actually takes solid diagnostic skills to achieve effective care. If a patient of mine has decreased dorsiflexion, that is just one piece of data in isolation. Combined with the other data I obtain (verbally and physically) and combined with the response to repeated dynamic testing, that piece becomes more intelligible. If you think you simply need to stretch your Achilles to gain more dorsiflexion, by all means, go ahead. It will help sometimes, but it’s not high on my list of treatments I use to gain dorsiflexion. There are many treatments I use more commonly than simple muscle/tendon stetching. So the answer to how I increase dorsiflexion is: “It depends.” -- Laura
Yes, some patients have problems that cannot be fixed with movement. But how will you know unless you test movements and interpret the effect? In almost all orthopedic cases, diagnosing should involve repeated movement testing. Morton's neuroma is currently diagnosed by imaging and provocation testing, but, as Michael David Post and Joseph R. Maccio's paper "Mechanical diagnosis and therapy and Morton's neuroma: a case-series" demonstrates, a repeated movement exam is needed to assess if patients will benefit from repeated movements.
If you take people with no toe pain and put them in an MRI, many will have neuromas. So we know they can be present without causing pain. When patients do have pain, then, we can't assume their neuroma is the cause. We need to investigate if the spine is the cause or the toe joint is the cause. Additionally, assuming a neuroma is causing pain still doesn't mean the patient won't do well with repeated movement treatment (but you have to find the correct movement).
What percentage of patients who complain of toe pain receive a competent repeated movement exam? How many with toe complaints will have a clinician investigate their lumbar spine? And what percent will even be recommended to see a movement-based therapist if the image shows a neuroma? If these three patients hadn’t resolved their problems in just a few visits with repeated movement, what types of therapies, injections, surgeries might they have had? In this case series, three patients with medically-diagnosed diagnosed neuromas abolished their toe pain with repeated movements, with those results remaining at one year. One patient required repeated movements of the lumbar spine (low back) and two patients needed repeated movements of the affected toe.
When it comes to movement testing, I believe in end-range repeated movement testing that investigates the relevant spinal segments as well as the relevant affected joint(s). This is the core foundation of the McKenzie method. Movement testing is not the same as orthopedic special tests or palpation tests or provocation tests. It means repeatedly moving a person in the clinic and at home and evaluating the effects if has on the person’s symptoms and mechanics. Looking at a picture and seeing if something hurts when you press on it is rarely enough. -- Laura
If someone complains of foot symptoms - pain, numbness, and/or tingling - it can obviously be due to several causes. When investigating to find the source (that is, diagnosing), I collect many pieces of information. First, there’s a good verbal history during which I ask pointed questions. Second, is the physical exam. With the physical exam I look at various things; nerve tension is one of them. If you put the lumbosacral nerves on tension (there are a few ways to test this), and a patient’s symptom appears or increases in the foot, we need to investigate spinal nerve irritation as the potential source. To be clear, a negative tension test does not rule out the spine, but a positive test more strongly rules it in as a possibility. It is common that irritated nerves in the spine create pain, numbness, or tingling in the areas of the body they're responsible for, and the nerves specifically in the low back are responsible for sensation in the feet. -- Laura
Rolling an ankle impacts more than ligaments and tendons. The ankle joints (there are several) are obviously involved - and possibly the structures that get injured. Before I jump to the conclusion that pain and tenderness on the lateral (outer) aspect of the ankle is coming from the lateral ligaments, I move the joints to assess the effect. The joints of the ankle can create pain anywhere near the joints. If a joint is indeed the culprit, most will resolve rapidly with directional preference exercises. If a ligament is to blame, then traditional treatment of a ligament sprain is indicated. Looking for the problem that usually gets better the fastest not only makes diagnostic sense, but also benefits the patient. Who doesn’t want to get better as fast as possible? -- Laura
When people twist or roll an ankle, the common diagnosis is that the ligaments are sprained. However, the joint itself is also affected! Here, a patient who twisted her ankle is treated successfully with simple repeated movements of the ankle JOINT. Therefore, the ankle JOINT was injured, not the ligaments. She was discharged with full recovery at visit number 2.
Clinicians MUST assess joints as joints are injured far more commonly than soft tissues such as muscles, tendons, and ligaments. (I learned how to assess joints like this through my post-doctoral studies with the McKenzie Institute, not in school.) -- Laura
If you have pain on the bottom of your foot, it is common that the source is a pinched nerve in your low back. As this image shows, nerves L4, L5, and S1 send signals to the foot. You can have a compressed nerve that does NOT create back problems, but instead creates pain, numbness, or tingling on the bottom of the foot. The plantar fascia is connective tissue on the bottom of the foot, which, when irritated or tight, can also produce pain on the bottom of the foot. A thorough McKenzie clinical examination aims to diagnose the true source of the problem - which leads to an individualized treatment plan. -- Laura
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