The increasingly obfuscated medical algorithms for simple problems

A physical therapist, commenting on my blog, recently shared an excellent point of view with me:

As a therapist myself, I don’t know that I’d want to be betting on that differential diagnosis of tear, rupture, etc. when giving online advice. What is good treatment for one, can be disastrous for the other. Seeing someone in person can make all the difference, especially with the amount of self-diagnosis that the internet brings. Just my twenty-years two cents.

I hear you loud and clear — and I get it. I honestly appreciate your concern and comments regarding the concept of differential diagnosis when it comes to any medical problem. On the surface — you are correct, but I think you are missing the diamond in the rough. Please remain open-minded while I capitalize on this opportunity.

There is certainly is a lot of misdirected treatment and undertreatment provided out there, but what concerns me is the issue where overtreatment is routinely directed at the wrong site. It may indeed be sound treatment, but it is aimed at the wrong target.

What is “disastrous” is the increasingly obfuscated medical diagnosis and treatment algorithms for simple problems like plantar fasciitis. All too often in medicine, as well as other areas of life, we make things too complicated, especially when simple will do and do it much better.

When it comes to the foot and ankle, I am referring to equinus and the many problems it causes. Face it, dedicated treatment of the equinus issue is rarely undertaken, while the focus is systematically square on the foot where the real problem does not exist. Wasted time and wasted money will often result in disease progression going untreated or creating unintended harm. Oh wait, that is exactly what you were referring to, and that is indeed disastrous.

An accurate diagnosis derived from a robust differential diagnosis is vital for most medical issues, especially when one considers the necessity of delivering precisely aimed treatment. After all, how can a medical problem, or frankly any another problem, be treated or prevented accurately if the underlying cause is unknown?

Generally speaking, symptomatic treatment of the painful source, plantar fasciitis, in this case, is just fine and will go along way to help patients quality of life and suffering. However, when the treatment stops there and nothing is directed at the underlying problem, the equinus, is like treating the symptoms produced by cancer, but not directing treatment at the cancer itself.

In no way am I asking people to ignore seeking standard medical diagnosis and treatment, even palliative treatment directed at the foot. What I ask is for them is to do the right thing that few others will tell them, do it consistently and do it correctly — treat the cause, stretch the calf. Simple!

In my 31 years of experience, not including ten years training, I have come to one irrefutable fact: Equinus is the singular cause of the majority of non-traumatic acquired foot and ankle pathologies we develop, and most can be treated, and most importantly, prevented by calf stretching. The evidence is overwhelming that just one simple thing works for so many things going on with that foot of yours — addressing the equinus.

The problems I am talking about here are easy to diagnose by the experienced, and most even by those with little experience. The list is long, but to name a few there is plantar fasciitis, insertional Achilles tendinosis, Achilles tendonitis, posterior tibial tendon dysfunction with stage 2a or less acquired flatfoot deformity, midfoot OA, second MTP synovitis with second hammertoe formation. They all have one thing in common: they are all problems that result from equinus, period. Now let’s get into an example of the obfuscation at its medical best, plantar fasciitis.

How many diagnostic names can we give plantar fasciitis: chronic plantar fasciitis, plantar fasciopathy, plantar fasciosis, PHP (plantar heel pain), and more. Really!? Plantar fasciitis is plantar fasciitis, and it is just that simple.

There are three reasons why good old plantar fasciitis continues to get increasingly complicated.

  • The current “accepted” treatments continue to fail. Thus this diagnosis must be more complicated than we think, right? So, we keep looking for more treatments and names for plantar fasciitis. Maybe I could be right, and the underlying cause of plantar fasciitis rages on basically untreated.
  • The growing indiscriminate testing we perform today is an indictment of where the practice of medicine is headed. We have replaced time-honored, experience-guided history acquisition, sprinkled with a bit of basic physical exam with tests. Now it is a five-minute office visit straight to an MRI or ultrasound, etc. A $2,500 MRI is now the norm. The MRI has no place in the diagnosis of plantar fasciitis. Yes, I just said that.
  • The third reason is clearly hypocritical of me because I sell a product. Increasingly more methods and devices are released every year to treat this problem, but virtually none address the root cause — equinus. I don’t care how you stretch, just stretch.

So, this is my challenge for you and others: no matter what you have done or what you are doing now, start stretching your calves.

What do you have to lose? I can almost guarantee that you or your patients will be blown away. However, be honest with yourself, be patient and do it right. I refer you to my pal the AngryOrthopod who uses my protocol on a step, which he learned from yours truly.

Simple is as simple does. Stretching works!

James A. Amis is an orthopedic surgeon who blogs at Onestretch.

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