CLERKING FOR BIOMECHANICS& MAKING A DIAGNOSIS

Andy HorwoodProduct Designer & ResearcherVisiting Fellow Staffordshire University

CLERKING FOR BIOMECHANICS

● INTRODUCTION: WHAT IS A DIAGNOSIS?● PROCESSES & PATHWAYS…..BENEFITS & ISSUES● ASSESSING THE BODY SYSTEMS● APPROACHING THE PATIENT● ASSESSING THE STRESS-STRAIN RELATIONSHIP● ASSESSING THE TISSUES MECHANICALLY● AVERTS!

● Hyper-pronation?

● Functional Hallux Limitus?

● Hallux Rigidus?

● Plantar Heel Pain?

● Achilles Tendinopathy?

● Anterior Knee Pain?

WHICH IS A DIAGNOSIS?

BIOMECHANICAL EVALUATION

WHY DO WE DO IT?

● To give a diagnosis and a mechanism of injury = tt plan.

● FLAGS● Process & Pathways: SOAPIER/ SIN/ OLDCARTS● Assessing Body Systems: GRAGCELS● Approaching the Patient: Asking the right questions!● Aims of Clerking: Establishing the stress-strain relationship.● Assessing the Tissues Mechanically: Diagnostic confirmation

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● SUBJECTIVE………….what the patient reports● Objective ………………….what the clinician sees, and finds on examination● Analysis……………………….what we perceive from the above (a diagnosis)● Plan………………………………….What are we going to do about it?● Intervention……………..The treatment that we apply● Evaluation………………….Check with the patient that is good for them● Re-evaluation………..Get them back and check the treatment

worked.

BIO-PSYCHO-SOCIAL MODEL OF CARE

●●●● Onset…...history of the problem.● Location…….one finger test to one spot.● Duration……….symptom patterns.● Character…...e.g. Burning stabbing, shooting, radiating, dull ache, etc● Aggravating factors……..what upsets or helps it.● Radiating or Referred…...relative description….failure of one finger test.● Temporal Patterns………..daily symptom complaint patterns.● Severity …...AGAIN!

Clerking the body systemically. CRAGCELS

WHY IMPORTANT?

● Cardiovascular = heart disease, vascular disease, anemia. ● Respiratory = COPD, asthma.● Alimentary =IBS, Crohns.● Genitourinary = urinary patterns and infections.● Central Nervous System = Parkinson’s, Motor Neuron Diseases.● Endocrine = diabetes, hypothyroidism.● Locomotor = DJD, etc.● Skin = psoriasis, etc.

Don’t forget to consider age.

● Closed Question; definitive answer.

“Where does it hurt”?

● Open Question; invites explanation.

“When does it hurt”?

● Searching Question; (avoid leading the patient).

Good example: “Does the heel hurt most at any particular time of the day?”

Bad example: “Is the heel pain worse when you stand up”?

● Probing Question; establishes patient perceptions.

“Why do you think your pain is related to work”?

● The patient should give you the most likely diagnosis if you ask the right questions.

● Examination of the patient should be for confirmation.

HOW GOOD ARE MY PATIENTS TISSUES MECHANICALLY?

Stress =

Strain =

Foot converts kinetic energy into potential energy during vault changes.

Compliance & Stiffening!

Foot releases potential energy as kinetic energy on returning to shape if stiffness energetics correct.

Strains too much before adequate stiffness…….energy lost

Strain too little tries to heel lift on compliant foot……..stored elastic energy not used.

Both result in poor energetics

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● Associate or disassociate the information from the symptoms/complaint.

Combination of point 5 with any of the above.

Clerking a patient uncovers the nature of the tissues under load and is directly influenced by the heath and physical condition of the patient!

This informs us of the potential for dysfunction in compliance and stiffness within the foot.

Normal stress on normal tissues. Shouldn’t be in clinic!

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Also pain sensitive (Fibromyalgia, psychosocial)

tissue fatigue

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Normal Healthy Tissues Fatigued Tissues

Once injured tissues are abnormal

Examples:

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(how much pressure causes a diabetic ulcer?)

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The catch-22 situation

Pros Cons

Clinical imaging

Clinical examination

Palpation

Cyriax

(Pellechia et al, 1996, Greenwood et al, 1998, Howard, 2000)

● Different tissues do different thing● Different structures tend to be injured by specific stress/strain events.● Most tissues are anisotropic

Eg:

● Joint surfaces = compression and shear● Tendons, ligaments and fascia = tension (especially with torque)● Bone = torque.● Muscles = isometric and concentric contraction rather than eccentric● Nerves = under compression or compressed tension.

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Active inversion/ resisted eversion pain

Passive eversion pain

Be careful with tibialis posterior

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High sensitivity reported at 98% positive with pain (Klein et al, 2013)

Varus Compression for DJD Valgus tension for medial collateral

● Tissue Quality.

Healthy or Unhealthy

● Activity. High/ Low / Specific

● AIM Status

Alignments/ Instantaneous joint Axis Location/ Morphology

● Gait determinants

Features of kinematics/ kinetics/ energetics

•References:

• Greenwood MJ, Erhard RE, Jones DL (1998). Differential diagnosis of the hip Vs lumbar spine: five case reports. Journal of Orthopaedic and Sports Physical Therapy. 27(4): 308-315.

•Howard PD (2000). Differential diagnosis of calf pain and weakness: flexor hallucis longus strain. Journal of Orthopaedic and Sports Physical Therapy. 30(2): 78-84.

•Klein EE, Weil L, Weil LS, Coughlin MJ, Knight J. (2013) Clinical examination of plantar plate abnormality. Foot & Ankle International. 34(6): 800-804.

•Pellechia GL, Paolino J, Connell J (1996). Intertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. Journal of Orthopaedic and Sports Physical Therapy. 23(1): 34-38.