For a long time I've believed that my practice philosophy is unfortunately more unique than universal. There shouldn't be anything special about my practice. Yet, for many of the nearly forty years since I've begun seeing patients I've been told I'm the last resort, the best, the only one to see. Of course this could never be verified for any doctor, and I would have a big problem if I let myself believe that, though it's sobering to have such responsibility in patients' eyes. Now that I'm trying to put it in words, I guess the best way to concisely describe the guiding light of my approach is doing everything possible to put your best interests first.
My ability to formulate what "your best interests" means is based on certain factors. I have to get to know you a little, so when we first meet, we'll chat about your family, your work, your trip in to my office, someone who referred you, etc. This gives me an idea of the best way we can communicate, and just breaks the ice. I want you to feel comfortable and get to know me as well. It helps.
I have to get an idea of your lifestyle, both long-term and immediate. Like how important walking or certain sports are to you, or how adapted you are to the activities you want to do. I have to determine if your work, or your family requirements, like taking care of a big family or an ailing husband, put excessive strain on your injury, for example.
When I'm satisfied with that, we'll get into your injury. Most times it's best to tell me exactly what the problem is first, then give me a detailed list of things that may have contributed to it. That's usually the best order to do it, because I thus will have a feel for how the subsequent information flow I want you to give me should be directed. Things will click better in my brain if we do it in this order. If you think some other order is best, we'll try. The information flow I'll want will include anything pertinent, like accidents, surgeries you've had, other parts of your body causing you to shift weight to the injury, changes in shoes, any orthotics or heel lifts, any change in activity, or sport, or body weight, dance teachers, tennis courts, running surfaces, changes like that. Even if you never come to see me, you should always approach your life, at least from an orthopedic point of view, as a "living history." Changes like these can trigger problems. As soon as you feel a problem starting to roost, think chronologically about such factors. You might be able to avoid the doctor, or at least help a doctor figure out your problem.
Then I'll want to know what treatments you've had, and your response to them. If something helped, it'll help me to figure out your problem and how your tissues respond. If something hurt in a treatment plan, likewise. You may not even be aware of these factors before you come visit me. It's my job to pluck them out.
We'll do our best to figure the current status of your injured and uninjured tissues. I'll use my eyes, my hands, my fingers, my practiced ability to sense temperature, and tissue quality, and feel irregularities in your tissues. We'll check your strength and flexibility. I'll ask you to walk, and I'll look for blatant or subtle aspects of your gait which may be big-time clues in getting you better (see some of the case histories on this site). I may ask you to demonstrate how you dance or run. I'll look at any necessary additional sources, such as MRIs, X-rays, bone scans, nerve studies, blood tests, CAT scans, or letters from consultants. If I don't think the data package is complete, I'll order what's needed.
I'll check the angle of your bones, shapes of your bones, motion in your joints, length of your legs, status of other problems or tissues, whatever is necessary to complete the picture. All this to see how bad the injury is, whether it's worsening or healing, and why.
Now for that big "why" I just mentioned. If your tissues should be healing, but they're not, there may be a gremlin in the mix. Every problem has a reason. Most often the reason begins to evince during the history, which I must allow to develop and evolve along a free path, yet keep shepherded in a coherent direction. Maybe something you're doing, either on your own or thanks to some therapy, is perpetuating your injury. The reason may indeed lie in the string of injuries or treatments you've had before you come to see me. Or maybe you've been asked to do certain therapy and you haven't done it. Maybe you've been asked to do certain therapeutic exercises and you're either doing them incorrectly, or you were shown them incorrectly. We may go there, too.
Maybe some shoes, slippers, or even orthotics you were given are peppering your life in such a way as to sustain your injury. Maybe there's been a change in your bone density, or some systemic illness or some medication or even dietary foible is making your problem look orthopedic but it actually is not. Perhaps there's a systemic arthritis or other condition, like Lyme disease, which should be taking you to a rheumatologist or infectious disease expert instead of a podiatrist. Don't worry, you may not realize any of these things when you come in for your visit. It's my job to be acutely aware of these possibilities, and hone your history and physical exam to make the necessary discoveries.
I have to be ready to click upon any of these factors. I can't describe how my mental flowchart starts, or why a visit takes me in any particular direction with any particular patient, but I can say I will not be satisfied until I have arrived at your diagnosis and the reason for your problem and I will tell you if I'm not satisfied.
After all of the above, and quite possibly even more, I'll attempt to nail down both your diagnosis, or exactly what your injury is, and its cause. Now we can get to work.
We must decide the most likely, quickest, safest, and if possible, cheapest way to get you better. We have to determine if this will be just a short-term fix, or will things like orthotics, exercise prescriptions, shoe caveats, heel lifts, avoidance of certain activities or sports, etc., become more or less part of your life for some duration. I may perform prolotherapy, a simple injection technique I frequently perform under ultrasound guidance, to restore stability to sprained ligaments, tendons or plantar fasciitis. I may refer you to interventional radiologists to perform more elaborate techniques best done by more than one doctor. And I have to figure if I'm the right doctor for you, or do you need consultations with other doctors, or to be better off in the hands of another doctor, or surgeon, as we proceed.
Finally, I have to put this whole package together and see if the urgency you had displayed, or the depression you may be experiencing, is commensurate with the degree of difficulty I think it will take to get you better. Some people have low pain thresholds, some high pain thresholds. Each of these situations can be a double-edged sword. If you experience a lot of pain for relatively little tissue damage, it's my job to point out that there is but little damage, and turn your sensitivity problem into a bit of reassurance that you likely will get better easily. If you have a high pain threshold, I must guide your approach to your treatment so that you "pull back on the reins" a bit. Otherwise, you may incur so many cumulative injuries here and there that the whole thing mushrooms into something more difficult to rescue.
While we're talking about pain thresholds, let me offer that pain-killer and anti-inflammatory medicines have limited value when treating many injuries, especially if you take them while you continue doing whatever is causing the injury. An early-stage injury should not be treated with anti-inflammatories alone, or you can take your small amount of tissue damage and keep beating it up until it turns into something you'll have to deal with long-term. This especially happens as we get older, but it's a crime to let it happen in youth. Thus, you may keep your injury from yelling at you at first, but masking it will only coax the injury to scream and be more difficult to ultimately calm down. If you take anti-inflammatories, it's of supreme importance to figure out why the injury occurred, do whatever has to be done about that, and cut back on your activities till it heals, before gradually going back to hot and heavy activity.
This is what I meant in my first paragraph by in "your best interests." And this is what I mean by "there shouldn't be anything special about my practice." Isn't this the way you expect to be treated when you go to a doctor?
I will tell you what I believe I'm good at, and what I think you'd be best treated by someone else for.
I'm most confident at treating mechanical aches and pains. The whole list of sports, dance, and walking-related problems you'll see linked on hundreds of other podiatry websites. But you won't see links to definitions and treatment plans for these myriad injuries here. By all means, visit those doctors with links. I sincerely hope they get you definitively better for ever. But if the doctors you've seen can't get you better, please call me.
I believe I'm good at defining a diagnosis, and spotting the reason for a person's problem. Why? Because I believe there is a reason for every diagnosis. Thus I do not feel it is a waste of effort to seek a reason.
You may be referred to me for orthotics. Don't be disappointed if I tell you to forget about orthotics. If they're not right for you, I'll tell you. If you've had 33 pairs of unsuccessful orthotics and you show them to me, I'll probably try to help you without orthotics. But don't be surprised if I ask to adjust an old pair of orthotics that never worked for you. I love running into my shop and turning a disaster into an instantaneous success. If I think you need a 34th pair, you might not detect the courage it takes me to tell you, but you can count on my giving you an explicit, soup to nuts reason.
I may prefer to give you pristine or modified over the counter orthotics or a cheap slip-on ankle brace, or some exercises. I may simply advise you to change to a higher or lower heeled pair of shoes. It's a pleasure when this gets someone definitively better who'd expected to pay hundreds of dollars for orthotics.
If I think you need surgery, or rather, that surgery would be the most likely way to get you best, fastest, I'll tell you. I don't do surgery, though I did one of the best podiatric surgical residencies in the U.S. Despite the vaunted status of the residency, when I started my practice I didn't feel adequately prepared to decide who should have surgery and who shouldn't. That's one reason I started this Sherlock Holmes-y job and didn't become a surgeon. Now I know who should consider surgery over conservative treatment, but I did not acquire this realization till years after the surgical expertise of the residency had dulled.
Other things I don't like to do? Though I love salvaging nails from unnecessary surgery, and teaching patients the right way to cut them, I don't love treating severely ingrown toenails. I'll do them, and be certain to do a thorough job. I just don't like them. I love dermatology, was tops in my class in dermatology, but not being a surgeon, I don't biopsy, so I might refer you.
Don't be surprised if I refer you to a different doctor for many things (except investigative things). I refer approximately 5% of initial patients without treating them. After we have our visit, I feel it best that I don't assume their management. Some come back to me after they've cleared up important possibilities with consultants, some are best only in the hands of the consultants. I refer about 20% of patients while I'm still in charge of their case for consultations with specialists, physical therapists, or diagnostic services. Recently a patient said to me "Are you competitive? Are podiatrists competitive?" My response just came automatically, "I'm not competitive. If I think there's someone who can treat you better than I can for any problem, I'd sure better refer you to them. Otherwise, I'm doing you a disservice, no?"
Ulcers?I have a love/hate relationship with ulcers. I'm extremely strict at getting rid of the cause of an ulcer. I had wonderful training in my residency, and this mixed with my love of improving contact forces gives me a high degree of confidence when I exorcise a mechanical cause for an ulcer. The problem is ulcers require frequent visits and I may not have a convenient spot in my schedule for you available at your required frequency. I'll see you to eliminate the cause of your ulcer, but may refer you to another podiatrist or a wound management specialist for your repeat visits. I'll probably ask you to return to me at critical junctures to make sure things are going according to plan.
While we're talking about appointments, I hate being tardy. I like to run on time, and I have acquired a cadre of patients who love counting on being seen on time so they can get on with their day. If you're late beyond the minimum time required for me to treat you without seriously inconveniencing the succession of subsequent patients counting on their appointment time, you may be asked to reschedule. Unless I have an unalterable obligation that evening, I will be delighted to stay late for you and ask my secretary to stay so I can see you that day after my regularly scheduled patients. I'll come in early or stay late for you.
And I don't take insurance. We'll be happy to fill out your insurance form, and fight for you to get reimbursement in the form of letters of medical necessity or phone calls to your insurer. I remember several days when my secretary seemed to be on the phone all day long to help one patient get reimbursed.
One final sidebar…
I can’t expect a patient to get better unless I nail the diagnosis. Exactly, precisely, comprehensively. Hands-on, feel for little irregularities under the skin, visualize, check the strength, flexibility, color, temperature, appropriate size of the part for the body, injuries to the area of complaint, history of injuries to the area, check treatments rendered to that area… were they complete, appropriate, inappropriate, did the treatments help, have no effect on or worsen the areas? Check shoes and orthotics for perpetuating the injury, habits like crossing ankles over the complaint site, check X-rays, MRIs, ultrasounds, CT scans. Look at all the reports of the radiologists and insist on looking at the images. If the images are poor quality, fight with the insurance company to have a better facility redo the images. Look for uninjured areas on the MRI the radiologist may have therefore overlooked, but areas where an extra muscle or tendon happens to be, or a muscle which is attached to a funny place on the bone, because you’ve been studying MRI’s of this tiny foot and ankle every night to the point of eye fatigue for 24 years. Question all the radiologists reports until you verify them with your eyes by looking at the images. Question all the therapy a patient has been given until you verify with your eyes and ears that it was appropriate and still is. Estimate the degree of tissue damage. Look for likely insufficiency or possible damage to other tissues or structures which might be perpetuating the presenting complaint. And so on.
Put all this into the stew. Stir it around, figure out the injury, what it will take to get it better, and prevent recurrence and/or further injury. Look at the injury and associated circumstances broadly, with respect to the dancer’s career. Advise the dancer steps that should be taken to prolong the career and minimize injury in the future. Be familiar with the dancer’s choreography and class. Does your diagnosis make sense? That said, is it something that you’ve never seen before? Don’t discount it just based on statistics. Believe in what you’ve arrived upon. Estimate within a few days how long the 6-month long, heretofore unsuccessfullytreated injury will take to get better.
Give the dancer an exact return to activity schedule, something like…OK, in 3 and a half more weeks, begin weaning out of the camwalker boot. Gradually, one hour less each day boot, one hour more each day those sneakers I advised you to buy. But if you have to go on a long walk, sling the boot back on. You are welcome now to do flat pedal vertical, not recumbent bike cycling in the gym, as long as you use a stiff-soled shoe and push with your arch, not the ball of your foot. And keep the gearing light because of your history of sacroiliac pain. You may also swim now, just take the camboot to the edge of the pool, be careful not to push-off, and keep the water at armpit level so the buoyancy will float the pressure off the injury. Keep doing your Pilates in the meantime, but don’t go overboard on the hip abductor work after you come out of the boot because we have to get your calf stronger and the Pilates might keep your calf a little lazy. Begin the physical therapy for your ankles and toes and balance as soon as you start weaning out of the boot. Make sure you do the peroneus longus strengthening properly…that is key. If you have had no pain for 10 days walking, begin single-leg releves on a dense half-foam roller, eventually working your way up to 20 6- second round trips twice per day, using the roller to keep the work out of your toes and focus on the calf. If you can do 10 of these foam roller releves without pain, then you may give yourself a 20-minute home barre, double leg, in flat shoes. Every other day. Stop doing any of these things I’m telling you, and tell me, if there is any pain whatsoever. Continuing, if there is no pain with the home barres double leg, go to “XXX”’s class, as she is known for healthy teaching, has a great floor, and will let you take a slow barre in the back of the class. Take her regular barre, yes single leg, and sit out the rest of the class or go home. Do this or your own version of this at home every other day for a week. If no pain, then take this barre for five days in a row. If no pain, then barre + adagio (obviously no partnering) for five days. Do all of the above in flat shoes. At the end of the week, just try some temps leves and sautés. Wait two days. If there is no pain. you can take barre, adagio, and petit allegro the following week, up to but not including the turns. Oh wait, you are 29 and you’ve been out for three months…do the petit only every other day, not 5 days in a row. If there is no pain halfway thru that week, you can begin doing pointe class on the same schedule as you’d done for flat class, starting with the single-leg barre. Back to flat class…if there is no pain after a week of the abbreviated flat class, you are home free and the next week you may resume full class! This should time out right for rehearsing Snowflake, as there is so much pas de bourree. And ps, don’t forget to check your future shipments of pointe shoes that the platform is angled the way I told you to the vamp!
Tell the dance company manager or physical therapist our estimate so they can arrange replacement dancers and rearrange their schedule, or include or not include this dancer on the European tour. Don’t give in to your plan if the dancer “really wants to go”, remembering those dancers early in your career you gave in to this way who horribly had a complete recurrence of the injury thanks to your acquiescence. But don’t be unnecessarily rigid if there is something she can get away with, like a character role. And be sure that your assessment of what it takes to get better stands minimal chance of making the patient worse, and even under that aegis, closely monitor the patient to be sure. Do this for 42 years. And subconsciously apply all you’ve learned from treating dancers to your regular population of patients.
I owe my career to dancers.
Now please keep the following a secret, because I cannot apply it to anyone else if I wish to stay in practice, but if you are an obviously dedicated struggling dancer I often find myself charging you a very small percentage of my regular fees, quite modest compared to NYC doctor’s fees.
This, my dedication, and my forever gratitude and devotion, is my thank you.