Thursday, December 3, 2009

Running: Physiologically Speaking
The Trouble with P.T.

As a runner and as an M.D., I get asked a lot of questions about the body as it relates to running. Why can’t I lose as much weight running marathons now as I did when I used to run track? (Your appetite and corresponding metabolism isn’t the same.) Why can I run faster with less effort during the winter as supposed to summer? (Your evaporative powers are maximized in the cold dry air.) What is the best way to take GU during a race? (A little at a time over a long distance to prevent sudden spikes in blood sugar and insulin levels.) In general, I welcome questions because they allow me the opportunity to apply what I know about human physiology to the sport of running. Most of the time, the answers are pretty obvious to me. Sometimes, I have no clue what people are asking and have to defer to my sports medicine or orthopedic colleagues/friends for their clinical advice and acumen. Rarely, one of my running buddies will tell me about what their P.T. told them about some injury they have and I have to do a double-take. Say that again. My P.T. told me that my hip/knee/groin/ankle/foot pain is caused by x,y, and z and recommended that I do these specific exercises. Really? Hmmm, okay, I don’t mean to insult your intelligence, buddy, but that makes as much sense as me going to the local drugstore and asking the sales clerk behind the counter which of these 1000 vitamins and supplements is going to cure my sinus infection!

The truth of the matter is that a lot of people, runners included, do not understand the qualifications or job description of a physical therapist and get in trouble when they seek out their trusty PT to diagnose and treat any and all injuries. This edition of “Running: Physiologically Speaking” is meant to educate my running friends so they are a bit more informed about how the evaluation, diagnosis, and management of sports injuries are supposed to work and who is qualified and licensed to do what job. I understand that many do not understand how different components of the healthcare system are supposed to work, so hopefully this will help shed a little light into the situation for you.

Suppose my friend, Joe Blow, is a newbie runner, who all of a sudden, while out running a long run one day, experiences a sharp shooting pain in the back of his ankle. He stops his run and limps home. Maybe he does the right thing and ices, compresses, and elevates. Maybe he doesn’t. Either way, he feels better the next day. There is no pain. He is happy. He trots out and tries his long run again (after all, he knows he can’t ever miss a long run if he’s “in marathon training”…no way!) Same thing happens again. This time he can barely make it past first mile before the pain cripples him. Crap! He goes home, all dejected. He repeats the same pattern for the rest of the week, but it doesn’t get better. He finally reluctantly calls his runner doctor friend, me, and I advice him to find a sports medicine doctor (or orthopedist) near his home. He goes, gets an X-ray and gets his diagnosis: tiabilis-posterior tendonitis. Treatment: Pain meds, no running, and 4-8 weeks of PT. Not the worst news in the world, but he isn’t so thrilled with the no running part. Still, he wants to get back to the road as soon as possible (after all, he has a marathon to train for!) so he does as he’s told. He finds a good PT, goes to all the sessions, but at the end of the two months, something’s still not quite right. His pain, which started at the back of his ankle has migrated somewhat to the bottom of his feet. His PT tells him he just needs more time, his muscles feel tight and he’s willing to continue the therapy for another 4-8 weeks without a prescription. I advise him to go back to the sports medicine doc and be re-examined. He wants to believe PT guy because he’s been seeing him for 8 weeks and figures he knows him pretty well by now and doesn’t want to go through the hassle of booking another appointment and getting more tests. On the other hand, he isn’t sure if he really needs the PT or if it’s really working. What should he do? What would you do? Are you one of those who’s perpetually in PT, or one of those who seems to have more of a relationship with PT and trust him/her more than practically anyone else you know? If you are, or think you are, or know someone who you think might be, please read on.

First of all, let me start by saying that I think physical therapy, in all its many forms, is necessary and important in injury healing and prevention. When properly done for the appropriate injury by the right qualified person, it is indispensable in helping patients recover fully from any muscle, tendon, or ligament damage they may have sustained as a result of trauma, accident or injury. I myself had to utilize their services when I suffered a clavicular fracture last winter and lost some mobility in my rotator cuff. The caveat though is that the right physical therapy must be tailored for the right injury for the right patient. It must be prescribed by a licensed medical professional (usually someone with an M.D. degree) after a thorough physical examination of the injury and evaluation with lab tests or imaging studies. A physical therapist is not qualified to perform these diagnostic tasks. They, the ones who are licensed anyway, have gone through physical therapy school, not medical school. Their main responsibility is to develop a treatment protocol (for a finite period of time, usually in the order of a few weeks to a few months) once a definitive diagnosis has been established. Coming up with the right diagnosis for the injury is not part of their job description, nor should it be. In fact, after the prescribed amount of PT is over, the patient should return to the physician who ordered the PT for a re-examination to determine if PT was successful and produced the desired effect. If not, the patient should be re-evaluated to determine whether there is some other underlying problem or to pursue whether other therapeutic options would be more appropriate. The answer is never to repeat the same set of PT exercises if they didn’t work or work well enough the first time. Is this distinction clear? I always hear of runners and other athletes who go to the same PT year after year, rehabbing the same injury the same way over and over, without the supervision of an M.D. and it frustrates me to no end. In my mind, the situation is similar to the people who goes to the local pharmacy to seek recommendations there on how to treat every disease and symptom they come across. Nothing very good ever comes out of those stories.

I hope this was a helpful discussion for some of you. Again, I’m not trying to knock the field of physical therapy or the people that perform them. Heck, I have friends who are in that line of work! However, I think it is important for everyone to know what the limits and responsibilities of their line of work. As someone who’s been on both sides of the provider/patient equation, I think it is to everyone’s benefit that we don’t overstep our boundaries and do or say things that although well-intentioned may end up hurting others in the process.

As always, comments, stories, and questions, welcome. Hope you all are having a fine day. Get out there and run, if you can. Class dismissed!


lindsay said...

very interesting. i've never had pt (knock on wood) so i can't speak to that side of things.

i think overall i'd agree with your opinion - a pt is there for the pt, not the diagnosis. i'm sure there are some pt's out there who are very knowledgeable and may be able to say "this is probably what it is and doing this would help", but in general i think most pt's don't have that talent (/extra education). on the other hand, even md's can screw up the diagnosis from time to time. i guess in the big picture - my thoughts are to just find a good doc who knows what s/he's doing and is humble enough to refer you to someone else instead of guessing. (my experiences with non-running medical issues... love those 5 minute doctor visits where they give you some generic answer and prescribe you prednisone...) anyway i'm veering now, sorry!

Anonymous said...

so so true. i've had really good success with ART but I've never had a serious injury. i think even a PT would agree with you-- at least a competent one!

i think if you continue these posts you should do one on how your endocrine system is affected by running. for example, for a woman how it affects the monthly cycle, changes in metabolism, etc. but then again i like medicine and science :)

Running and living said...

This post is very brave and v well written. So many times I had to bite my tongue so not to state my feelings about PT for certain conditions. I work mostly with hand and arm pain patients, and work with many PTs. I myself went to a PT once, learned a set of ex., and did them at home myself. A lot of the PT methods (e.g., TENSE, ionophoresis) are not better than placebo in scientific studies, yet they are frequently used and presented as efficacious. Anyhow, I will stop here, but good job with this post!

Anonymous said...

agreed wholeheartedly. i've been really lucky with any injury sending me to PT or in the PT clinic i interned in where the therapist's thinking were in line with you.

unfortunately it's so darn hard to get appts with specialist doctors nowaways. you need to book far in advance in many places (at least around me) so i can understand the reluctance on a patients part to go back to the doctor rather than just continue the pt and hope things get batter

joyRuN said...

Well, I guess I get to find out the benefits of physical therapy myself next week when I start. I can already tell that I'm going to be a picky & pain-in-the-neck patient. A running nurse - feel sorry for the poor therapist who'll get stuck with me ;)

Lisa said...

This is a very interesting post. I agree that it's important for people to seek advice and diagnoses from the correct professional.

I also agree with marathonmaiden. It is extremely difficult to get in to see the right specialists (if you can even find one), which is often very discouraging.

I look forward to reading more of these posts. Thanks!

Jesse said...

Interesting thoughts on the topic. I admit to being ignorant to a lot of this, even though it sounds obvious now that I've read it. Thankfully my wife is smarter than I, and sent me to my D.O. rather than the Physical Therapist (I was just going to go straight there) when I hurt my knee.

Irish Cream said...

Great post, Lam. I think this can be quite an issue with the running community, so it's great that you addressed it. My guess is that people also fear being told not to run (in addition to the hassle of trying to get in to see a specialist) . . . they think if they go straight to the PT, they'll just learn some exercises they can to do "fix" whatever's wrong with them.

We learn a lot about these types of professional "boundaries" in my program--and it's a little shocking to me that a PT would even try to diagnose anyone even if they were somewhat knowledgeable about the specific injury. Anyway, thanks for sharing! I always love these posts.

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RunMishiRun said...

Thanks so much for this post. I'm definitely going to keep this in mind as I do my PT. I may need to consult with you in the future about this.

By the way, I love that you always PR in the Garden City Turkey Trot! It's my hometown and I try to run it every year (except this one due to the fact that Thanksgiving was at my house). I hope you run it next year so we can say hi at the race!

sRod said...

Thansk for sharing. Very helpful as always.

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