Diagnosis and therapy

But, as is clearly visible, that is not the case, and the reasons are partly apparent and partly hidden from a superficial glance.
Orthopedic diagnosis is pathoanatomical. This means it starts from the idea of the integrity of anatomical structures in the body as an indicator of health and identifies changes in that anatomy, declaring them pathological or undesirable. The names of these changes become diagnoses. The causes of these changes are only partially within the scope of orthopedics, while for the most part, they remain unresolved or are handed over to other branches of medicine for investigation.

For instance, if you are unfortunate enough to suffer a bone fracture from a fall, the diagnosis is clear—a fracture, and the cause even clearer—trauma. However, with all other conditions of the locomotor system, which are the cumulative result of small, invisible injuries that only become evident when they escalate, the diagnosis is clear in the pathoanatomical sense, but its origin may involve various factors. The true cause or causes, along with the contributing factors, remain hidden within the complex functions of the locomotor system. Detecting them can be difficult, requiring deep knowledge of the specificities of the system, extensive experience, and the utilization of modern technologies and diagnostic procedures. Even then, these same causes can be elusive. Examples include joint arthroses, spinal spondylosis, chronic tendon inflammations or their attachments, chronic spine or joint pain, and many others.

One of my colleagues once remarked that our profession is similar to an auto-body shop where a car is brought in after a traffic accident. Perhaps from the deformation of the bodywork, we cannot determine who caused the damage, but that doesn’t matter, as the question is simple—can we, and how, repair the damage and restore the car to a drivable condition? While he is partially correct, at least regarding trauma, I would say that most cars brought to a repair shop that are not in drivable condition were not involved in a traffic accident. In such cases, there is no simple or obvious cause, and identifying the exact cause is crucial for repairing the damage and preventing its recurrence. For example, the fact that an engine won’t start is a diagnosis, but the reasons for this malfunction can vary, requiring different approaches to repair. This is similar to a swollen knee. Swelling and arthrosis can be a diagnosis, but the causes of the swelling, pain, and even the arthrosis are varied. Without thoroughly understanding their genesis, any therapeutic approach is symptomatic, almost blind, and the final outcomes depend as much on luck as on the therapist’s skill, and less on the understanding of the pathological process occurring in the background.

I often return to the parable of a blister on the heel after walking. The blister itself is a pathoanatomical diagnosis, as it is an obvious change on the skin. At the same time, it is the result of cumulative damage and does not appear all at once. Clearly, it directly causes pain, and the first reaction is to treat the blister to reduce this pain. Such actions are necessary in everyday clinical practice.

However, the cause of the blister could be a shoe that is too tight or too loose, a poor-quality sock, damp or overly dry skin, the shape of the heel bone, walking style, and much more. Identifying all these factors is an essential part of the diagnostic process, most of which exceeds the scope and knowledge available in orthopedic medicine.

As my dear friend, a university professor and a doyen of orthopedics in Croatia, beautifully summarizes using the same parable: “My task is to determine that it is a blister, precisely locate and measure its size, and then send the patient to you to see how you can heal the blister and determine why it appeared in the first place. As you can see, my task is simpler than yours.” In this way, a pathoanatomical diagnosis no longer sounds like a verdict but as an observation whose context needs to be established.

At first glance, it may seem that orthopedists are not interested or motivated to look for the causes of the tissue damage they treat. But the truth is far from that. Modern surgical orthopedics is a highly complex science and skill that requires years of refinement to become effective. From the wide range of possible pathoanatomical changes and systemic diseases, through their recognition and diagnostics, to the details of surgical procedures available, their refinement and individual adjustment, and the ability to predict treatment outcomes—all require narrow subspecialization and specific knowledge and skills. In this vast and deep field, there is sometimes not enough space for other aspects of medical procedures, both diagnostic and therapeutic. As orthopedic knowledge expands, the need for subspecialization grows. Thus, the orthopedist knows more and more about an ever-smaller part of their field. As a result, the question of functional assessments and diagnoses remains open and, over the years, has transitioned into the domain of physical medicine, physiotherapy, and kinesiology.

So, do we have two diagnoses, one orthopedic and another physiotherapeutic or kinesiological? Absolutely not! The diagnosis is always and only orthopedic. Everything else is a hypothesis about its origin. In our Polyclinic, we nurture precisely this approach, which, after making an orthopedic diagnosis, requires a physiotherapeutic examination and the formation of a physiotherapeutic hypothesis about what led to the orthopedic diagnosis or the occurrence of the painful condition within that diagnosis. This hypothesis is invariably individual because we are all simply different. The same diagnosis or locomotor system injury may (and usually does) have different causes and contributing factors that lead to the condition for which the patient seeks help. Additional precision to this hypothesis is provided by specific kinesiological tests and diagnostic procedures. Only when the hypothesis is established does treatment begin, which is as individual as the hypothesis. However, the hypothesis is not immutable and may be modified during treatment if necessary to improve the efficiency of physiotherapeutic procedures. This is because, during physiotherapeutic interventions, the body or part of it may respond unpredictably to the initial hypothesis. Thus, the therapy itself becomes part of the diagnostic process, which is fluid and changes whenever necessary.

I understand that everything written so far is complex, perhaps even insufficiently comprehensible to the average reader without medical and clinical knowledge. I also understand that it would be simplest to always treat one diagnosis in the same way.

But…

Our differences, both external and internal, do not allow for shortcuts and rigid adherence to protocols. They encourage the ability of physiotherapists and kinesiologists to maximize the individualization of diagnostic and therapeutic processes. Otherwise, the therapy results will be anything but satisfactory.

This is why we have developed the tension model (click for article) of the locomotor system. It allows us to apply everything described above but in a simplified form, usable in a clinical setting, and understandable to both the therapist and the patient.