Almost everyone has heard of the Hippocratic Oath taken by physicians upon graduation from medical school. Most people are aware of the general philosophy, if not the specifics, of this oath. While disparate versions may be found in different areas of the country, a widely known phrase commonly attributed to the oath is the very succinct, “First, do no harm.”
Unfortunately, in the healthcare arena errors sometimes do occur – albeit unintended – and when they do they are referred to as “iatrogenic” injuries or illness. While the word iatrogenic [i-at-ro-jen’ik] derives from the Greek meaning physician (iatros) producing (genic), current usage is not limited to the mistakes of medical doctors, but rather applies to the entire spectrum of healthcare professionals.
I would like to tell you that physical therapists are exempt from this group, but given Stedman’s Medical Dictionary definition of iatrogenic (denoting an unfavorable response to therapy; induced by the therapeutic effort itself) I would indeed be on very shaky ground making such a claim.
Iatrogenic injuries or illness in the medical field most often occur as a result of improper diagnosis, medication prescription, or surgical error. In my neck of the woods, patients may suffer adverse effects from one or more of several mistakes. These could include improper or overly aggressive exercise programs; improper application of physical agents (electrical stimulation, ultrasound, etc.) or; inappropriate “hands-on” treatment (soft-tissue and joint mobilizations, stretching, etc).
More specific to runners are problems that can arise as a result of poor advice on footwear. The ability to prescribe the proper shoe is only as good as the ability to identify the patient’s foot type – not always an easy task. The provider also needs to understand the specifics of shoe construction, again not an easy task given the frequency of changes in shoe models.
The worst problem that I see in this area of iatrogenic injury is the improper use of foot orthotics. In fact, the longer I practice physical therapy, the more convinced I am that foot orthotics are one of the most incorrectly and/or over-prescribed interventions for runners.
Orthotics are generally prescribed with the intention of reducing the amount of pronation, or rolling inward, of the foot during the early stance phase of gait. The problem is that orthotics are useful only when this abnormal movement pattern is due to a specific foot structure, while quite often excessive pronation may be the result of a whole host of other factors. In my opinion, the use of orthotics to attempt a correction of something other than a foot inadequacy, such as say a hip muscle imbalance to give just one example, more often than not will cause other problems.
Runners should be cautious when orthotics are recommended after only a cursory evaluation, if they are the first intervention advocated, and if the rationale is not easily understood. The pre-eminent runners’ orthopedic surgeon Stan James put it best:
Orthotics are not a panacea but have added a new horizon to our treatment armamentarium for the overuse syndrome.