Top down and bottom up

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When I went on some of my first interviews as a new grad, one of the most common things to talk about in an interview was whether I took a “bottom up” or a  “top down” approach to treating lower extremity injuries. Bottom up refers to the theory that how the foot hits the ground determines the kinematics of the lower extremity and is the focal point too treating these injuries. The top town approach is very much the opposite and refers to the theory that stability and motor control of the lumbar spine and hip determine how the foot hits the ground making it the starting point for all lower extremity injuries.

In my graduate studies an emphasis was placed on foot/ankle mechanics and recommended treatment was posting and orthotics to control the lower extremity. In contrast ,my first job was at a clinic in Los Angeles, was hyper-focused on gluteal strength for correcting lower extremity mechanics . A major influence being that at USC Dr. Christopher Powers was publishing a ton of evidence linking lack of gluteal muscle strength and patellofemoral knee pain.

Writing this out is seems painfully obvious that depending on the patient either, and often  both of these approaches are used. I have had great success treating ankle, hip, knee and even radiating pain in the thigh and buttock by addressing foot and ankle mobility and/or stability issues. Just as often, hip, knee or foot pain is addressed by beginning to treat the lumbar spine and pelvis and addressing proximal stability issues and muscle imbalances.
It can be difficult to self diagnose what the root cause of your pain is and it may very well be that it is a combination of these. My approach begins with gait evaluation (watching you walk). This is where we decide where to begin investigating. I do not automatically focus on one end or the other and try to let your movements tell the story rather than dogma, theory or a new research report. It makes it hard to answer someone at a party who asks me,”why does my knee hurt?” In that moment I simply do not know enough to answer that. I do not have a cookie cutter approach and I will not know unless I examine them. The answer becomes less cut and dry but the end results are much better.

Posted by Andrew S. Eisen DPT Seattle Physical Therapist