A Hermeneutic Enquiry into how MSK Podiatrists Interpret and Use Evidence in Practice

Podiatrists have developed an informal specialism within their profession which enables them to treat MSK injuries with functional orthoses. The podiatric biomechanics theories, on which this treatment is based, have been called into question and may have little scientific basis. Research evidence into functional orthoses suggests they may not be as successful at treating MSK injuries as it first appeared. This has lead to debate within MSK podiatry about which theories and orthoses to use in relation to the treatment of MSK injuries. It suggests that podiatrists may be unable to apply easily the principles of evidence-based practice in MSK podiatry. The aim of this thesis is to explore how MSK podiatrists interpret and use evidence in clinical practice; what influences their beliefs, their perceptions of the interpretation of research and other forms of evidence and it examines their lived experience of using evidence in clinical practice. A hermeneutic approach was used to conduct semi structured interviews with seventeen podiatrists who use orthoses to treat MSK injuries in a variety of practice settings. Interpretative phenomenological analysis was utilised to analyse the data. Ethical approval was given by the University School ethics panel and relevant permissions were granted by employers. The findings reveal there is confusion about evidence in MSK podiatry. The participants understand the concept of evidence-based practice to be the use of quantitative research evidence in practice. In reality there is little definitive knowledge from research and the main source of evidence used in practice is patient feedback supported by a process of active experimentation. Clinical knowledge in MSK podiatry is a form of practical wisdom, gained through the lived experience of practice. The uncritical acceptance of evidence based practice principles together with an emphasis on randomised controlled trials suggest other forms of evidence are devalued. Thus, MSK podiatrists have fears their practice is based on weak evidence. The discourse of MSK podiatry has changed, participants use a Tissue Stress approach with the biomechanics theories forming a framework to understand gait and as the basis of their active experimentation. The discourse has become more vague and individual. The language used by the participants reinforces the ambiguity, for example there is a wide range of terms to describe orthotic designs and modifications. This could be a way to maintain the status of MSK podiatry. The concluding discussion examines the findings in the context of current literature that MSK podiatry is a practical and experiential specialism. It could be described as a patient centred approach based in a practical wisdom. The participants are not undertaking EBP as they describe it because the lack of propositional knowledge undermines the research undertaken in this area. Therefore it is recommended that a national outcome study is needed to confirm the effectiveness of orthoses and to gain understanding about the orthoses being prescribed and the MSK conditions being successfully treated. There needs to be further exploration to establish understanding of the language of MSK podiatry . The professional body for podiatrists should consider a mentorship programme for practitioners to allow the individual knowledge of MSK podiatry to be shared and to maintain the community of practice in these changing times for healthcare provision in the UK.