Concerns Of Podiatric Biomechanics: One Podiatrist’s Observation
There was a time in the late 1960s when, prior to most advanced reconstructive foot surgery currently performed today, many schools of podiatric medicine required a complete biomechanical evaluation as a prerequisite to proceed with a procedure. Often students would seek out faculty members, who specialized in the then evolving principles of foot and leg biomechanics, to verify the accuracy of lower extremity joint ranges of motion, calculated their respective “neutral positions,” graded muscle strength, performed dynamic gait observations and documented a variety of other anatomical relationships. Drs. Root, Weed, Sgarlato, Smith and others (faculty members at the California College of Podiatric Medicine faculty circa 1960s) espoused ideas about the basis of common foot pathologies being in the dynamics created by abnormal retrograde forces exerted upon the various joints of the unstable foot.1
During this period of the evolution of podiatric biomechanics, one dispensed custom foot orthotics to the patient soon after healing from surgery. The theory I observed at that time was that custom orthotic devices would stabilize the foot in hopes of preventing deformity recurrence or to create the pedal environment that would assist in reducing various abnormal forces upon the joints of the foot and thereby reducing symptoms. Unfortunately, no in-depth, long term, multi-center prospective study exists that evaluates the influence and effect of biomechanical control on the foot. Countless papers espouse the benefits of custom orthotics, while others tend to question the validity of those studies. It was common for studies not to differentiate between custom versus over-the-counter devices. Many journals in which these papers appeared were not peer-reviewed, and as a result the biomechanical conclusions have been questioned. Additionally, in my observation, the authors of these papers did not often clearly define or explain the type of orthotic used, nor the positioning of the foot joints (ie ankle, subtalar, midtarsal, first MTPJ) during the process of obtaining a negative cast. As a result, the ill-defined documentation in these papers resulted in many questions as to the actual validity of their conclusions.2
Over 30-plus years as the director of a highly sought-after residency program, as well as conducting a major podiatric medical student externship program, I would regularly ask either students or residents to present a complete lower extremity examination. Over the course of many years, it became progressively more obvious that trainees did not consider or present full or even partial biomechanical evaluations during these sessions. I would often question the students regarding range of motion, foot type, gait analysis, etc., only to be met with blank stares. It was the exception to find a resident or student who, by his or her own initiative, would include any biomechanical evaluation as part of a thorough initial patient work-up. I also observed during this period changes in the podiatric curriculum as well as lowering requirements for certain board eligibility regarding biomechanics.
While attending national and state podiatry meetings nationwide, there were fewer and fewer lectures presented related to biomechanics. Surprisingly while attending non-podiatric scientific meetings (orthopedic, pedorthic, wound care, etc.) more in-depth lectures and workshops became dedicated to the biomechanics of the foot. Another observation I noticed is the decreasing number of orthotic laboratories that attend podiatry meetings as exhibitors or sponsors of workshops. Perhaps the orthotic laboratories found a negligible return on investment in supporting and attending podiatry meetings.
My concern is that diminishing exposure to lower extremity biomechanics on the part of our students and residents may impact outcomes of reconstructive foot surgery. I still contemplate the rationale for teaching biomechanical principals as part of basic podiatric education when it does not appear that trainees apply and/or incorporate this during clinical encounters. A review of numerous articles authored by a few of my fellow colleagues reveal their concerns regarding the general reduction in biomechanical principals being taught and discussed within our profession.3,4 It seems that major advancements in podiatric surgical procedures have increased while a general understanding of lower extremity biomechanics has diminished over time.
A December 2019 article by Jarrod Shapiro, DPM, suggests several definitive changes for incorporation at both podiatry colleges and residency programs.5 He further goes onto to praise the American Board of Podiatric Medicine (ABPM) and their recommendations regarding podiatric residency training. He also states that at a Council on Teaching Hospitals (COTH) meeting, a majority of podiatric educators in attendance actually wanted to reduce the course requirements in biomechanics for podiatric residencies. There appears to be a disconnect evolving within our profession as to what the benefits a biomechanical education contributes to patient care and to improved clinical outcomes.
Under the direction of the late Paul Scherer, DPM, the Prescription Foot Orthotic Laboratory Association (PFOLA) for many years conducted an annual biomechanical symposium that attracted hundreds of interested international health care professionals from a variety of disciplines. I found the lectures during these meetings emphasized not only the clinical benefits of biomechanical interventions but also the overall improved outcomes if one establishes a comprehensive, evidence-based perioperative surgical plan using these principles.
One cannot overlook the economics of incorporating biomechanics into one’s practice, notwithstanding the benefits to improved patient outcomes. I feel the lack of reimbursement for a thorough biomechanical evaluation and treatment has no doubt had a detrimental effect upon these outcomes. In my opinion, there is no justification for either private and/or governmental insurance plans to deny reimbursement for a thorough and complete biomechanical evaluation and subsequent treatment.
A long-term, comprehensive clinical study examining the benefits of incorporating biomechanical interventions is long overdue. If the profession does not embrace the understanding and application of assisting the biomechanically unstable foot, then it would seem that any untrained shopping mall clerk can just as easily scan a foot without concern for correct positioning of the forefoot, rearfoot, ankle and lower extremity. Such a comprehensive study, if well-designed and subjected to rigorous evaluation, might alter the current trajectory. However, if we continue to neglect the influence of the biomechanically unstable foot and how it affects the development of pedal pathology, then we as the premier foot care providers have failed. If the profession continues to emphasize surgical correction of the foot and ankle without evaluating the influence of abnormal biomechanics and its impact on osseous abnormality and symptomatology, then it would imply that it has no bearing on its development.
Dr. Stess is President and Co-Founder of the STS Company in Mill Valley, Calif. He is the former (retired) Chief of Podiatry and Residency Director of the VA Medical Center in San Francisco, a former (retired) Associate Professor at the California School of Podiatric Medicine at Samuel Merritt University and a former (retired) Assistant Clinical Professor at Hadassah Medical Center in Jerusalem, Israel.
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Reference
1. Root M, Weed JH, Orien W. Normal and Abnormal Function of the Foot. Clinical Biomechanics Corporation;1977.
2. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and pre-fabricated orthosis in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20(4)
3. Richie D. How can we make biomechanics relevant to podiatric residency training? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/how-can-we-make-biomechanics-relevant-podiatric-residency-training . Published December 31, 2020. Accessed November 11, 2021.
4. Kirby K. Whatever happened to biomechanics in podiatry? Podiatry Today. 2021;34(11):50.
5. Shapiro J. Has podiatry lost biomechanics. Podiatry Management. 2019 Dec;37-38.
