Podiatry’s Future: Biomechanics Versus Surgery Or Biomechanics With Surgery?

   Podiatric surgery and podiatric biomechanics were treated as two very different specialties, separate and distinct from each other during my podiatry school days. The faculty members for surgery and biomechanics were different. The surgery and biomechanics clinics were in different locations. Rarely was there a mention of surgery concepts in the biomechanics clinic or a mention of biomechanics concepts in the surgery clinic.

   In fact, as podiatry students, we often raised our eyebrows at each other when a surgery faculty member entered the biomechanics clinic or when a biomechanics faculty member entered the surgery clinic. We were certain that an “invasion” had occurred within our sacred clinical realms. This separation of podiatric surgery from podiatric biomechanics during my student years was quite real and readily accepted as how things were done within the podiatry profession.

   During the nearly 30 years that have passed from my years as a podiatry student, I optimistically expected to see the separation lines between podiatric surgery and podiatric biomechanics become much less distinct over time. I hoped that podiatric surgery would be taught with more emphasis on the specific biomechanics of the patient’s foot and on his or her characteristic gait pattern so we could plan better surgeries for our patients.

   I also dreamed that the important principles of biomechanics would be taught for both non-surgical and surgical treatment of feet so surgery and biomechanics would no longer be considered as separate entities, somehow unrelated to each other.

   The type of academic approach that seemed the most logical to me was for podiatry to integrate biomechanics into surgery. After all, it seemed obvious that foot orthoses — the mainstay treatment of podiatric biomechanics — and foot surgery — the mainstay of treatment of podiatric surgery — both modified the abnormal forces that were the cause of painful pedal pathologies. A foot orthosis accomplishes its mechanical effect by altering the external forces acting on the plantar foot whereas foot surgery accomplishes its mechanical effect by altering the internal structural components of the foot.

   Unfortunately, the gulf between podiatric surgery and podiatric biomechanics has grown wider. Podiatric residencies are becoming more geared toward producing outstanding podiatric surgeons who have little training in biomechanical analysis of their patients and minimal emphasis on effective mechanically-based non-surgical therapies such as foot orthoses.

   Many of the young, intelligent podiatric residents and podiatrists I have spoken with over the last decade seem to think that “doing biomechanics” means producing mediocre custom foot orthoses for their patients. There is a perception that as long as the postoperative X-ray looks good, one does not need to pay attention to how the patient walks after surgery.

   Will the lack of biomechanics training for these podiatric surgical specialists cause them to have more surgical failures? One has to wonder whether they have enough biomechanical skill to know when to not do surgery. Will they understand the painful mechanical realities that may occur within their patient’s feet over time with each foot surgery they perform?

   If the goal of our profession is excellence, then why does podiatry continue to be a “biomechanics versus surgery” profession instead of being the more mature “biomechanics with surgery” profession that it should be?

   Why can’t the highly intelligent podiatric surgeons that lecture around our country on the latest surgical techniques spend more time talking about the biomechanical effects of the surgeries they are performing? Why can’t pre- and post-operative gait videos and/or in-shoe pressure analyses be shown at podiatric surgery seminars so we can see the dynamic results of foot surgeries rather than the typical pre- and postoperative static radiographic bone shadows that give us little idea of the dynamic function that these surgeries have on feet?

   As a medical profession that specializes in the treatment of the part of the body that is subjected to the greatest mechanical loading forces, why would we want to separate biomechanics from surgery when we know these same forces cause the vast majority of the painful pathologies we see daily in our clinics?

   In order for us to achieve the goal of remaining the premier surgical specialists of the foot, we first need to understand that better biomechanical knowledge of the foot is imperative. To better attain that goal, we all need to realize that podiatric biomechanics needs to work with podiatric surgery rather than versus podiatric surgery.

Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Ca. He is in private practice in Sacramento, Ca.

Dr. McCord recently retired from practice at the Centralia Medical Center in Centralia, Wash.