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Have Biomechanics Become An Afterthought In Podiatry?

Discussion in 'USA' started by NewsBot, Oct 20, 2019.

  1. NewsBot

    NewsBot The Admin that posts the news.

  2. Dr Rich Blake

    Dr Rich Blake Active Member

    This is a good article by Dr. Bruce Williams, and it must change. Podiatry in the US is more and more surgical in general, but I think biomechanics is alive and well in Sports Medicine practices and all of us that just love it. The people in charge of seminars have to put on more biomechanical sessions. I just spoke to the Mid Atlantic Podiatry Group and the entire day was on biomechanics. I lecture in 2 weeks in New York at the Richard Schuster Memorial Seminar and it is all on biomechanics. The students I teach at the California School of Podiatric Medicine are excited about biomechanics. There is good energy out there. Rich Blake
  3. scotfoot

    scotfoot Well-Known Member

    Hi Rich ,

    Would it be true to say that the intrinsic foot muscles are not considered to be particularly relevant, in foot biomechanics , among podiatrists in America ?

  4. Dr Rich Blake

    Dr Rich Blake Active Member

    Gerry, for sure and this must change. When I lecture I try to give podiatrists the common 5 exercises to help tone up the foot muscles and keep them daily activated. It is simple, just not taught I guess. Rich
  5. I’ll give you a one word answer as to why biomechanics is not flourishing in the USA as it is in the rest of the world, actually I’ll give you two: 1) Money - more money available from performing surgery. 2) Root- you’re resistance to move on from the fundamentally flawed half a century old work of Merton Root has left you miles behind the rest of the world now when it comes to clinical biomechanics; wake up America (not preaching to the converted but too many stuck in the mud). Who’s coming over from outside the USA to speak at your conferences to challenge parochial thinking? Given the USA lag, maybe it would be useful to bring in experts from outside the USA now to update your profession, just as we once imported from the USA to bring us up to speed... times have changed ‘Merica- you could swallow your pride and start importing knowledge?
  6. Dr Rich Blake

    Dr Rich Blake Active Member

    Simon, I understand the money part. I also understand that the average doctor, medical or podiatric, practices forever what they were taught even if it is 40 years ago. I must admit that is what I practice to some extent because learning new techniques that you are not sure about has some fear factor. I know the dynamic person you are, one who I admire greatly, and I can hear you say these words. Your passion helps me. Thank you. I personally hope to be part of the solution not the problem. Rich
  7. OK Rich, I know you’re one of the good guys. I also think that the only way your country will move on is through a group of local heroes willing to challenge your status quo. I was always looking to recruit fresh minds when we were trying to change things here... who’s recruiting who over there?
  8. Dr Rich Blake

    Dr Rich Blake Active Member

    Boy, I am out of the loop. I am going to the big New York College Biomechanics Seminar in 10 days. I hope to see what is going on. Rich
  9. Who’s speaking and on what?
  10. Dr Rich Blake

    Dr Rich Blake Active Member

    If you send me your email, I can send the seminar schedule. Not sure if I can copy and paste here. Rich
  11. scotfoot

    scotfoot Well-Known Member

    Rich ,
    Is the plantar venous plexus / pump given much attention ,by podiatrists , in the USA ?
    I have had an interest in this pumping mechanism for some time ,and have even advanced a theory, (perhaps not rated by some , ) that the whole foot may be viewed as an "oseofascial" pump . I believe it is important to remember that venous return from the foot is not just about overcoming gravity but also the centrifugal effect generated by walking or running .

    The foot is so much more than just a piece of biological, mechanical engineering but is a sensory organ ,a blood pumping wonder and an adaptive marvel when it comes to human/ substrate interaction .


    Osseofascial pump explanation -
    Venous foot pump - Biomch-L

    https://biomch-l.isbweb.org › threads › 32039-Venous-foot-pump

    21 Feb 2019 - 8 posts - ‎2 authorsI read somewhere that the venous foot pump can be viewed as priming the calf pump in a fashion that resembles the atria priming the ventricles ...
  12. Dr Rich Blake

    Dr Rich Blake Active Member

    Gerry, some talk of it so we know of it. Perhaps a reason custom orthotics work when putting pressure in the arch. It may be helping venous return just as much as stabilizing. I use a lot of compression socks for foot pain which I say help stabilize, but perhaps some of the pain relief again is venous return. Good job! Keep up the thoughts and please do not care what people think. I have fought that my whole career. Rich
  13. It is the annual Richard Schuster Biomechanics Seminar at the New York College of Podiatric Medicine. I lectured once before for the seminar. Here is the lineup....http://www.nycpm.edu/CME/2019_Biomechanics.pdf
  14. Simon:

    Most podiatrists here in the USA simply don't realize how far behind they are in biomechanics knowledge since they are focusing nearly all their energies on the other money-producing specialties of foot and ankle surgery and wound care. Biomechanics and foot orthoses are, therefore, an after-thought here in the USA, unfortunately. Research and innovation in foot and lower extremity biomechanics and foot orthosis therapy will be need to be coming from countries other than from the podiatric academic community in the USA since biomechanics is a lost cause. Podiatrists have been permanently blinded to the benefits of understanding the biomechanics of the foot and lower extremity by the bright lights of the operating room.

    That being said, pedorthists and physical therapists here in the USA do show interest in biomechanics still so maybe innovation in the USA will need to come now from those specialties. In other words, in another decade, when many of the former CCPM Biomechanics Fellows will be likely retiring, you won't likely be hearing much from the USA in foot and lower extremity biomechanics since no one is being trained in this specialty any more here in the USA and the interest in attaining biomechanics knowledge within the USA podiatry community is at an all-time low.

    Sad but true.
  15. Jeff Root

    Jeff Root Well-Known Member

    When podiatrists in other countries have evidence that they are achieving better patient outcomes than podiatrists in the U.S. then perhaps U.S. podiatrists will take note. Is there any evidence that outcomes in the U.S. are not equal to or superior to that of podiatrists in other countries in both the surgical and non-surgical biomechanical arena?
  16. Dr Rich Blake

    Dr Rich Blake Active Member

    Thanks so much Kevin! Rich
  17. Dr Rich Blake

    Dr Rich Blake Active Member

    Jeff, I would agree that the average orthotic from the average podiatrist in my area, are good orthotic devices. There is a baseline biomechanics, typically Root based, that is good. I think the research in the rest of the world is sometimes so much better than US podiatry research. It gives the world a smaller view of the US. I do not know how to change it. I am part of the problem, since my practice has superseded any research due to the money I make. I have tried to balance the two, but it is hard. The US schools should be writing the grants, so it is my next 10 years to try. Rich
  18. Jeff Root

    Jeff Root Well-Known Member

    To become a pedorthist in the U.S. you need a high school diploma. You then must pass a certification course in orthotic and prosthetic education. I can't see this group producing research. While some physical therapists do provide foot orthotics and are capable of producing quality research, they don't provide many of the other essential aspects of foot care that should accompany someone treating foot and ankle problems with foot orthoses. The quality and depth of biomechanical education provided at the podiatry schools in the U.S. varies depending on the school. While foot and ankle surgery and wound care have become the primary focus of many younger podiatrists, this does not preclude them from practicing foot orthotic therapy and building on the biomechanical educational foundation they received in podiatry school.

    One of the primary problems with the current state of biomechanics throughout the world is a lack of consensus and practice standards on theory and treatment. While tissue stress theory has become popular outside of the U.S., it is not a treatment system because, in its current state, lacks the key elements of a true system (system: :"a set of principles or procedures according to which something is done; an organized scheme or method"). Until STS contains the elements of a true system, it can't be taught in a consistent and organized fashion and students will be left being taught by "this is what I do" or "this is what works for me" educators. Unless and until the current state of chaos changes, I would not expect things to change for the better in the U.S. and abroad.
  19. Have fun lecturing in NY, Rich!
  20. The best research we have shows that foot function is highly variable and subject specific. The best research we have shows that the response to foot orthoses is highly variable and subject specific. If you are looking for a recipe approach to management of patients in terms of if x then y degree of wedging, you’re gonna be waiting a long old time. But even chaos works within systems: https://www.sciencedirect.com/topics/engineering/chaotic-systems systems that are “dynamic and highly sensible to their initial conditions”- just like human patients. I’m comfortable with that. I’m comfortable with the idea that every patient is a different human, that there are many ways to skin a cat, that foot orthoses prescription does not need to be that accurate for the majority of patients and that foot orthoses certainly don’t = biomechanics.

    In terms of consensus for treatment, let’s take peroneal tendonitis as an example, I think most clinicians following a tissue stress approach should agree that the aim of treatment with foot orthoses should be to increase the external pronation moments acting at the foot-orthoses interface during the time period that the peroneal muscles are active. That can be achieved by different means, but consensus exists as to the therapeutic aim. Moreover, that Increasing the external supination moments, as other systems would have us believe to be “the treatment” because we’ve measured the angles of lines drawn on the skin of the leg and foot, while systematic, is fundamentally flawed.

    Beware those that forget about the individual patient in favour of an overly rigid and fundamentally flawed system.
    Last edited: Nov 1, 2019
  21. Amen to that, Brother Spooner!
  22. Dr Rich Blake

    Dr Rich Blake Active Member

    Thanks Kevin
  23. Dr Rich Blake

    Dr Rich Blake Active Member

    Simon, there is a lot of your thought process that is good and I love your passion. Biomechanics is all about controlling forces and moments and torques, but also about positions and the causes of those forces that we deem excessive. It is my belief that to be great at biomechanics we need to know what causes and aggravates pain or injuries, and how to treat those causes from simple to the complex. The more biomechanical examinations you know, the more treatments you know, the more you can help a patient. I do not care if my students know if the heel is inverted 4 degrees or 6 degrees, but it is crucial they know if the heel move to vertical if my orthotic device is set to place them there because of chronic ankle sprains. There is no other profession that can help those patients. I want my students to know that a patient has a high degree of forefoot valgus that I can correct for to help their neuroma symptoms, lateral instability, iliotibial band, low back pain, etc. The foundation of biomechanics is sound and it should be expanded on with Tissue Stress, Kirby Skives, Dannenberg’s Kinetic Wedges, etc, but it is still the foundation in my opinion. Rich
  24. Thanks Rich, not sure why you think it’s crucial to know if a heel is vertical or not, nor do I believe that a foot orthoses needs to change the rear foot alignment in order to successfully treat chronic ankle sprains- this is the difference between your lens and mine I guess.

    if by your statement that “the foundation of biomechanics is sound”, you mean Newtonian mechanics and structural engineering I concur, if you refer to Root, I disagree, but each to their own.
  25. Dr Rich Blake

    Dr Rich Blake Active Member

    I agree that there are so many ways to treat patients, we need to focus on what we share and how we can improve our profession. I try to look for the applications of every theory in my practice that have some validity. Some stick some do not. But, biomechanics is my love. Rich

  26. Petcu Daniel

    Petcu Daniel Active Member

    If it is allowed to me and if I've well understood this thread it could be possible for pedorthics in US to have a similar situation as podiatry from the 'biomechanics' perspective. In this regard I'll note that in other countries pedorthics education is above the level of high-school diploma:
    -Canada: http://postdegree.uwo.ca/Programs/peds/admissions.html
    -Australia: https://www.scu.edu.au/study-at-scu/courses/bachelor-of-pedorthics-3007307/2020/
    Important congresses highlight the role of orthopedic footwear technology in an interdisciplinary context, as for example OTWorld 2020: https://www.ot-world.com/news/inter...c-footwear-technology-at-otworld-2020/1079137

    In my opinion pedorthists has the 'chances' NOT to have the option to migrate towards surgery [as podiatrists] and to valorize their specific competences [as for example shoe last design and manufacture]. For this they should be smart enough to change from the image of a 'craft' based profession to a reality of 'science & technology' based profession.
    Last edited: Nov 2, 2019
  27. Dr Rich Blake

    Dr Rich Blake Active Member

    Thank you Daniel. I could not agree more!! I have met incredible pedorthotists whose knowledge of foot biomechanics could put some podiatrists to shame. Hey, we are a TEAM to help the field of biomechanics grow. There is no place for in-fighting or chest pumping. We need to learn from each other, help our patients, and help our professions. Is there a thread on this blog that people share biomechanics or is it just "I am better than you" mentality. Rich Blake
  28. The key problem here is an unwillingness to adjust ones position in response to the research evidence; vested interest has taken precedent over the evidence base repeatedly. You got to remember Rich that many of us have been running around these stumps for twenty odd years on social media: on the old Podiatry Mailbase and then on here. Right now, the sides are all dug in “ten trenches deep”. I know that several will never change their minds even when the weight of evidence shows that they are in all likelihood wrong. As a younger man I tried to provide learning experiences to further their education, now I couldn’t care about their opinions less- sad, but true- battle worn. Answer me this Rich: why should I care about the state of biomechanics within ‘Merican podiatry? I’ll keep publishing when I can, as will many, many others on the subject of podiatric biomechanics, but if the horse ain’t drinking... the problem is you got a horse over there that isn’t thirsty for change; rather, you got too many mules digging their heels in.
    Last edited: Nov 2, 2019
  29. Jeff Root

    Jeff Root Well-Known Member

  30. Jeff Root

    Jeff Root Well-Known Member

    It is also important to recognize and appreciate the fact that the educational path and the post-graduate continuing educational needs of podiatrists who are doctors of podiatric medicine (DPM's) are very different than that of podiatrists who are not DPM's because their scope of practice is much different. As a result, podiatric educational institutions who have students who are not going to become DPM's have more time and opportunity to focus their education and training on biomechanis than do those institutions who are educating DPM's. The DPM's three three year residency requirement, much of it focused on surgery and wound care, has definitely contributed to the shift away from non-surgical podiatric care such as foot orthotic therapy here in the U.S.
  31. Quality versus quantity. Surgery and wound care without biomechanics knowledge? Are you completely mad? Two words: “Integrated curriculum”; “biomechanics” does not equal foot orthoses. But ask Dave Armstrong if he worries about vertical calcaneum being achieved with his foot orthoses... fella understands biomechanics no doubt about that.
  32. Rich:

    Unfortunately, you are just now coming onto Podiatry Arena at a time when most of the best biomechanics discussions have already been made over 10 years ago when you weren't following Podiatry Arena. Most of us, including Simon Spooner and myself, have gone around the stump so many times on so many subjects that it doesn't really make sense to repeat ourselves. The archives for Podiatry Arena is where the best discussions are.

    Here is one on midtarsal joint axes from 13 years ago which you should read. https://podiatryarena.com/index.php?threads/the-midtarsal-joint.1521/

    That being said, if you have something to add to that discussion, you can do so to stimulate further discussion.
  33. Jeff Root

    Jeff Root Well-Known Member

    To the best of my knowledge the Podiatry Arena isn't a place where surgeons historically have come to discuss the biomechanical implications of surgery. Biomechanics and biomechanical implications certainly should be understood and considered when doing many types of foot and ankle surgery. Whether or not the U.S. podiatry schools are doing a good job of teaching biomechanics as it relates to surgery is one issue. Whether or not the U.S. podiatry schools are doing a good job of teaching biomechanics as it relates to non-surgical patient care, especially as it relates to the use of foot orthoses, is another issue. Biomechanics does not equal foot orthoses and you can practice biomechanics without foot orthoses but you can practice foot orthotic therapy without (influencing) biomechanics.

    Getting back to the central topic of this thread, Bruce Williams wrote "
    Dr. Langer started the session by asking what we thought was right or wrong with the current state of podiatric biomechanics and orthotics. This question, a doozy to lead with, ended up taking up most of the allotted discussion time.
    I responded first and stated that it seems very much to me that most podiatrists don’t really care about foot and ankle biomechanics or orthotics anymore. I think most practitioners see foot orthotics as no more than a part of the conservative management process that insurance companies mandate we attempt prior to surgical treatment".

    some cut, he also wrote:
    "Dr. Huppin raised an interesting point that many podiatry schools are cutting back on the amount of time students spend learning foot and ankle biomechanics, both in lecture and in workshops. He stated, and all of us on the panel and most in the audience agreed, that understanding foot and ankle biomechanics is key to becoming a quality foot and ankle surgeon as well. To glaze over this subject because it is potentially seen to only be associated with foot orthotics is doing a huge disservice to all our students and soon-to-be podiatric colleagues".

    My point in my previous post was not to suggest that biomechanis isn't important in surgery. My point was to to point out what Dr. Huppin and many others have observed, and that is that the podiatry schools in the U.S. have cut back on the teaching of biomechanics and that much of what is taught relates to foot and ankle surgery and wound care, not foot orthotic therapy. If DPM's were not trained as surgeons you can bet there would be much more focus on biomechanics and foot orthotic therapy.
  34. I taught biomechanics, sports medicine and foot orthosis therapy to podiatric surgical residents at the Kaiser Sacramento Podiatric Surgical Residency Program for 28 years. During that 28 years, from 1989 to 2017, here is what I observed.

    During the last 10-15 years of my training the residents, the residents seemed to have progressively less knowledge on how to properly prescribe foot orthoses, how to modify foot orthoses, how to troubleshoot foot orthoses, how to take measurements for foot orthoses and on the basics of shoe biomechanics. However, their gait examination skills were about the same over that 28 years, they had no decline is orthosis casting skills and there was no drop-off in overall intelligence of the residents during that 28 years. They simply seemed to have less and less training on how to prescribe orthoses, troubleshoot orthoses and how to evaluate patients for proper foot orthoses.

    This lessening of clinical skills in foot orthosis therapy appears to have been due to the training in podiatry school being either weak or ineffective in these subjects or possibly being due to the fact that I was training them during their third year of surgery residency. They had, in other words, what it seemed to be very little time during their first two years of their residencies to be taught the nuances of custom foot orthosis therapy. 90% of these residents wanted to learn more about orthoses and orthosis therapy, but they simply had so little training in biomechanics and foot orthosis therapy that I had to spend more time reviewing the basics, than having them learn the more advanced aspects of foot orthosis therapy.

    At the completion of their 3-4 months with me, they all were more confident at casting and ordering custom foot orthoses for their patients, even though very few were confident in doing orthosis modifications I do in my office on a daily basis, especially in the use of a grinder. Unfortunately, I don't see a good solution to this other than me quitting my own private practice and devoting myself to full time training of podiatry students and podiatry residents in foot orthosis therapy. Since I still need to work, however, I don't see this happening for at least another 5-10 years, if ever.

    The bottom line is that I really don't feel that the US podiatry profession is that concerned with conservative care methods such as foot orthoses since surgery has taken over the minds of the younger members of my profession. Maybe, the US podiatry profession will wake up and see what they are missing in their training of their podiatry residents that allow them to provide their patients with the best conservative care methods in order for them to avoid surgery. I highly doubt this will happen within my lifetime from the way things have been going here over the past decade. I hope to be surprised, but, since I am a realist, it will only likely get worse in the next 10 years.
    Last edited: Nov 3, 2019
  35. Dr Rich Blake

    Dr Rich Blake Active Member

    Kevin, a wonderful summary of the focus of those who run the residency training of podiatrists which is not pro-biomechanics as it could be. It is our profession that we are watching the leaders give up on biomechanics. The students seem just, if not more interested now than before, and the weight of the teaching is falling on the podiatry labs. I know you are connected with Precision, would Jennifer be willing to sponsor seminars? I am hopeful that Root Lab may (I know you are listening Jeff). The work you have done Kevin for the profession in biomechanics is beyond words and galactic in realm. And I thank you. Rich
  36. Dr Rich Blake

    Dr Rich Blake Active Member

    Jeff, amen! I could practice biomechanics with never prescribing orthotic devices and be very successful. Foot orthoses are part of biomechanics but foot orthoses are not biomechanics. Rich
  37. Dr Rich Blake

    Dr Rich Blake Active Member

    Kevin, yes I understand that, and definitely feel that I am intruding into a world I little belong. You know where my heart is. Thank you. Rich
  38. Dr Rich Blake

    Dr Rich Blake Active Member

    Thanks Simon, I respect you completely. You have given and given, so I understand your feelings. I hope things change. I am leaving full time practice for half time. I have tried to give back, and biomechanics is all I really know slightly. But, I can teach and feel good. Maybe the next Mert Root, Kevin Kirby, or Simon Spooner will walk into my classroom tomorrow and I will lit a spark that will affect the next generation or two. I tell the students that what we know how is a small part, their generation will shape it some way, and I hope expand it. May the Force be with you. Rich
  39. scotfoot

    scotfoot Well-Known Member

    Rich ,
    It strikes me that to bring about change in the way certain conditions are treated you have to convince the money men that one option is more effective /cheaper than another . In the UK such people would be the respective health boards and in the USA it would be the providers of health care insurance .

    With that in mind an interesting paper has just been published by Prof Isabel Sacco , on foot health in diabetes (below ) .

    Here is a quote from the paper .

    "In a prior study, the atrophy of diabetic foot muscles was verified in a subclinical stage of DPN before the development of clinical DPN symptoms [60]. This showed that predicting/assessing foot strength and function of individuals with DM, and following such predictions with early interventions, could be a viable strategy to prevent the accelerated loss of muscle strength and to reduce the risk of developing ulcers in patients. This strategy could contribute to a better quality of life for these individuals."

    So , in my opinion , we potentially have podiatrists actively monitoring and supervising intrinsic foot muscle strength to avoid or reduce future pathology . In effect the " compression of morbidity " in diabetes sufferers . A full blown health care initiative .

    Paper -
    Foot function and strength of patients with diabetes grouped ...

    4 days ago - Foot function and strength of patients with diabetes grouped by ulcer risk classification (IWGDF). Authors; Authors and affiliations. Jane S. S. P.
    Last edited: Nov 3, 2019
  40. Jeff Root

    Jeff Root Well-Known Member

    There are many providers of health insurance in the U.S. Some cover foot orthoses and some don't. Some of those companies who do cover foot orthoses don't reimburse enough to cover the orthotic lab fee, let alone the doctor's services. As a result, those providers don't offer foot orthoses because they would lose money on them. In addition to private insurance there is government insurance such as Medicare. Medicare doesn't cover foot orthoses except for certain diabetic patients. Trying to get a collection of public and private health insurance providers to have a similar policy regarding the coverage of foot orthoses is virtually impossible. Some of us financially supported Lee Rogers, DPM for congress to bring awareness to this issue. Unfortunately Lee lost the election.

    Some insurance companies have used research from foreign countries that suggests that custom foot orthoses are no more effective than OTC devices to justify not covering this service. And given some of the conflicting research who can blame them for not providing coverage?

    In some countries where foot orthoses are a covered service there seems to be an over utilization of foot orthoses. Some providers even offer free goods such as handbags, etc. to encourage patients to come in and get foot orthoses. Some are even entitled to one new pair annually. While the practice of offering free goods may not be legal, it still occurs. So just because foot orthoses are a covered service doesn't mean that they are being prescribed appropriately and that the motives of the providers are ethical.

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