Losing Biomechanics?
Are We Crazy?
On the cover of the September issue of Podiatry Management Magazine was a very concerning title. I was disheartened to see the title, in bold black letters Is Podiatry Turning Away from Biomechanics? Jason Kraus of the Langer Biomechanics Group discussed the change in podiatry over the past years, towards a primarily surgical subspecialty that is in the process of bequeathing its prior biomechanics expertise to other specialists. He rightly describes this loss of skill to the educational arena (our schools and residency programs diminishing the amount of biomechanics education) and research (very little new research is produced by podiatric physicians). Additionally, he points to our national conferences as spending too small a portion of their time on biomechanics tracts (despite its apparent popularity).
I have one question: are we nuts?
I agree that podiatry as a profession has been giving up this portion of our expertise for some time. This was obvious while I was in podiatric medical school (1999-2003), and it’s only become more so over my young career. I can site numerous personal examples of the disregard for this aspect of our profession. When I was in school, for example, there always seemed to be an uneasy dichotomous relationship between the “surgery” department (composed of certain doctors) and the “biomechanics” department (composed of an entirely different group of doctors), and they always seemed mutually exclusive. Similarly, during my residency, I recall a more vitriolic statement made by one of podiatry’s national speakers who said, “Orthotics? I’m a surgeon. If my patient wants orthotics, I’ll send him to the guy down the street.”
How has Podiatry Distinguished Itself?
Here’s the way I see it. Podiatry has made its name and become an integral part of the larger medical community in two ways. First, diabetic limb preservation. I don’t need to explain this one. Podiatrists are on the forefront of wound care research and are involved at the international level on various influential panels. I can easily provide a list of names that have international recall (Harkless, Armstrong, Lavery, Frykberg…). The list goes on. The second way we have established ourselves is through biomechanics and orthotic therapy. Agree or disagree with their theories, Root, Orien, Weed, and their descendants firmly established podiatry as the experts of foot function.
Just to tie these two concepts together, it’s actually our biomechanical understanding of the foot that has made us so prominent in diabetic limb salvage. Any surgeon can amputate a toe or part of a foot. But almost no one else understands the mechanics of a partially amputated foot the way we do (did?). Your local general or vascular surgeon can perform a transmetatarsal amputation, but most likely doesn’t understand the effects of equinus on plantar pressures and the role of the TAL in these patients.
The vast majority of surgical treatment of foot and ankle disorders is performed by orthopedists, just as it is by podiatrists. Ankle fractures are “bread and butter” for orthopedists, indicating how commonly they address trauma. Fracture care, bunions, hammertoes, fusions, and complex reconstructions (including Charcot reconstruction) are commonly handled by ortho. There’s nothing special about the work we podiatrists have done in these fields. Myerson, Jahss, and Mann are all orthopedists, not podiatrists. If you look at the vast majority of the work on posterior tibial tendon dysfunction, you’ll see orthopedists’ names, not podiatrists’.
And yet again when it comes to advancing the surgical understanding of some of these disorders, it has been the work of a few biomechanically oriented podiatric surgeons such as Kevin Kirby, Doug Richie and Thomas Roukis, among a very few others, who have made significant contributions. If you don’t understand how these names have moved forward our understanding of disorders such as PTTD, flatfoot, and hallux limitus, then you’ve just proven my point.
Now, don’t get me wrong. I’m a surgically trained podiatric physician, and I enjoy the surgical aspect of my practice. I’m proud to say I’m a podiatric foot and ankle surgeon. Surgeons are looked up to; there’s glamor in being a surgeon. We have an intimate relationship with the human body that very few other people ever experience. Many of the pathologies we treat require a surgical fix, and I’m happy to provide that fix.
However, I’m perturbed that the profession I love would so easily and meekly hand over the very thing that allows us to say we are “the foremost experts of the foot and ankle.” How true will this be if we give up our understanding and use of biomechanics?
We should also keep two other things in mind before we give up on biomechanics. First, as Mr. Kraus so clearly points out, a lot of potential income is lost when we stop utilizing these tools.
Second — consider this carefully before we get too comfortable — other professions would just love to take our business away. Most of us are aware, for instance, that physical therapists are trained to prescribe orthotics. But did you also know physical therapists are also trained to do wound care? Think about it for a minute. There are no sacred cows. We’ve already given up our shoe expertise to the pedorthotists and prosthetists. We’re in the process of giving up our biomechanics expertise to the physical therapists among others.
How long will it be before our physical therapist colleagues are doing the TALs? Don’t think it’s possible? That’s what the orthopedists must have thought when the chiropodists wanted to do surgery.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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