Practice Perfect 743
Why Are Podiatry School Graduates Not Grasping Biomechanics?

Here in Southern California at the Chino Valley Medical Center podiatric residency, we completed our CRISP online interviews for next year’s residents. Overall, I found it to be a successful process, despite my personal dislike for online interviews. Interviewing someone via teleconference is definitely not the same as in person, but we all understand the necessity. I applaud the CASPR folks for an organized process thus far. Hopefully, the match will be just as organized. 

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As grueling as interviews can be both for the interviewees and the interviewers, I still enjoy them. I especially love finding out new and interesting aspects about our applicants. Each year, there seems to be a theme to how they go, and this year the theme was biomechanics. Despite the clear intelligence, hard work, and humanism expressed by this year’s applicants, there was an almost universal weakness in biomechanical thought process.

Among the applicants to our residency program this year, there was an almost universal weakness in biomechanical thought process.

Before discussing this further, I’d like to point out that I am also a teacher at one of the nine podiatric colleges, and I have been involved in teaching our students biomechanics for years. As such, I’m going to be somewhat defensive to comments we commonly hear from individuals around the country that say the colleges don’t teach biomechanics (or they don’t teach it well). This is a very simplistic and reductive criticism, and I’d like to defend all of the schools for just a moment. 

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The first issue is boards. The 2nd and 3rd year board examinations for podiatry are written by a relatively small number of individuals, and, for the biomechanics topics, test mostly Root biomechanics. This means that people like me, who subscribe to alternative biomechanical principles, still must teach this topic. I’d love to stop “teaching to the boards,” but my students still need to pass them. 

Second, to say our biomechanics teachers “don’t know how to teach” is myopic, especially since many of them have been teaching for a very long time, and some of them actually write the board exam questions. This also puts the onus entirely on the teachers and not on the learners. Why do students not read about biomechanics principles during their clinical years? Do they not have time to read people like Kirby, Richie, and Scherer or study the many journal articles discussing these topics? How many students have read Dr Albert’s textbook? I have yet to meet the student who can give me a clear rationale or risk factors for hallux valgus or plantar fasciitis. I have personally taught my students how to write foot orthosis prescriptions and yet some still can’t seem to do this in practice. 

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Some of the blame goes to the students, but there’s another aspect to this. Some of the blame falls on the rest of the podiatry community: a lack of clear available resources and ambiguity about biomechanics in general. Is there one single resource that clearly instructs our students what to read? ACFAS has a reading list pertaining to surgical topics. Why don’t we have this for our students for biomechanics? To help, I’ve put together a list of important reading resources here. This hasn’t been vetted by the community so it may not be fully comprehensive, and I apologize if I left out important articles.

To help, I've put together a list of the important reading resources in biomechanics, a BM bibliography here.

How can we expect our students to be clear about biomechanics when there are so many competing ideas, some with evidence and some without? This is one of the reasons I’m so happy to see Dr Richie’s new textbook1; as it collates the best evidence on fundamental biomechanics topics in a clear way. I don’t recall this ever being done before. We need more of this. For example, how useful would it be if the Journal of Foot and Ankle Surgery published a monthly series that reviewed the best evidence on using biomechanics principles to choose surgical procedures for specific pathologies written by a group of our best biomechanics/surgical minds? Or if the Journal of the American Podiatric Medical Association did the same thing for orthotic therapy? A year ago, I was honored to guest edit an edition of the Clinics in Podiatric Medicine and Surgery where there were several articles that would help with clinical decision making, including an article I wrote about surgical decision making.2 We had some top-of-the-profession contributors such as Christensen, DeHeer, and Richie, among others, provide high-yield articles on a variety of fundamental topics. We must provide students and residents clear and accessible resources to empower their education.

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When residency interviewees tell me the purpose of a functional foot orthotic is “arch support” or they are unable to state any two orthotic modifications for the treatment of adult acquired flatfoot, then I have to conclude there’s a fundamental structural problem with the entire biomechanics issue. And, like everything, it is not a simple problem with one solution. This requires resource availability, clarity of important concepts, consistent education, and practice. Until all these occur, we should continue to expect lower quality performance from our trainees.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Richie Jr DH. Pathomechanics of Common Foot Disorders. Springer Nature Switzerland, 2020.
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  2. Shapiro J, editor. Biomechanics of the Lower Extremity, An Issue of Clinics in Podiatric Medicine and Surgery E-Book. Elsevier Health Sciences; 2019 Nov 28.
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