Insights On The Evolving Nature Of Orthotic Education And Casting

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Guest Clinical Editor: Doug Richie Jr., DPM, FACFAS

   “I believe the problem goes much deeper into the profession, though, and underscores many problems that continue to haunt the entire gamut of biomechanical knowledge and practice,” says Dr. Phillips. Those problems include:

   A change at the entrance level of podiatry school by discarding the podiatry school admission test and adopting the MCAT. While Dr. Phillips says this certainly makes sense in terms of making it easier for medical college applicants to also apply to podiatry schools, it has the disadvantage of sending a message to applicants that they do not have to have basic 3D visualization skills, which are of paramount importance in understanding biomechanics.

   The struggle for podiatry to become recognized as a true medical specialty has increased the number of hours spent in general medical studies, often at the expense of biomechanics training. Despite this, Dr. Phillips notes the schools still continue to train students in surgery as if new graduates are going to practice surgery before entering residency training. Residency interviews concentrate on how many bunion surgeries the prospective resident already knows, not on the mechanisms that lead to bunions, which he calls “totally backward.” He argues that the standard pat answer that bunions form because of first ray hypermobility “is at best a very superficial answer.”

   Dr. Phillips notes that applicants for residency programs are required to discuss flatfoot surgeries without any idea of all the various types of flat feet, which flat feet are normal and which are abnormal, and how to examine an excessively pronated foot. In addition, he says applicants for residency programs must enumerate a number of joint destruction surgeries without any discussion of what changes to expect after surgery on the function of the foot and other parts of the body. Even with the upgraded CPME 320 residency requirements, Dr. Phillips says the minimum activity volume for the number of surgeries is more than five times the number of biomechanical examinations, which he calls “exactly the reverse of the real practice of podiatry.”

   Failure of schools to actively recruit the brightest biomechanical minds for teaching. Dr. Phillips acknowledges that there are “extremely dedicated people” teaching biomechanics at the schools but there are far too few of them. He says few if any funds are dedicated to biomechanics research at the schools and faculty are not well rewarded for producing strong biomechanics research.

   The publication in recent years of a number of biomechanics research papers that claim to discredit Root biomechanical theory. Dr. Phillips says although such papers surface in reputable journals, podiatrists rarely write them. Recently, he personally contacted a number of authors of orthotic efficacy papers regarding the reasons they selected their particular orthotic materials for research.

   “I shouldn’t have been too surprised to find that none had any idea about the properties of the materials they chose,” says Dr. Phillips of the study authors. “As a result, in almost all research, all orthotics are considered to be equivalent, regardless of foot type, orthotic casting technique or orthotic shape, orthotic prescription variables and orthotic materials. With equivalency of all orthotics, then, straw man arguments are set up as to whether Root theory is correct or incorrect.”

   Failure to further research and teach midtarsal joint function. Although the orthotic cast’s most important function is capturing the forefoot to rearfoot relationship, Dr. Phillips says physicians spend little time researching and teaching how that relationship changes when the subtalar joint pronates and supinates. He says the profession continues to teach only to the level of understanding that the foot is either a mobile adapter or a rigid lever. Yet if one asks any student what type of lever the foot is, he says almost none can tell you whether it is a class 1, 2 or 3 lever.

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MBsays: June 2, 2014 at 10:35 am

The reason so many orthotics do not reduce symptoms is that those feet are attached to a body and a pelvis that may not tolerate what the orthotics try and make the feet do. Podiatrists should work with skilled orthopedic physical therapists to determine and work with patients who have restrictions and imbalances elsewhere in their body.

There are numerous pedorthic programs across the country. I took one at Temple that was only 2 weeks. Great class. Young podiatrists should seek out those programs to learn how to cast and how orthotics are made instead of relying on a lab that will never see your patient's foot nor do they want to.

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Robert D. Phillipssays: June 25, 2014 at 10:22 am

In response to MB's comment:

Pedorthotic programs are good and I do avise you learn as much as you can from them. However, they will not be able to teach you how to cast for a "Root functional orthotic" nor teach you the theory that they are built on. You should use such programs to add to your knowledge base, not to replace it.

As to the need to work with physical therapists, again that is important, however the podiatrist should be trained to also fully examine the patient for restrictions in movement. We expect the podiatrist to learn to do a complete H&P because we want podiatrists to do their own admissions to hospitals. Why shouldn't a podiatrist know how to fully examine a patient for abnormalities that create gait limitations? Are we not the "gait experts?"

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