Will Physical Therapists Be Teaching Us Biomechanics In 2030?

Page: 97
Author(s): 
Kevin A. Kirby, DPM

During my four years as a podiatry student at the California College of Podiatric Medicine from 1979 to 1983, among my very distinct memories were the frequent comparisons between podiatrists and orthopedic surgeons.

   In terms of differences, we learned that podiatrists focused only on the foot and ankle whereas orthopedic surgeons were less expert than podiatrists since they needed to focus on all of the bones and joints of the body. We learned that orthopedic surgeons didn’t know much about the biomechanics of the foot and lower extremity in comparison to podiatrists since podiatrists only had special intense training on orthoses and biomechanics. We also learned that orthopedic surgeons did incorrect surgical procedures, such as first metatarsophalangeal joint (MPJ) fusions. Of course, all podiatrists knew for a fact that one must preserve first MPJ range of motion and never fuse this joint, but use an implant instead.

   It is very interesting now to see how things have changed regarding the differences between podiatrists and orthopedic surgeons since I was a podiatry student. We now have orthopedic surgeons called “foot orthopedists,” who focus only on surgery of the foot and ankle. We also have standardized three-year podiatric surgical residency programs. Unfortunately, it is often the case that our residents receive very little practical biomechanics training in these residency programs.

   Major scientific meetings for foot orthopedists organized by the American Orthopaedic Foot and Ankle Society often include more lectures on foot and lower extremity biomechanics than do many podiatric surgical seminars. Finally, a quarter century since we learned that orthopedic surgeons were doing subpar surgery by performing first MPJ arthrodesis procedures rather than implant procedures, podiatrists are increasingly doing the same first MPJ fusions that we once shunned as a profession.

   Since I have been teaching biomechanics, sports medicine and the biomechanics of surgical procedures to podiatric surgical residents over the past quarter century, I have made a few observations that I believe are ones that many other podiatrists have also noted. While it seems that the podiatric surgical residents have become much more advanced in their surgical and medical knowledge, they have also collectively mastered progressively fewer practical skills in biomechanics. As a result, at the end of their podiatric surgical residencies, they simply possess too few practical skills in biomechanics and foot orthosis therapy techniques to practice the full range of conservative practice that many patients desire.

   While I appreciate that better skills in foot and ankle surgery are an important part of the training for our future podiatrists, it seems that we, as a profession, are currently going down a path that we may one day regret.

   For the last decade, there have been no post-graduate podiatric programs that emphasize the intricacies of foot and lower extremity biomechanics. From 1984 to 1985, I had the good fortune to receive such training via the Biomechanics Fellowship at the California College of Podiatric Medicine. Former graduates of this biomechanics fellowship, such as Ronald Valmassy, DPM, Richard Blake, DPM, Eric Fuller, DPM, and Larry Huppin, DPM, will likely no longer be available to teach podiatrists practical and advanced biomechanics techniques by the year 2030.

   Without a post-graduate training program in biomechanics developing by 2030, podiatrists won’t be the ones teaching these subjects at many of our professional seminars. Rather, other medical professionals, such as physical therapists, who more greatly respect the importance of conservative therapy through biomechanics knowledge, may very well be the ones teaching biomechanics at our seminars.

   What will we, as a profession, become by the year 2030 if we continue on the current path we are heading down?

   We will become exactly the same profession that we derided back in the early 1980s when I was a podiatry student. We will be foot and ankle surgeons with a limited knowledge of biomechanics and foot orthosis therapy techniques. We will be limited in scope of practice due to our non-MD degree. We will, by the year 2030, simply become limited license orthopedic surgeons who are very well qualified and eager to cut, saw and fixate the bones of the foot and ankle. However, we will be very inadequate at being able to offer the best conservative care measures that our patients desire and deserve for their painful foot and ankle pathologies.

   I, for one, hope this vision is wrong and that the podiatrists of this country can see the light.

   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, Calif. He is in private practice in Sacramento, Calif.

   Dr. McCord retired in December 2008 from practice at the Centralia Medical Center in Centralia, Wash.

Comments

Dr. Kirby is so right. I am a DO and see the same problem in my profession. The lack of hands-on applicable biomechanical knowledge of many physicians, podiatrists and others is appalling. If you do not spend the time learning the multiple approaches to a mechanical problem, it is easy to apply the wrong principle.

In the case of a fracture, the bone must be healed and then the soft tissue fun begins. This is one of the many things that standard medical care is so lacking. Most physicians prescribe physical therapy without understanding what needs to be done. The whole idea of healing as a unit is so lost today. It is almost like everyone forgets what you learned the first year of medical school, which is that the body is a unit and must heal as one. The problem is that the knowledge of each process of rehabilitation is complex and the basic knowledge of biomechanics is essential to help a patient heal. Evaluating the whole person is needed prior to making a diagnosis. This does not always happen today.

As a classmate of Dr. Kirby, I agree with him 100%.

So many of today's graduates never watch a patient walk, never put the lower extremity through any kind of biomechanical exam, never take a correct negative impression or scrutinize someone else's impression, and never evaluate orthotics to make sure they fit and are accomplishing what they were designed to do.

Our profession currently has a great void in the area of biomechanics in the training of current students and residents. They do get excellent surgical training. However, before you order a CT, MRI, Tc scan, etc., perhaps observing the patient stand and walk would save you a lot of time and unnecessary expense.

Biomechanics of the lower extremity and knowledge of how that affects not only foot pathology but its potential contribution to musculoskeletal pain is what has distinguished podiatric medicine as a profession from other branches of medicine.

I have a personal history of significant flexible pes valgo planus, which led to chondromalacia patella. That condition could not be adequately addressed by orthopedic surgeons but was by podiatric biomechanics with functional orthotics having addressed that successfully for decades.

Musculoskeletal pathology is caused, in a large percentage of cases, by pathomechanics. I feel that podiatric surgeons who recognize this and endeavor to incorporate this into their surgical decision making obtain better results.

A major weakness of our podiatry schools has been the lack of fundamental research in the area of biomechanics, research that is critical to advance such knowledge, support the work of ciinicians and provide the evidence required by third party payors and decision makers in government.

The APMA dropped the ball in a major way when it failed to lobby for CPT codes that adequately described the biomechanical services needed by podiatric physicians to describe such services and obtain fair reimbursement. Our "system" often requires that one "break the skin" to obtain reimbursement, discounting or not paying for non-surgical services. So our profession has "followed the money" in a conversion to becoming orthopedic surgeons of the foot and ankle but with a non-MD degree.

It is sad to see so many colleagues practice what I term "cortisone or cut podiatry," not incorporating the broad spectrum of physical medicine and biomechanical treatments that are not only beneficial to patients but often more cost-effective.

Physical medicine and biomechanics provide treatment options that minimize worker loss of productivity and time loss which is important in our current economy.

Here's to someone making good sense. Kevin is SO right. I practiced podiatry for 14 years and kept many patients out of surgery only to be shunned by the insurance companies, most orthopedists and dare I say it — even some of our own. While this is only my humble opinion, I see NO interest today in anyone learning how to do foot mechanics and joint-specific adjustments that work well with orthoses nor look into funding research and do more to enhance our profession other than some new hardware to insert into a bunion wound. Instead, we have followed the path of the orthopedist and most likely the money trail that the insurance company leaves for us. Nothing short of a major revival in good old-fashioned podiatric biomechanics and joint specific foot manipulations in the colleges would do.

And while we are at it, insurance companies need a basic lesson in finances. Biomechanics/adjustments saves patients a lot of grief and give them a quality of life that I dare say exceeds the practice of reaching for the knife as a first line of podiatric care.

PTs and chiropractors will be the new biomechanic specialists after pioneers like Kevin and others in our generation exit from this great profession.

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