Standardization of Biomechanics in Podiatry

[Bored Snorlax]

While I was reviewing Biomechanics, I've learned that the west and east coasts have different approaches to certain areas of biomechanical exam and treatment.

1. Is there any push to standardize biomechanics training not only for board examination purposes, but also to eradicate confusion among providers living in different geographical regions?

2. How often do you guys use a goniometer in daily practice?

Appreciate any insight!

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[Adam Smasher]

1. Is there any push to standardize biomechanics training not only for board examination purposes, but also to eradicate confusion among providers living in different geographical regions?

no

 

[Pronation]

No

 

[Shiyuan]

Whats a goniometer? 😜

 

[GreenHousePub]

No and Never

 

[Bored Snorlax]

Whats a goniometer? 😜

Podiatrist's stethoscope? xD

 

[Weirdy]

Podiatrist's stethoscope? xD

Calm down.

Focus on finishing your first year of school. I understand you are giddy about podiatry.

You will see less of goniometer use in residency but you will still be using basic biomechanics for relevant procedures to offload ulcers, tendon transfers, forefoot/midfoot/rearfoot procedures, fusions etc.

 

[Boba Foot]

I've learned that the west and east coasts have different approaches to certain areas of biomechanical exam and treatment

Don’t you know that biomechanics are factually different geographically east versus west of Dallas, TX? Sorta like when an Aussie flushes the john and it goes the other way…

 

[Bored Snorlax]

Don’t you know that biomechanics are factually different geographically east versus west of Dallas, TX? Sorta like when an Aussie flushes the john and it goes the other way…

That's interesting! I did not know that. Appreciate you making my lunch less appealing .

 

[Pronation]

Podiatrist's stethoscope? xD

Does anybody else listen to the DP pulse with a stethoscope? I’m getting tired of the weird looks I get from patients when I tell them to take a deep breath in and out. PCPs have told me to stop sending them referrals when I hear a bruit.

 

[Jummy Biffett]

Does anybody else listen to the DP pulse with a stethoscope? I’m getting tired of the weird looks I get from patients when I tell them to take a deep breath in and out. PCPs have told me to stop sending them referrals when I hear a bruit.

I remember our pod school gave us pediatric stethoscopes as part of the 'medical equipment' that we overpaid for as part of tuition. Such a joke.

 

[Pronation]

I remember our pod school gave us pediatric stethoscopes as part of the 'medical equipment' that we overpaid for as part of tuition. Such a joke.

Makes sense. That’s the “medicine” part of podiatric “medical” school.

 

[DYK343]

The day I graduated school was the day my goniometer went in the garbage.
Useless in real world applications. Completely useless.

You gotta understand the basic principles. What happens if the P longus is transferred or severed. What happens if you remove the 5th met base and lose function P brevis. What happens if you lose the TA tendon, etc.

Gotta know and understand how to manage a flatfoot or cavus. Know when or when not to lengthen an achilles (like pseudo equinus).

But taking a non precise angle with a goniometer and trying to measure improvement is subjective at best. It is not evidence based and different from person to person on measurements. No standardization. Should not be taught anymore.

Root biomechanics is also known to be not accurate but is still the basis of biomechanics coursework. Or at least it was a decade ago when I was a student.

 

[air bud]

Don't need a goniometer. Just use an ipad to scan the foot and will tell you everything you need to know.

 

[Hybrocure]

I haven’t touched a goniometer in the entirety of my residency or in practice.

 

[air bud]

I haven’t touched a goniometer in the entirety of my residency or in practice.

This is the way.

 

[diabeticfootdr]

1. Is there any push to standardize biomechanics training not only for board examination purposes, but also to eradicate confusion among providers living in different geographical regions?

Yes, we’re working on this. Mostly for BC exams so that there are no eponyms and the language is genericized. It’s unfair to use regional terms.

We started a committee and the chair unfortunately died. Then it got delayed by COVID. But we have some new enthusiastic people restarting this.

Our goal is to publish it.

 

[AttackNME]

Real biomechanics includes CORA. The stuff Bradley Lamm published about

 

[DexterMorganSK]

This is the only book I used during school and on those rare occasions in residency. IMO, a must have for students and practitioners.

 

[Bored Snorlax]

The day I graduated school was the day my goniometer went in the garbage.
Useless in real world applications. Completely useless.

You gotta understand the basic principles. What happens if the P longus is transferred or severed. What happens if you remove the 5th met base and lose function P brevis. What happens if you lose the TA tendon, etc.

Gotta know and understand how to manage a flatfoot or cavus. Know when or when not to lengthen an achilles (like pseudo equinus).

But taking a non precise angle with a goniometer and trying to measure improvement is subjective at best. It is not evidence based and different from person to person on measurements. No standardization. Should not be taught anymore.

Root biomechanics is also known to be not accurate but is still the basis of biomechanics coursework. Or at least it was a decade ago when I was a student.

Fantastic summary. Thanks!

Real biomechanics includes CORA. The stuff Bradley Lamm published about

Just looked him up and found out he's a Temple alumni. People like Drs. Lamm, Khan, Pontious, and Meyr have really made my school and podiatry proud.

This is the only book I used during school and on those rare occasions in residency. IMO, a must have for students and practitioners.

View attachment 371216

100% will check these out during the summer. Thank you for these resources.

Yes, we’re working on this. Mostly for BC exams so that there are no eponyms and the language is genericized. It’s unfair to use regional terms.

We started a committee and the chair unfortunately died. Then it got delayed by COVID. But we have some new enthusiastic people restarting this.

Our goal is to publish it.

Definitely not fair for BC; same goes for APMLE if there are any regional terms not taught in certain parts of the USA due to the high stake nature of these exams. Sorry to hear about the passing of the committee chair, may he/she rest in peace.

 

[Hybrocure]

Long story short, if you’re looking at something clinically and actually expect to measure out something so minuscule like 1-2 degrees you’re honestly just bsing at that point.

It’s one thing to map it out or plan a surgery on a radiograph with an automated program that allows for degree measurement, but if you’re whipping out a goniometer to measure xCSP on a standing (likely rocking back and forth) patient, while bent over breaking your back holding a goniometer and think that natural human error or trembling can’t turn that 1 degree into 7 in an instant, you’re kidding yourself.

 

[MicroPod]

I used to joke to students on externs that I always kept my goniometer in my front shirt pocket so it was close to my heart at all times. But yeah, have not used one or seen one used in residency.

 

[Adam Smasher]

This is for any software engineering types lurking on the forums. If it doesn't exist already, some AI software could interpret a 3D scan of the patient's foot in neutral position, pick out the anatomical landmarks using surface anatomy, and calculate a full biomechanical exam with measurements. Then those measurements get populated into the prescription order form and it could tell you exactly what kind of posting an orthosis would need. You wouldn't need to use a plastic goniometer. Hell, you wouldn't even need a podiatrist!

 

[PatchAdamsFan]

Hell, you wouldn't even need a podiatrist!

I mean... this has been true since the beginning of modern medicine.

Anyway, I agree with @DYK343 about understanding your biomechanics principles. I've seen so many second opinion surgical train-wrecks from older pods who supposedly "understand" - I wouldn't trust them to even make a proper custom orthotic (95% of patients do not need them anyway).

 

[shadesofgrey]

Imagine for a second if every podiatrist suddenly disappeared. Where would our loss be felt in the medical field? The wound care centers would be hurting for a few months until they could fill the gaps with NP's and PA's. Ortho would be strained but would eventually absorb our musculoskeletal patients. General surgery would begrudgingly climb onto the pus bus. Honestly, where would our disappearance be felt the most?? Imagine for a moment, the poor PCP's being inundated with millions of angry elderly people who suddenly need to find someone who can shave their calluses and trim their nails.

Staff: Doc, Ethel called and is wondering where you want her to get her nails trimmed? (phone ringing in background)
Doc: Send her to the Asian spa, they do pedicures.
Staff: Doc, Vernon is complaining the nail tech cut him last time and is refusing to trim out his ingrowns (phone ringing)
Doc: Tell him to go somewhere else.
Staff: There is no where else! Also Ethel just called back and said she needs to go somewhere that trims her nails for free. There is no way she is paying $45 to have her nails trimmed. (phone ringing)
Doc: Where the hell did the podiatrists go!
Staff: Norma wants to know why you can't just cut them? Her old foot doctor cut them, but when she went to the Ortho clinic the foot doctor said no. She's already been to the dermatologist.
Doc: .............

 

[Feli]

.

.

...So, I realized after posting this that I'm old. So, for anyone who doesn't get this.. one of the best sound bites in sports history:

 

[Adam Smasher]

Imagine for a second if every podiatrist suddenly disappeared.

Podiatry is largely nonexistant outside of the English speaking world (ok fine there's Spain too). Meanwhile, the countries like Pakistan, India, and China have a sharply growing prevalence of diabetes. Someone is trimming their nails, I wanna know who???

 

[dtrack22]

Meanwhile, the countries like Pakistan, India, and China have a sharply growing prevalence of diabetes. Someone is trimming their nails, I wanna know who???

They are trimming their own nails, or family is, or someone who charges cash with no formal training (aka a pedicurist) is doing it.

I would love to see 117XX and 1105X and any G codes go away. It would be in the best interest of Medicare spending and in the best long term interest of the profession. Unfortunately it’s a major revenue stream for the profession as a whole and therefore APMA could never publicly lobby CMS to make those changes.

 

[Hybrocure]

They are trimming their own nails, or family is, or someone who charges cash with no formal training (aka a pedicurist) is doing it.

I would love to see 117XX and 1105X and any G codes go away. It would be in the best interest of Medicare spending and in the best long term interest of the profession. Unfortunately it’s a major revenue stream for the profession as a whole and therefore APMA could never publicly lobby CMS to make those changes.

Would it though?

I wouldn’t want to be in a profession where everyone is fighting over bunions as a primary source of income which already reimburses poorly. There’s only so many surgical cases that if overnight all routine care went out the window a large part of the profession would struggle

 

[Adam Smasher]

I would love to see 117XX and 1105X and any G codes go away. It would be in the best interest of Medicare spending and in the best long term interest of the profession.

Agree. But this is not really about podiatry. This is senior citizens not wanting to pay out of pocket for what is at its core a matter of personal hygiene. If those codes go away, senior citizens will march on Washington in protest. Never in history would there ever be so many walkers and mobility scooters in the National Mall. @air bud meme this please

 

[Pronation]

Agree. But this is not really about podiatry. This is senior citizens not wanting to pay out of pocket for what is at its core a matter of personal hygiene. If those codes go away, senior citizens will march on Washington in protest. Never in history would there ever be so many walkers and mobility scooters in the National Mall. @air bud meme this please

Yup.

Is there a good study out there showing that a provider cutting toenails, even for those with LOPS, has any significant impact in preventing complications? I’m truly amazed that Medicare isn’t cracking down on this. When a fat American is too fat to wipe their own arse, can they make an appointment to the proctologist with the complaint that the dingleberries are causing chaffing and discomfort with sitting and ambulation? Why does any insurance reimburse a provider clipping toenails for “comfort” purposes?

 

[Hybrocure]

Yup.

Is there a good study out there showing that a provider cutting toenails, even for those with LOPS, has any significant impact in preventing complications? I’m truly amazed that Medicare isn’t cracking down on this. When a fat American is too fat to wipe their own arse, can they make an appointment to the proctologist with the complaint that the dingleberries are causing chaffing and discomfort with sitting and ambulation? Why does any insurance reimburse a provider clipping toenails for “comfort” purposes?

Not sure about the study, but there’s been quite a few times where if I haven’t seen my routine cares come in at their 2-3 month mark, like say they leave for a season or whatever, and come back 6 months later, more often than not they develop an ulcer or a nasty ingrown or something else that just sat brewing

 

[Pronation]

Not sure about the study, but there’s been quite a few times where if I haven’t seen my routine cares come in at their 2-3 month mark, like say they leave for a season or whatever, and come back 6 months later, more often than not they develop an ulcer or a nasty ingrown or something else that just sat brewing

Dear fellow onychomycologist,

I’m talking patients that strictly come in to get their toenails clipped, not calluses, not preulcerative calluses.

Sincerely,

A total toenail replacement surgeon

 

[wakaflocka88]

Would it though?

I wouldn’t want to be in a profession where everyone is fighting over bunions as a primary source of income which already reimburses poorly. There’s only so many surgical cases that if overnight all routine care went out the window a large part of the profession would struggle

Anddddddddd that’s the reason why this profession needs to shrink. Not grow.

I’ve stopped seeing referrals for nail care. No more routine diabetic foot exam. This isn’t even billable and not going to bicker with a patient over the $20 co pay they feel cheated from. But good job to our profession to keep promoting to students why we need more than 20,000 podiaitrists because of the ever increasing obesity pandemic.

 

[dtrack22]

Would it though?

I wouldn’t want to be in a profession where everyone is fighting over bunions as a primary source of income which already reimburses poorly. There’s only so many surgical cases that if overnight all routine care went out the window a large part of the profession would struggle

Yes. If nobody is willing to pay cash for a service that, in reality, does not require any special training or certification, then we will find out exactly how many podiatrists are actually needed in this country.

And your argument that no routine foot care = everyone fighting over surgical pathology is misguided. There is plenty of non operative pathology for thousands of podiatrists to continue to be successful. I would venture to guess that DPMs relying routine foot care as a main source of revenue now, could actually do better if those codes weren’t tied to Medicare. Then, you could not only charge cash for the service at a price you feel is worth your expertise and time, but you could also allow low wage employees to provide 100% of that care while you see real pathology that reimburses better than nails. Remember, nail care is a CPT code which means you the Dr. must be performing the service. If not you are committing fraud. Still waiting on Medicare to take me up on my offer to go on surprise site visits and bust podiatrists who are billing for RFC and having MAs do all of the work. I worked at 2 offices that did this. It’s Medicare fraud.

 

[Pronation]

I would venture to guess that DPMs relying routine foot care as a main source of revenue now, could actually do better if those codes weren’t tied to Medicare.

I bet a majority of those patients would just go to the salon if it’s cheaper.

 

[dtrack22]

I bet a majority of those patients would just go to the salon if it’s cheaper.

Maybe. But maybe you can offer competitive prices when it’s an MA or “nail tech’s” time and not yours.

Maybe you use it as a loss leader to some extent. After all, we are all told how nail care really brings in all that goodwill/referral $$$…🙄 Oh and they could be converted to e/m’s for all those other things they complain about. You could pop over and address it real quick. Keep the price of your office’s new spa services reasonable.

 

[Pronation]

Maybe. But maybe you can offer competitive prices when it’s an MA or “nail tech’s” time and not yours.

Maybe you use it as a loss leader to some extent. After all, we are all told how nail care really brings in all that goodwill/referral $$$…🙄 Oh and they could be converted to e/m’s for all those other things they complain about. You could pop over and address it real quick. Keep the price of your office’s new spa services reasonable.

Oh wow, podiatry really is a hidden gem; best kept secret in medicine. Thanks!