06/25/2020    Marc A. Benard, DPM

Where Did Biomechanics, the Foundation of our Profession, Go? (Bret M. Ribotsky, DPM)

I agree with Dr. Ribotsky with respect to a
distinct absence in gait analysis and applied
biomechanics, as well as his indicating “… are we
losing the skill to determine the difference
between open chain kinetics and closed chain
kinetics pathology. If so, how can correct
surgical procedures be explained?” I can attest
that I observe this deficiency at close hand
through my didactic lectures to residents both in
person and recently via webinars, as well as
through on-site observation at Operation
Footprint (formerly The Baja Project for Crippled
Children) during patient screenings, grand rounds
and intra-operatively. I’ve also engaged in
discussion with program directors on the problem.

In truth, the problem has always existed, if my
43 years of dealing with the issue holds any
validity. Fundamentally the partitioning of
“biomechanics” and “surgery” fractionated the
perspective of students and residents who, as
they moved on to practice and possibly teaching,
recapitulated this dichotomy, where in fact none
existed.
Compounding this problem was the dogged pursuit
of increased surgical exposure and diversity by
the profession (with which I agree) both in
resident training and practice, however to the
exclusion of the needed biomechanical clinical
assessment. In all honesty, I’m stunned, as
apparently is Dr. Ribotsky, at the intelligence
and acumen that residents and younger
practitioners bring to surgical technique, in the
absence of a well-grounded functional
understanding of foot and ankle mechanics.

In the past decade or more, access to the array
of surgical procedures attendant to our scope and
training has been largely accomplished, yet all
too often the underlying understanding of foot
and ankle function has been nothing more than the
verbal recapitulation of biomechanical “rhetoric”
with no real ability to connect the dots linking
mechanical dysfunction to functional restoration
through surgery plus non-surgical modalities.

Many, but certainly not all, residency directors
with whom I’ve interfaced have raised the point
that the structure of current residency training
precludes adequate access of the resident to a
proper biomechanical assessment prior to taking
the patient to surgery. The expectation for this
training simply does not exist, and is considered
by some to be an annoyance. It appears that even
if the will were there, the residency director
would have difficulty carving out the time on
task as well as the appropriate faculty with the
surgical and clinical biomechanics skills to
really train the residents.

Ironically, I would look forward to a rebuttal to
what Dr. Ribotsky and I have written so as to
prove us wrong. I’m sure we would both be happy
seeing evidence of it.

Marc A. Benard, DPM, Jackson Springs, NC

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