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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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