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08/05/2021 Kevin A. Kirby, DPM
Why are Podiatry School Graduates Not Grasping Biomechanics
Dr. Jarrod Shapiro’s recent article, “Why Are
Podiatry School Graduates Not Grasping
Biomechanics?”, hits the nail squarely on the head.
In the 36 years that I have been in private
practice and teaching foot and lower extremity
biomechanics both nationally and internationally,
28 of those years involved training podiatric
surgical residents on the principles of foot and
lower extremity biomechanics, foot and ankle
surgical biomechanics, sports medicine, and foot
orthosis therapy. As Dr. Shapiro also observed, I
have noted a gradual decline in the biomechanics
knowledge that these third-year podiatric surgical
residents possessed when rotating through my office
over the past 10-15 years. As such, I believe a
few comments are in order about “biomechanics”,
what it means, and what we, as a profession,should
do about teaching “biomechanics” to our podiatry
students, podiatric surgical residents and
podiatrists.
First of all, we must all understand that the term
“biomechanics” does not simply mean evaluating,
casting/scanning, prescribing and adjusting
orthotics. Rather, to any non-podiatric scientist,
the term “biomechanics” refers to the examination
of the forces acting upon and within any biological
structure and the effects produced by these forces.
In other words, “biomechanics” does not just mean
“orthotics”.
Therefore, when a podiatrist surgically repairs the
plantar plate of the second metatarsophalangeal
joint to reestablish better digital purchase and
reduce the pain within the plantar
metatarsophalangeal joint, that podiatrist is
“doing biomechanics”. When a podiatric surgeon
performs a Lapidus bunionectomy, that podiatrist is
“doing biomechanics”. When a podiatric surgeon
performs a posterior calcaneal medial displacement
osteotomy for adult acquired flatfoot deformity to
reposition the posterior calcaneus more medially so
that ground reaction force and Achilles’ tendon
tension forces produce more supination moment
across the subtalar joint axis, then, by
definition, that surgeon is also “doing
biomechanics”.
In fact, “doing biomechanics” is something that
each and every one of us, as podiatrists, do every
day of our clinical practice, even if we don’t cast
or scan a patient for custom foot orthoses, and
don’t grind or modify an orthosis. Why? Because
the human foot is the most mechanically important
and complex structure in order for us to be able to
properly perform our daily activities – a structure
that Leonardo DaVinci called, over five centuries
ago, “a masterpiece of engineering and a work of
art”.
The foot is the structure that is subjected to, by
far, the largest magnitudes of external forces of
any structure of the human body. Therefore, when
we treat the foot in any way, the science that
examines the force acting upon and within the foot
and the effects produced by such forces on the foot
(i.e. biomechanics), is involved. Every time a
podiatrist places a pad inside a shoe, trims an
offending toenail, shaves down a corn, debride and
offload a diabetic ulcer, applies a low-Dye
strapping, does an osteotomy, transects a ligament,
lengthens or transfers a tendon, and/or do an
arthrodesis, they are affecting the biomechanics of
the foot.
That being said, with the scientific realization
that the foot is an extremely important and
inherently mechanical organ that we all rely on to
function properly during our daily weightbearing
activities, why is it that more hours are not
devoted during podiatric medical school, podiatric
surgical residencies to teaching the intricacies of
foot and lower extremity biomechanics? Why are
“podiatric surgical seminars” practically devoid of
any discussion of foot and lower extremity function
when the structure they are advocating performing
surgery on is such an important and complex
mechanical structure?
Put in other words, if one wanted to be trained as
a professional who repairs and restores the
function of any mechanical object, whether that
machine was an automobile transmission, an electric
motor, an air conditioner, or a foot, one would
expect that a large part of the time spent in that
professional training would be devoted to teaching
how that machine worked. In that way, successful
troubleshooting and repair of that machine could be
maximized and temporary or permanent repair
failures of that machine could be minimized.
Unfortunately, over the past 10-15 years, we, as a
profession, have been increasingly training
technicians that are educated to perform many
different types of surgeries on a mechanically
complex part of the human machine but are not
completely trained on the intricate biomechanical
function of that machine that we know as the human
foot.
What makes me say these things? Let’s look at a few
examples. Why are podiatry students still being
taught half-century-old notions in foot
biomechanics, based on faulty research and
speculation, that have been disproven by scientific
research from decades ago? Why do lecturers at
podiatric surgical seminars spend so much time
showing pre- and post-operative static bone shadows
(i.e. x-rays) and not show pre- and post-operative
gait kinematic and kinetic studies to discover how
their foot surgeries may have altered the dynamics
of gait, rather than change the apparent static
structure of the foot? Why do we continue to
overemphasize all different types and colors of
shiny surgical hardware and technologies for
surgically repairing foot and ankle “deformities”
in podiatry seminars and spend so little time
emphasizing and researching how these surgical
procedures affect the weightbearing function of the
foot and lower extremity?
My belief is that for podiatry, as a profession, to
truly achieve the goal of remaining as the premier
surgical specialists of the foot, we first need to
spend more time training our podiatry students,
podiatric surgical residents and podiatrists in the
biomechanical function of the foot and lower
extremity. Whether we, as podiatrists, are “doing
biomechanics” by performing foot and/or ankle
surgery, are “doing biomechanics” by debriding and
offloading diabetic foot ulcers, are “doing
biomechanics” by performing a partial nail
avulsion, or are “doing biomechanics” by making
custom foot orthoses for our patients, we first
need to understand, as a profession, that better
biomechanical knowledge of the foot and lower
extremity is not only important, but essential. In
this way, we will better be able to achieve optimal
conservative and/or surgical therapeutic results
for our patients, while minimizing unwanted pain
and disability within our patients as a result of
our lack of better comprehension of foot and lower
extremity biomechanics.
Kevin A. Kirby, DPM, Sacramento, CA
Other messages in this thread:
08/17/2021 Robert D. Phillips, DPM
Why are Podiatry School Graduates Not Grasping Biomechanics
I am grateful and encouraged by the many so far who
have responded to Dr. Shapiro's essay on the lack
of biomechanics understanding by resident
interviewees. While I agree with most of the points
of the various responders, I would also like to
consider a few additional points that may have
contributed to the current hand-wringing..
1. When I entered podiatry school in 1976,
prospective podiatry students were required to take
an aptitude test to predict their success in
podiatry school. Part of this test was a 3D
visualization section. This part of the exam
alerted students that part of the curriculum would
involve being able to visualize geometric shapes
and what happened when they were rotated. I'm not
sure how many prospective students it might have
scared away from going into podiatry, however, it
did make a point of the aptitude needed to be a
good podiatrist.
Somewhere along the way, podiatry schools decided
that they needed to attract more of the medical
school applicant pool. To make it easier to do so,
they started accepting the MCAT, which had no
section that pointed to the need to be able to
visualize 3D objects rotating in space. As such, a
number entered the profession with the idea that no
mechanical and little mathematical knowledge was
needed to practice podiatry. I have to say that
there are a great many in the profession today who
openly profess extreme math phobia. The idea that
they might have to know what a sine or cosine is,
or what an integral or differential is sends them
into a state of high anxiety.
Yet basic mathematical skills are needed to read
any of the dozen or so journals in biomechanics,
where a majrity of the research is being published.
So when we see that students and residents are not
able to read the biomechanics journals, can we
expect them to understand the nomenclature, lingo
and keep up to date? One is hard pressed to find
an American podiatrist participating in conferences
of organizations such as the American Society of
Biomechanics and the international Foot and Ankle
Biomechanics organization is most appalling.
It is important to realize that biomechanics is not
a clinical science, but actually a basic science
that governs all animal movements, from microbes to
blue whales. It governs principles of cardiac
output and blood pressure. It governs the
stability of being able to stand and to walk. It
should be part of the basic science, not part of
the clinical science part of the curriculum. While
it impractical to go back to discontinue using the
MCAT in favor of a podiatry college aptitude test,
it is possible to improve the prerequisites for
admittance to a podiatry college. My recommendation
is that an undergraduate course in biomechanics
should be a prerequisite for entrance into any
college of podiatry today.
We also need to strengthen the prerequisites in
mathematical skills, with at least 1 semester of
calculus being the minimum, with preference to at
least 2 semesters and one additional semester in
another mathematical course at the 200 level. With
better skills our abilities to read the research
being published increase and we can better
communicate interprofessionally and participate in
interprofessional research and symposiums.
2. A great many of practitioners today attended
traditional podiatry schools which were divided
into 3 basic departments, medicine, surgery and
biomechanics. While this may have been a way of
trying to better teach students and administer the
college, the end result has been disastrous in that
it has created and fostered the idea that one
either practices biomechanics or one practices
surgery. Even in the discussions of this thread I
see uses of phrases that indicate people still
believe that biomechanics is a nonsurgical way of
treating orthopedic deformities.
In the traditional school model, the people in
surgery departments basically didn't do
biomechanical examinations and people in
biomechanics departments didn't do surgery. To the
best of my knowledge, Dr. Leonard Levy pioneered at
Des Moines University the move away from making
surgery and biomechanics different departments.
With no departments, professors there were asked to
teach something in any course that affected
clinical practice of podiatry. This model seems to
have been furthered as other podiatry schools have
become just part of larger medical schools.
Unfortunately, some may interpret the lack of an
actual "biomechanics" department at a school as a
statement that students don't need to know
biomechanics rather than a statement that
biomechanics is part of almost everything a
podiatrist does. Hopefully in a de-departmentalized
podiatry college, biomechanics will be taught by
all the podiatric faculty, including those who
specialize in surgical approaches and by those who
specialize in conservative approaches.
3. There continues a continued push to decrease
biomechanics teaching at the residency level. When
ABPM and ABFAS agreed that there should be a single
podiatry residency training model, ABPM dropped its
MAV for biomechanical exams from 150 to 75 over the
3 years of training. Now, a recent proposal in the
rewrite for the new CPME 320 document shows that
MAVs for biomechanical exams would be decreased
from 75 minimum to 50 minimum. When I pushed the
head of the ad hoc rewrite committee on this
decision, the only answer was that it came from the
opinions of the "community of interest." It was
argued that many programs were having problems
meeting the 75 number. This points to a problem
that we continue to avoid addressing -- we continue
to push residency as a way of turning out highly
competent surgical technicians instead of
physicians who know how to follow a patient from
entering the system until there is resolution of
the problem. Part of the evaluation of the patient
includes an assessment of function and causes of
abnormal function. Dr. Jeff Robbins has recently
suggested that such an assessment should be renamed
"the pathomechanical exam." I agree totally with
this suggested change in terminology. I have found
that in only a few select programs is biomechanical
examination pushed as the path to good surgical
decision making. How is it that we can say that it
takes a minimum of 80 digital surgical procedures
to make one competent to perform the needed
procedures, but only 50 biomechanical exams are
needed? One program that I am aware of pushing
more biomechanical evaluations than the minimum of
75 is that headed by Dr. Shapiro, who requires his
residents to perform a minimum of 150 examinations
as part of their training. If biomechanics is the
foundation upon which all musculoskeletal
procedures are based, how can one justify asking a
resident to perform a surgical procedure without
doing the examination before? I noted recently one
program where residents were being required to do
all the pre-op H&Ps, yet few of these included a
good biomechanical exam. Maybe it was because the
H&Ps were being done in the last few minutes before
the patient was rolled into the OR. Good
biomechanical examinations require time and also
they require thought about how findings answer the
question of why surgery is needed and what the
result will be after surgery. The director of
medical education at our local VA hospital recently
told me that ACGME approved programs are de-
emphasizing the work load and instead are more
emphasizing the evaluation and thought process that
leads to making diagnosis and treatment decisions.
Is that also a goal of the new CPME 320 document?
4. I can point in each school to specific
instructors who are committed to biomechanics
teaching, however their time is so taken up between
preparing and giving lectures, remediation, writing
and grading tests, clinical work and committee
assignments that few have a moment to spend in
doing the research and writing the articles that
are needed to improve biomechanics knowledge and
applications. A few of the schools do have a
biomechanics laboratory, some of them better
equipped than others for doing research. One
school has an extremely well developed lab that has
received a significant number of grants to do
research, however it is the exception and not the
rule. Overall, how much importance does each
school put on biomechanical research and publishing
in the podiatry journals? I do know that a
majority of the biomechanics research papers
submitted to JAPMA come from outside the United
States, and a majority of the reviewers of
biomechanics papers are also outside the United
States. If students are coming out of the schools,
knowing more about the technique of repairing an
ankle fracture than about how to evaluate a patient
for flatfoot surgery or unable to decide whether a
Richie brace or a shoe modification is the best for
the patient, then it is not the fault of those
charged at the schools with teaching biomechanics,
but instead is a measure of the goals of the
institutional heads themselves? How can
biomechanics research and publishing be rewarded?
Why has the number of new biomechanics texts
produced by podiatrists since Root's 1977 book be
counted on just a few fingers? One of the very big
biomechanics labs in the country is at the Hospital
for Special Surgery, an institution famous for its
orthopedic surgery. Which of the podiatry schools
can compare itself to that biomechanics lab? The
board members at the schools need to readdress
their missions in fostering biomechanics knowledge
and research.
4. In the 1970s, almost all podiatrists made their
own orthotics for their patients. If one wants to
learn a lot of biomechanical principles, make a
device to put on the patient and have them wear it
and report back on whether or not it is working --
then, it if it's not working, fix it. Today almost
no podiatric graduate has any idea about the
process of making an orthotic or brace or what goes
into the design of it. We have turned almost all
the design and fabrication over to "professional
orthotic companies" with trained pedorthists and
prosthetists. So many podiatrists, then, act as
only the middleman in the conservative biomechanics
chain of custody.
For many years, many taught that there was only one
biomechanics rule, "Take a neutral cast." Now,
many clinicians don't even take the cast. I
remember Dr. John Weed explaining that he felt that
taking a good neutral cast was more difficult to do
than good hammertoe surgery. So many physicians
today write a two or three work prescription to
their orthotists to just make orthotics for their
patients with no instructions on how to take the
cast nor any instructions on how to make the
orthotic. Many clinicians find that if the first
pair of orthotics don't work, they don't fix the
problem, they just send the orthotic back to the
lab or send that patient back to the orthotist, or
they just say that orthotics didn't work and
recommend that the patient needs surgery.
How many podiatrists keep track of whether their
orthotics and braces that they prescribed are still
being worn by their patients 1 year later?
How many patients have come to see me with a whole
bag of orthotics that didn't work, with no one
trying to find out why the previous doctor's
prescription didn't work? How many of these people
have been amazed to have me lie them on their
stomach and pull a measuring instrument out of my
drawer? If we are going to prescribe orthotics,
we've got to do more measuring and actual
prescribing.
5. The prejudices against podiatry continues to
dwindle, yet many are still institutionally there.
The fact that the AMA owns the CPT codes that
every insurance company uses and every government
agency uses continues to amaze me. While
additional HCPCs codes have been added by the
government, the coding system used by the
government are still a myriad of confusion to
understand and bill correctly. The fact that
people have had difficulty being paid for the time
doing a good pathomechanical exam of the lower
extremity has been frustrating for many well-
meaning practitioners. Let's hope that new
guidelines for billing time spent into the E&M
coding system will help many practitioners spend
the time needed to better understand why their
patients are suffering injury and deformity.
Many of the prejudices were very early broken down
by those who did do surgery -- by putting on
surgical scrubs, they were better identified by the
public as being real doctors. Because many
podiatrists had their own office surgical suites,
hospital administrators saw podiatrists doing
surgery in their own facilities as major cash lost,
and so they made sure that that cash was redirected
into their hospital system. On the other hand,
arch supports are being sold in every marketing
corner possible, from TV advertisements to
pharmacies to department stores that will 3D print
your orthotics while your shop, to mall kiosks,
etc. -- all of them claiming to be biomechanically
sound, and few using little to any technology and
none using hands on examination. So if a
podiatrist isn't doing surgery, can he/she be
considered a real doctor? Only the mature
podiatrist can feel secure in his/her self-image as
a physician if he/she isn't in the operating room.
While some of the big CME programs do feature some
very good biomechanics lectures and speakers, many
of these lectures are poorly attended, especially
by the young practitioners. Currently, there is
only one American podiatric conference that is
devoted purely to biomechanics thoughts.
As I noted, there are many reasons, some of them
deeply rooted in tradition and history, that have
brought us to the concern that today's graduates
may not understand biomechanics. I welcome this
invigorating discussion as everyone concerned puts
their energies into solving the problem to see
podiatry take the lead again in foot and lower
extremity biomechanics.
Robert D. Phillips, DPM, Orlando, FL
08/11/2021 Dennis Shavelson, DPM, CPed
Why are Podiatry School Graduates Not Grasping Biomechanics (Richard A. Simmons, DPM)
Over the past 15-20 years, DPMs have focused on
foot surgery focusing on improving the bio-
architecture of our patients. Our surgeries alter
pedal structure more optimally allowing the patient
to then be engineered more optimally. Our
interventions do not fix gait, sports performance,
or living our lives more optimally and efficiently,
they only make us, on a case to case basis, more
fixable.
Improving the stability, support, strength,
symmetry and balance of our feet via podiatric foot
surgery allows Wolff’s and Davis’ laws to
seamlessly adapt to the many changing influences we
encounter on a daily basis. That is a great and
valuable contribution to society.
When it comes to human stance and movement, there
are three platforms that need to be controlled and
maintained. These are the structural, functional,
and performance platforms of human movement. Each
has a longitudinal history of research, evidence
and clinical applications. Rarely and at great
sacrifice can one clinician or researcher study and
practice all three.
This means that the combination of a human movement
oriented diagnostician and clinician, a human
movement-oriented foot and ankle surgeon and a
human movement therapist, coach and/or trainer
combining professionally are necessary when
approaching human stance and movement.
In my opinion, the well-trained and practiced
podiatric foot surgeon sits atop of the pyramid of
those performing, rehabilitating and monitoring
human movement foot and ankle surgery utilizing
bio-architectural and biomechanical principles and
methodology. We are appropriately marching together
to fill the void that exists in Medicine when it
comes to human movement. We are not trying to be
engineers or therapists to the extent that our DPM
ancestors and pioneers. We are leaving that to
others and them.
Unfortunately, there are those who fail to realize
that in order to fill our brains, skills, practice
and experience as great human movement foot
surgeons, we have reduced the energy we put into
our expertise, practice and experience as great
human movement diagnosticians, clinicians and
therapists and in order to eventually deserve the
title of MD/DPMs in Medicine.
https://www.researchgate.net/publication/325812221_
A_Biomechanical_Paradigm_Shift_Part_I_Transforming_
Lower_Extremity_Biomechanics_Terminology_Nomenclatu
re_and_Science_as_an_Upgrade_to_STJ_Neutral_and_Nor
mal_Biomechanics
Dennis Shavelson, DPM, CPed, Tampa, FL
08/10/2021 Paul Kesselman, DPM
Why are Podiatry School Graduates Not Grasping Biomechanics (Kevin A. Kirby, DPM)
Two years ago at the APMA 2019 National, Karen
Langone, Jeffery Ross and I provided a morning
session on 21st Century Biomechanics. Not more than
75 DPMs attended that session with most being over
the age of 45. Few young podiatrists attended this
while other surgical courses were being offered.
During the intervening two years, I have posted a
similar LTE as Drs. Ritchie and Kirby, and have met
with Dr. Shapiro, whose recent article has spurred
this most recent conversation. Two years ago,
rather than receiving letters of support on actions
by which to resolve the issue, I received several
letters from academia, defending the courses they
taught at their various podiatric institutions,
rather than acknowledgement that there was an
issue. Several orthotic laboratories did however
acknowledge the "problem".
Dr. Kirby's recent LTE is spot on and is identical
to what I was taught over 40 years ago while a
student at ICPM.
Unfortunately, the current students today lose much
of what they are taught from the biomechanical
perspective because it is lost by the time they
graduate or after their first year of residency. My
initial experience as an attending in residency
programs, required that the resident complete a
biomechanical exam on every elective surgical
patient. That (and correct me if I am wrong) is
most often no longer the rule.
Dr. Kirby's LTE along with others, screams of the
need for a multi-faceted approach in order to fix
this problem. The time on this is ticking as other
professions in the past five years have presented
far more research papers than I have seen either in
the podiatry literature space or at meetings.
Research along with evidence-based medicine either
proving or disproving podiatric theories will
either support or bury us. Owning this research and
having the academic capable students and residents
is more needed now than ever.
Dr. Shapiro and I have met several times either in
person or via Zoom over the past two years and have
begun our own "think tank" on how to right the ship
and fix this problem. At this point we both know it
will require lots of logistics and financial
resources from a myriad of sources.
What is needed now is a focus on the future and not
a defensive posture on what you or your institution
has done. Obviously whatever has been done has been
insufficient. We need visionaries, fellowships,
research centers and those who have ideas on how to
move this discussion in the correct direction.
I applaud all who have written in who have
acknowledged the problem and are willing to address
it in a positive direction.
Paul Kesselman, DPM, Woodside, NY
08/06/2021 Gregory T. Amarantos, DPM
Why are Podiatry School Graduates Not Grasping Biomechanics (Richard A. Simmons, DPM)
I understand Dr. Simmons' position and embrace
biomechanics in my practice. I too and 65 years old
and remember the "good old days' of more favorable
reimbursement. There is no doubt medicine is a
business and primary care physician provides a
complete physical while I am in a hospital gown and
minimally clothed. He also utilizes each CPT for
counseling to his advantage and I do not begrudge
him. I value the comprehensive care he provides.
Regarding the biomechanics vs. surgery discussion,
I prefer to look at it through a different lens. I
enjoy doing surgery and am satisfied when I achieve
the desired outcomes. Oh, yes and doing surgery has
a certain cache to it. Let’s look at 2 patients and
the medical economics of the care provided. Patient
A has a painful bunion and pronates, while patient
B has fasciitis. Both get the initial visit code
(99203) and radiographs (CPT 73630).
The bunion patient is scheduled for surgery and let
us assume the CPT is 28296. The fee schedule is
about $800 which includes the 90 day global period
and let us assume 3 post op visits with x-rays
(3x73630). For this, you will have to be at the
hospital by 7:00 in the morning and if all goes
well, be out by 8:30.
For my fasciitis patient, I can get to the office 5
minutes before the appointment, do the exam and I
strap and pad the foot (29540). I will leave out
night splint and injection fees for this
discussion. I see the patient 1-2 weeks later
(99213) and if there is improvement, I may advise
orthotics. I believe because I taped the foot, the
patient had tangible evidence they will get relief
from orthotics, instead of "you need orthotics",
because I know so. I do not have to sell the
patient on the efficacy of orthotics for they
perceived the value of the strapping. I do a
biomechanical exam on the foot and I take the
impression while utilizing the principles I was
taught as a student. Let us assume the orthotic fee
is $475 (self pay or insurance). The patient
returns in 3 weeks to dispense the orthotics
(99212-99213) and in one month for a follow up
(99213).
As we digest the medical economics, please decide
for yourself. Patient A: $125+ $65 x-ray+$65 x-ray
with 3 additional charges of $65 for x-rays= $450+
$800=$1250. Patient B presents with $125+$65+$65+ 3
follow up visits 99213 $70+ orthotics $475=$940
minus the cost of the orthotics.
There is a $350 differential in the patient care
and I opine that although surgery is glamorous, in
a down economy elective surgery with the high
deductibles is the first to take a back seat, while
comprehensive, value based care can and continues
to withstand the forces of medical economics.
According to the annual survey of podiatrists
published by PM the past 30 years, my revenue has
placed me in the upper echelon of the profession
while my surgical income as a part of my entire
revenue is approximately 10%. All the while having
an excellent quality of life.
In my opinion there is a place for both in our
profession, but it is not medical economics that
have changed the dialogue. The educators have moved
the cheese. Instead of focusing on surgery, they
should provide a quality biomechanics course along
with practice management lectures given buy
successful practitioners. I am convinced if
students saw the data, the emphasis on biomechanics
would return.
Gregory T. Amarantos, DPM, Chicago, IL.
08/06/2021 Richard A. Simmons, DPM
Why are Podiatry School Graduates Not Grasping Biomechanics (Doug Richie, DPM)
Dr. Richie, with all due respect, rather than
change the topic of the question, please offer your
opinion. I am simply offering my opinion. I believe
medical economics and billable CPT codes are
driving all aspects of medicine right now. I am 65
years old, and for the last ten years my annual
physical exam with 5 different PCPs have all
occurred with me fully clothed. I’m sure the
reason why is that the medical group had to crunch
numbers and interpret the CPT codes then determined
that reviewing my clinical lab results and reading
some snippet off of WebMD was “an annual physical
exam.”
I am old enough to remember reimbursements of $300
for matrixectomies; now, it is less than half and
barely more than a simple nail avulsion. I
performed vascular exams for more than $200 each
and simply stopped doing them because the money is
not there.
There really is not a CPT for a biomechanical exam
of the foot and ankle and we can only stretch the
current codes so far. If you’re fortunate enough to
live in a wealthy area like Long Beach, CA (Long
Beach is estimated to be 146.6% of the national
average making it one of the more expensive cities
in the US), you may be fortunate to have a patient
base who is willing to pay for services out of
pocket(my city is 98.6%). Most young podiatrists
are scrambling to get on insurance panels that
dictate pretty much everything they can do, while
at the same time are trying to figure out how to
pay back tremendous student loans.
Do “I personally” think biomechanics is important,
yes; but I also am a realist who sees that all of
medicine is being driven by money and the least
common denominator.
Richard A. Simmons, DPM, Rockledge, FL
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