03/22/2022    Richard Stess, DPM

RE: NY Podiatrist Discusses Supination (Paul Kesselman, DPM)

I am pleased to have read Dr. Paul Kesselman's
posting regarding the sorry state of podiatric
biomechanics. I want to commend him for raising
this topic and hopefully some practitioners will
chime in. In previous papers that have been
published, many authors have suggested that
successes in reducing pedal pathological symptoms
are directly related to custom functional foot
orthotics. No long-term controlled clinical
studies have been published that have
substantiated the verifiable benefits of custom
devices. Further, most studies have never
specified specifically how the exact position the
foot was to be maintained during obtaining a
negative model nor if a weight-bearing or non-
weight bearing impression provides greater control
of the abnormal foot motion.

I harken to my biomechanical instruction many
years ago and how positioning of the foot, while
obtaining a negative cast, was the key to
achieving the optimal clinical result from a
functional foot orthotic device. Positioning of
the subtalar joint in the neutral position
following an extensive measuring of ranges of
motion of the major joints of the lower extremity
was the hallmark of successful outcomes. It was
not uncommon that as students, multiple negative
casts of the foot had to be obtained in order to
achieve the most optimal model of the foot.

To achieve the optimal foot model emphasis was
laced on making certain the neutral position of
the STJ was correctly identified then maintained.
Once the position was identified by both moving
the STJ through its entire range of motion and
then moving it so that it was neither pronated nor
supinated, palpating the talus so that it was not
protruding but rather aligned with the navicular
and then maintaining this “ideal position” by
placing an upward pressure the 4th and 5th rays
(either in the sulcus of the MPJ or directly on
the metatarsal heads) and thereby locking the mid
tarsal joint.

I spent my 35 years while in clinical practice
casting patients with these principals believing
that they provided the most optimal biomechanical
benefits to my patients. I firmly believed that
the thousands of patients that I casted in this
manner benefited from my consistent approach. I
further believed that these principals were based
on solid concrete facts only to discover after
many years that no such basic clinical scientific
studies had ever been conducted.

Within the last few years, I have observed an
increase in the use of foot scanners by many
within my profession. The original scanners that
were first introduced allowed for the practitioner
to position the foot and then maintain it in a
similar manner to the traditional casting methods
that we were taught in the 60s. Recently, I have
observed the use of iphones and ipads to capture
the models of the foot. I concurrently have
observed and now wonder how the positioning of the
STJ, locking the mid tarsal joints and then
maintaining the “proper” positioning is achieved.
I have concluded from observation that these
biomechanical positions cannot be achieved solely
by one person holding a device or without some
device that would assist in maintaining that
position (Smartcast° foot positioning system by
Northwest Podiatry lab being the exception).

There is no doubt that scanners will provide
accurate measurements of the anatomy. However, if
only the anatomical measurements with no
particular attention to positioning are the goals
to achieving the most biomechanical efficient
orthotic then why does a patient need to seek a
podiatrist to cast them. They could just as easily
go to a supermarket, big box store or pharmacy for
a high school drop out to hold an iphone or ipad
to scan the foot. Probably at half the cost. I
have struggled with this for a while trying to
determine if my observations are founded on
science or merely on my experience or bias as co -
founder of the STS Company that manufactures
casting materials.

I continue to believe that our profession was the
leader in the biomechanical treatment of the foot
and lower extremity and we achieved that by
adhering to the methods and materials that were
taught by Drs. Root, Weed, Sgarlato, Orien,
Schuster, Langer, and others. I also believe that
we should continue to expand and to improve upon
the science that they initiated. If we, however,
as a profession, wish to maintain the distinction
of the leaders in all aspect of biomechanical foot
care then we must conduct well-crafted research
protocols exploring all areas and procedures that
hopefully will substantiate those methods and
practices that achieve the most accurate methods
of positioning and image capturing. If those
methods, materials and positions cannot be proved
to be significant or beneficial in providing the
most accurate orthosis then they should be
abandoned or ignored.

It seems necessary that in order to achieve the
best possible patient outcome we as a profession
must do diligence in producing the evidence that
should dictate our practices. These studies should
be conducted prior to introducing them to us. If
however we do not conduct these rigid peer
reviewed research studies then those individuals
in the future believing that custom designed
orthotic devices will resolve their symptoms will
eventually find the provider located in the local
supermarket or department store. As to the
funding issue that Dr. Kesselman raises I question
whether podiatry orthotic laboratories should be
the sources of such funds.

I have observed at pre-Covid podiatry meetings
that very few practitioners who attend these
scientific meetings would actually take the time
to visit orthotic lab exhibits or speak with their
representatives. As a result, fewer and fewer labs
actually attend these meetings as their return on
investment by attending these meetings has
significantly decreased over the years. There are
many sources of funding that are available for
legitimate research proposals regarding pedal
biomechanics and locomotion. Practitioners,
residents and/or students can certainly apply for
these types of grants if their proposals will add
to improved patient outcomes.

Richard Stess, DPM, President and Co-founder of
STS Company

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