03/19/2026    Paul Kesselman, DPM

Who casts for orthotics? (Gregory Amarantos DPM, Greg Caringi, DPM)

I too am an alumnus of the Illinois College of
Podiatric Medicine , Class of 1981. For my
colleagues reading this they too will remember
being taught biomechanics both theory and
practical from sophomore to and through senior
year and even in post graduate residencies and
preceptorships.

As part of our clinical rotations we were mandated
to cast a patient, take it up to the lab, poor the
positive, and mold/vacuum press the orthotic, add
the top cover and complete the entire assembly
process. Of course this was after performing a
complete lower extremity biomechanical examination
from the hip distal to the toes.

While orthotic fabrication during my clinical
practice years was left to the laboratory,
adjustments were mostly performed in house by me,
having learned that skill set during my
undergraduate medical education. No patient was
casted for orthotics prior to a complete lower
extremity examination being performed.
Whenever students or residents rotated through my
office, they were compelled to do the same. About
15 years ago I started to notice that most
students and residents had little to no training
(or if they did have training the lack of
repetition is was lead to their losing the skill
set) in biomechanics.

Casting, (well let’s keep the conversation polite
here) by saying most had no idea where subtalar
neutral was or if it was even necessary for a
given patient.

Most who read PM News, know this is not my first
foray in drawing attention to this matter and at
times it has received rather defensive reactions
from college faculty rather than offering positive
solutions. Drs. Carigni and Amarantos raise a
point that seems to continue to go unnoticed by
the younger generation of podiatrists.
Biomechanics is what made this profession what it
is today. As my 11-year-old grandson, a Lego
expert, knows, if you don't have a stable
foundation, why are you building a roof? The
parallel here is that biomechanics is our
profession's foundation. It is what sets us apart
from others attempting to treat foot and ankle
pathology. Looking at perfect results on the OR
table does not necessarily translate to a
functional foot when the patient starts to
ambulate.

This profession has or will soon lose its
foundation entirely if the younger generation
doesn't grasp with the fact that there is a
limited supply of patients who are both in need
and willing to undergo Charcot reconstruction,
TAR, hallux valgus or hammertoe repair and other
surgical procedures. However, there is an almost
endless need of patients who need or are willing
to undergo routine foot care, wart and ingrown
toenail surgery, diabetic foot and ulcer
treatment, etc. Many if not all of the
aforementioned have a biomechanical component. Why
is this not being addressed by our young aspiring
podiatrists?

How embarrassing is it for podiatry to see an
explanation of nail dystrophy possibly having a
biomechanical etiology with pathological staging
being published in a dermatology journal? Why is
the Good Feet Store even allowed to dispense
orthotics in states where pedorthic licensure is
required yet no pedorthist is working in their
stores? Why have we handed the keys to the store
to others who are widely successful in dealing
with our patients' biomechanical issues because
our members cannot fathom being thought of
anything but surgeons?

The reality is that most of our professions would
generate more revenue staying out of the OR,
whether in our office or hospital and stick to the
"mundane". That routine foot care patient will
know your name when they sustain a digital or
metatarsal fracture or their family member or they
themselves develop plantar fasciitis, or some
other pathology requiring orthotics. That routine
foot care patient who may be with you for twenty
years who has an IPK may need 10 pairs of
orthotics over those two or more decades. That’s
quite a sum of revenue generated from one patient
who if happy will no doubt generate many referrals
for you.

As Drs. Amarantos and Caringi ask: Who casts or
scans for orthotics?? My answer is that it should
be no one but the doctor. Let the ortho/
foot/ankle surgeons employ casting technicians who
by the way only know for the most part how to
apply a cast for immobilization purposes.
Do you really trust your medical assistant to scan
or cast a patient?

Those few minutes while you scan or cast the
patient gives them an opportunity to ask you
questions about you, your profession, and what you
do on a daily basis. Keep the keys to the store
(our profession) in your hands! Provide them with
an understanding of how complex lower extremity
biomechanics is and help them understand that the
$800 device they may be paying for is well worth
it and not the equivalent of the $20 arch support
their PCP or ortho foot/ankle surgeon may have
suggested.

In the words of Drs. Aronson and L. Weil Sr., who
provided me with the foundation of biomechanics, "
It will take you five years to fully comprehend
lower extremity biomechanics." I have to say it
was definitely more than five years and forty-five
years later, with digital technology, there still
appears much to learn. And that's fine. I am still
a work in progress.

Paul Kesselman, DPM, Oceanside, NY

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