Connecting Biomechanics as a Catalyst of an Optimal Orthotic Treatment Program

The role and intensity of one’s education in biomechanics in podiatric medicine and surgery has recently emerged as a topic of discussion. In this Orthotics Q & A, the panelists reflect on what role biomechanics play in their orthotic prescriptions and the related courses of treatment, along with sharing key pearls of their examination and decision-making processes.

Q: How do you connect your biomechanical exam to an orthotics prescription? Are there key exam points that you rely on and examine every time? If so, what are they and how do they influence your choices?

A:

Alicia Canzanese, DPM, ATC, FAAPSM says that findings from her biomechanical exam directly relate to how she prescribes an orthotic. She says she always evaluates the patient seated and in weight-bearing, and often during gait. Throughout these exams, she focuses on certain key points, including first MTPJ and first ray range of motion.

“This will help me determine if the orthotic needs features such as a reverse Morton’s pad and/or first metatarsal or ray cutouts in the shell,” she explains. “Another key exam point is how rigid or flexible the deformity is through the rearfoot and midfoot and if the biomechanical foot type is compensated, partially compensated, or uncompensated. These findings will help determine the type of device, stiffness of the shell, and depth of heel cup that I choose.”

Robert Conenello, DPM, FACFAS, FAAPSM says that he finds there are four components to better outcomes in functional orthotic therapy: the biomechanical examination, the non-weight-bearing cast, materials selection and biospecific pads and corrections.

“With those 4 components, you can get a great outcome,” he shares. “The key to these components is that they cost no more time or expense than if you made a device with less detailed decision making. Bottom line, you create happier patients and develop a positive reputation in your community.”

Nicholas Romansky, DPM  urges clinicians to look, listen, and feel during a biomechanical exam for potential orthotics.

“Ask yourself why are we prescribing these orthotics, and for what needs,” he says.  “Clinicians many times forget the clinical reasons and applications for custom orthotic use. The final device and fabrication are based on the patient’s needs. Many podiatrists’ prescriptions are for only one type to fit all needs, which is incorrect thinking.

Karen Langone, DPM, DABPM, FACPM, FAAPSM places a large emphasis on sagittal plane mechanics in her orthotic prescription writing and spends a large portion of her examination evaluating first MTPJ range of motion, ankle dorsiflexion, hamstring flexibility off weight-bearing, in stance, and dynamically.   

“Using slow-motion video, I then evaluate loading of the first MTPJ, hallux dorsiflexion, ankle motion and position at heel contact, midstance, and propulsion, knee position in the same phases of gait, and trunk alignment,” she relates.

Another important component that Dr. Langone examines is calcaneal position during gait, using video to evaluate the entire movement pattern of the body. If patients participate in a sport that involves running, she will also make a point to watch them run.

Q: How important is your biomechanical exam to your orthotics prescribing?

A:

Dr. Conenello shares that, in his experience, the biomechanical exam is pivotal to positive, reproducible orthotics outcomes. He goes on to say that such an exam does not rely on taking specific measurements or angles, but rather, by utilizing the practitioner’s eyes and judgement.

Dr. Romansky agrees that biomechanics are vital to a successful orthotic treatment plan, and that, in his opinion, most foot, ankle and lower extremity problems stem from abnormal mechanics and load management issues. Citing an example of postoperative orthotics (short- or long-term use), he relates utility in maintaining surgical soft tissue and bone correction or helping facilitate complete surgical healing. Biomechanics continues to play a role when considering that orthotics can and should be used to help functional healing postoperatively, especially for load management to help eliminate or distribute abnormal mechanical forces. Understanding the mechanics of postop offloading is also important, as orthotics may prove useful in CAM walker boots or surgical shoes as well.

Understanding dynamic motion, according to Dr. Langone, is the only way to truly create the best orthotic for a patient.

“Human movement is complicated and it is impossible to address fully the issues that a patient experiences without examining the capabilities of the movement chain and how the various segments interact to propel this patient forward in their daily life,” she says. “Then, we must figure out how this movement pattern leads to the patient’s presenting complaints.”

Dr. Canzanese asks podiatrists to consider, without a biomechanical exam, how would one know which type of device, and with what features, to prescribe? One has to establish and recognize what the pathology/deformity is in order to treat it, making orthotics without any type of biomechanical exam, in her opinion, synonymous with doing osseous surgery without first getting an X-ray.

Q: How did you arrive at your preferred approach to orthotics? What pitfalls or challenges did you experience, if any, along the way?

A:

Dr. Conenello explains that, in a busy private practice, one does not usually know when a patient will come in who needs functional orthotic devices. Therefore, he feels his biomechanical exam needs to be quick, efficient, and reproducible. He shares four moments in time, that in his opinion, are crucial to evaluate:

• Neutral calcaneal stance, which tells about the relationship between the tibia and the calcaneus before heel purchase;

• Relaxed calcaneal stance, which tells about the deformity when fully concentrated and exhausted;

• Root load, which involves looking at the patient in open chain kinetics, placing the foot in subtalar joint neutral and maximally pronating the midtarsal joint to inspect the forefoot position as it relates to the rearfoot; and

• Reduction load, which involves the same maneuvers as above, with the addition of maximally dorsiflexing the hallux to mimic the propulsive phase of gait.

“All of these stages represent a moment in time of gait and influence the orthotic prescription,” he says. “The first two moments above are seen with the patient weightbearing and the last two are seen in the chair.”

Specific to first ray pathology, Dr. Conenello says he quickly assesses the length, elevation and range of motion of the first metatarsophalangeal joint. This allows him to utilize components such as a first metatarsal cutout or ray cutout, a reverse Morton’s extension or Morton’s extension.

Dr. Langone relates that she does not have a preferred algorithm for her orthotics, instead tailoring the features of the devices to the findings in her biomechanical and physical exams. She says she examines range of motion, flexibility and strength in her patients, having them perform squats and lunges to see how their system responds to being stressed. She will also watch them in gait, and watch them run if they are in a running sport. As a result, she then looks for whatever aspects of their function are suboptimal.

“I then use my orthotics to address the biomechanics, looking to create optimization of movement and also utilize physical therapy extensively to address their strength or flexibility deficits,” she adds.

Dr. Romansky acknowledges that there will be variations in podiatrists’ preferences when it comes to orthotics.

“Everyone has a personal preference on what works in their hands. There is the science and the art of orthotic casting,” he details. “Like feet, which are all different, orthotics should be made differently.”

He goes on to say that he aims to control the rearfoot and subtalar joint around neutral with a deep heel cup. He also prefers to extend the arch with varying heights of medial flange and the midtarsal area to control the medial column. Further, Dr. Romansky says he prefers to accommodate forefoot correction using metatarsal bars, metatarsal pads, and first ray cutouts. Many times he says he skives or inverts the rearfoot for further correction/control. Finally, he streses the importance of not overcontrolling or overcorrecting for foot type with the wrong type of materials or with over posting.

In her experience, Dr. Canzanese arrived at her current method for prescribing orthotics by learning from mentors through school, residency, and post-residency life in addition to staying up-to-date on current concepts in the literature, trends, and from sports medicine meetings.

“I think one of the best pieces of information I’ve learned is to consider individual pathomechanical factors and injury history to make the best orthotic for that individual patient and to avoid a “one-size-fits-most” approach to making custom devices,” she says. “I think a common pitfall that I have noticed, especially for new practitioners/residents, is them finding something that works for one person and then using the same type of device for all their patients regardless of differences in pathology.”

Q: Is there anything else you would like to add?

A:

Dr. Conenello stresses that the key to better outcomes starts with practitioners understanding why pathologies exist. One final note, though, he feels is very important:

“I make my patients aware that an orthotic does not necessarily need to be a life sentence, but rather an opportunity to decrease the stresses on their tissues while they are in a pathologic state,” he states. “The hope is that they can work to strengthen their body and eventually the orthotic device becomes redundant.”

Dr. Romansky would like readers to remember that the art and science of biomechanics have distinct differences, in that, what a patient needs academically may differ from what works or is tolerable clinically. He also feels it is important for clinicians to read Kevin Kirby, DPM’s 2021 Forum column in Podiatry Today, “Whatever Happened to Biomechanics in Podiatry?”¹ Dr. Romansky says this piece contains key concepts on the history and future of biomechanics in the specialty.

Dr. Langone concludes by reflecting on the history and future of biomechanics in podiatry.

“Biomechanics historically is what elevated podiatric medicine and surgery,” she says. “It is the backbone of our profession. It is impossible to treat a patient successfully for a wound or surgically without a thorough understanding of their biomechanics and an ability to address those biomechanical deficits.”

Through the years, Dr. Langone relates working very hard to develop an examination process that best gives her the information that she needs to successfully treat patients.

“It has been this devotion to complete biomechanical analysis that has led to my ability to successfully address foot pathology and its super-structural implications,” she explains. “It also is what should distinguish podiatrists from other practitioners who dispense custom foot orthoses. Our superior evaluation, understanding and knowledge of biomechanics sets us apart from others who utilize orthotic therapy. It is our professional responsibility to provide an exceptional level of expertise and therefore an elevated ability to help the patient. Our curriculum in schools and in postgraduate training needs to reflect the essential nature of biomechanics in podiatric medicine and surgery.” n

Dr. Romansky is a Diplomate of the American Board of Foot and Ankle Surgery and the team podiatrist for the U.S. World Cup and National Men’s and Women’s Soccer teams. He is a Major League Baseball podiatrist for Umpire Health and practices in Media, PA.

Dr. Canzanese is a Fellow and Treasurer of the American Academy of Podiatric Sports Medicine. She is a Diplomate of the American Board of Podiatric Medicine and a Certified Athletic Trainer. She practices in Glenside, PA.

Dr. Conenello is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is an Honorary Police Surgeon for the New York Police Department and the Clinical Director of Special Olympics New Jersey and practices in Orangeburg, NY.

Dr. Langone is a Diplomate of the American Board of Podiatric Medicine and a Fellow of the American College of Podiatric Medicine. She is a Fellow and Past President of the American Academy of Podiatric Sports Medicine, and the current President of the American Association for Women Podiatrists. She practices in Southampton, NY.

Reference

1. Kirby KA. Whatever happened to biomechanics in podiatry? Podiatry Today. 2021;34(11). Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/forum/whatever-happened-biomechanics-podiatry . Accessed March 14, 2022.