The Results are in.... You Make the Call! - Case Study: Weeping Atrophic Skin Lesions
The case presented last week was a difficult one. You'll see below that there were quite a differing of opinion as to what the proper diagnosis is. Here are the survey results:
|
|
| |
Robert Frykberg,
DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage
|
Biomechanics – Remember Your Roots!
Happy New Year to you all! With the New Year under way, I thought that it would be appropriate to redirect you back to one of the core precepts of Podiatry – that being Biomechanics. I know, you are all in that great quest to become Podiatric Super Surgeons- some of you prefer to call yourselves Foot and Ankle Surgeons. While that certainly may be true (depending on which State you practice in), never forget the “roots” of Podiatry. Roots seems to be an appropriate word in this regard, since Dr. Merton Root, a legendary Podiatrist, is considered to be the “Father” of Podiatric Biomechanics. While not a trained scientist, he was a keen observer of the mechanics of the foot in the “normal” and pathological states. Much, if not most of what you learned in Podiatry School in the area of biomechanics came from his teachings- to many of our own instructors and Professors. Although some of his theories and principles as espoused in the “Compendium of Podiatric Biomechanics” by Tom Sgarlato have come under scrutiny in recent years, most of his theories remain at the center of foot biomechanics today. I had the opportunity to have Dr. Root lecture to my class when I was a first year Podiatry student many years ago. At that time, I probably could not appreciate that opportunity. But I did have the pleasure of being taught by one of his closest disciples – John Weed, DPM (now deceased). Dr Weed was a gifted biomechanist (I called him a “biomagician”) who had an intimate knowledge of the mechanics of the foot- he knew it so well that he thoroughly confused us during each lecture!
We would come out of those classes with our heads spinning! But indeed, we learned podiatric biomechanics in its greatest details. Anyone coming out of CCPM in those days could not help but to have a good understanding of this discipline – it was in our upbringing, so to speak.
I never considered myself to be a real biomechanics aficionado. In fact, I rather disliked the variability in measurements that several different examiners would obtain with the evaluation of the same foot. Hence, my use of the term “bioimagination”. I, like many of you, preferred to concentrate on surgical management of the foot, while putting biomechanics on a second shelf. It was interesting (although disconcerting) in my residency interview when I made the reply to a long forgotten question that I really didn’t like biomechanics very much. What do you think I was grilled on during the second round of questioning? Of course, Biomechanics in all its glory! Luckily, I was prepared, because of my education in this regard. I also remember stating, “ I said that I didn’t really like biomechanics. I didn’t say that I didn’t know my biomechanics”. I got the job. The point remains that the very essence of Podiatry is podiatric biomechanics – that’s what makes us the profession we are and distinguishes us from other specialties performing the same services that we provide.
More to the point, you should all be aware that previous and current requirements for Podiatric Residencies (PMS-36 and PMSR) stipulate that a certain number of biomechanical examinations must be performed and logged during your training. Although the former residency format was more rigorous in this regard, the new PMSR program requires a minimum of 75 biomechanical cases. Why do residents always put these requirements on the back shelf? Biomechanical exams should be a routine part of all your pedal examinations – this includes preoperative as well as postoperative evaluations, not just for flat feet, heel pain, or that nebulous “metatarsalgia”. In the course of your bunionectomy evaluation, put the first ray and hallux through a range of motion examination – loaded and unloaded. Is supinatus present? Examine that subtalar joint and the midtarsal joint- find the neutral position. Be sure to do an ankle examination for range of motion and quality of motion. Look for restriction in both plantarflexion and dorsiflexion, as well as dorsiflexion with knee extended and flexed. Look for equinus – it is fairly common. Have the patient stand and walk – note the position of the calcaneus and its motion in gait. Note the attitude of the arch, forefoot and rearfoot relationship, look for an abductory twist or early heel off. Look at the position of the knees, at the tibiae, look for tibial varum and genu valgum. Then evaluate your radiographs for clinical signs corresponding to clinical findings (break in the Cyma line, calcaneal inclination, talar- first metatarsal angle, midfoot faults, forefoot superimposition, etc.). Now you have done a cursory biomechanical examination that not only evaluates your patient’s foot function and status, but also qualifies as a biomechanical case once logged.
Most of you don’t realize that our Podiatric brethren from Australia, New Zealand, and the U.K. have carried on the torch for podiatric biomechanics to a much greater extent than we have here in the USA. They have made this the center of their practices and research projects. This imbalance is most likely due the growth of surgery in all of our practices here in American Podiatry. But we need to be sure that the discipline that distinguishes us is not lost from our practice. Constantly investigate underlying biomechanical function of your patients’ feet – it is often the primary cause for the presenting pathologies that you are seeking to treat or operate on. Do you really think that the hallux ulceration you are treating is due to an IPJ sesamoid or an exostosis? Have you not yet discovered that most are actually due functional hallux limitus?
Not only are biomechanical exams required for your training programs, they are essential components of your discipline. Remember your roots!
See you next time.
Robert Frykberg, DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage
 |
We at PRESENT love hearing from you. I would encourage you to share your experience, pearls, and wisdom on this topic, or on any other that you would like to share with our online community via eTak. Your continued participation is what makes this Web portal great! |
Get a steady stream of all the NEW PRESENT Podiatry
eLearning by becoming our Facebook Fan.
Effective eLearning and a Colleague Network await you. |
 |
This eZine was made possible through the support of our sponsors: |
Grand Sponsor |
 |
|
| Diamond Sponsor |
 |
|
| |
Major Sponsors |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
