Practical Biomechanics for the Podiatrist: Book 1

By Richard L Blake DPM MS, Carlos Martínez Sebastián, Joseph D'Amico DPM and Álvaro Gómez Carrión

Dr Blake outlines the basic principles that have governed his practice of podiatry, lower extremity biomechanics, and sports medicine for over 40 years. Along with these basic principles, he discussed in great detail the concepts of gait evaluation, and biomechanical examination techniques.

• Language: English
• Publisher: BookBaby
• Release date: Apr 17, 2022
• ISBN: 9781667827629

Book preview

Chapter 1: Introduction to the General Principles

This chapter concerns some general information about the book and some general rules that govern my practice. They include:

1. Utilizing this Book in Developing Plan B

2. Purpose of Book

3. General Book Topics

4. What classifies as Podiatric Biomechanics

5. Is This a Book about Orthotic Devices or a Specific Theory?

6. Biomechanics in a Nutshell

7. The Author’s Personal History

8. More About Rules

9. Phases of Rehabilitation

10. Keep it Simple (whenever possible)

11. Slight Changes at the Foot can make Big Differences

12. Sources of Pain

13. Rule of 3

14. Occam’s Razor

15. Treat Asymmetry

16. How Much Correction? And Where Do We Start?

17. Standard Biomechanical Treatment

Utilizing this Book in Developing Plan B

Welcome to Practical Biomechanics for the Podiatrist which is the accumulation of my 42 years of being a practicing podiatrist in the fields of biomechanics, sports medicine, and general lower extremity rehabilitation. I have been privileged to practice in a multi-discipline center with orthopedists, sports medicine MDs, physiatrists, physical therapists, and dance medicine specialists. I also trained under top biomechanical specialists and focused on the mechanics of injuries, which help in overall rehabilitation, cause reversal, and hopefully prevention of recurring injuries. I went into practice with one of the top orthopedists in the world Dr. James Garrick in the field of rehabilitation of injuries which continued my early training. I have learned that the mechanics of any injury or pain syndrome can be either complex or rather quite simple. I hope I can give the reader the tools for either beginning a practice based on mechanics or improving the ones they already have. Please feel free to use any of the information for developing office handouts (see Chapter 18 in Book 4), EHR templates, or just reference. I have questions throughout the book with answers at the end of the book for self-study. I have a podiatry blog called drblakeshealingsole.com where the reader can get more information. The world of biomechanics and rehabilitation, in general, is wide and deep and will be practiced by everyone differently due to our disciplines, training, and experience. The goal of this book is to make you see things you didn’t look for previously, or maybe allow you to think about it from a little different viewpoint. Thank you for joining me in this fascinating and ever-changing world of biomechanics.

I once did a review article on legitimate treatments for plantar fasciitis. I found 72 treatments that help plantar fasciitis which almost all fell into 3 categories: mechanical, inflammatory, or flexibility. All practitioners are limited by your disciplines to some degree, but there are so many ways to help patients. I have definitely found what helps one patient may not help another at all. The average practitioner will offer the patient about 5-6 treatment options within the first 3 office visits. So, when the patient is not improving in their treatment, or hits an impasse in some way, there may be many other options available that you can learn. This book will definitely help your initial treatment for injuries or pain syndromes, but probably help you the most with developing a Plan B or C or D when the injury is not improving dramatically.

Practical Biomechanics Question #1: What position is the ankle in when it is the most relaxed, or the least stressed?

Practical Biomechanics Question #2: What are the 3 Phases of Athletic Rehabilitation that we help patients work through to get well?

Purpose of Book

The purpose of this book is to train the next generation of podiatrists, and those interested in this field, on how to think mechanically about the problems that our patients have in terms of cause, cause reversal, and treatment options. During these last 4 writing years, I have traveled to Toronto, Canada, Santiago de Compostela, Spain, Charlottesville, Virginia, and New York, New York, and I found great excitement to learn biomechanics in many young podiatrists and podiatry students. I also teach part-time at the California School of Podiatric Medicine at Samuel Merritt University, Oakland, California, as a guest lecturer, and I am so excited about the enthusiasm of the students. The next generation of podiatrists will create some of their own rules fueled by new technologies, and thoughts, and their own experiences. I have loved my sports and biomechanics practice, and with all the different sports out there, it has been and will always be challenging. I hope to keep some of the past thoughts alive as the pace of the human race speeds forward with the speed of light. This book is more about how to think through a problem mechanically, than exactly what to do, although I will have many examples of treatment options. Most overuse injuries have a mechanical cause(s) and discovering that cause or causes will help in the treatment and prevention of the injury. This is of vital importance to the longevity of an athletic career. Finding the weaknesses of a patient through an analysis of why they got injured, for every injury that they get, and correcting those weaknesses with simple or complex measures, will help patients stay active. And, luckily this patchwork of health management can be pieced together over a long time.The healthcare provider is mending the weak links of a patient. I will have my own approach to problems but will emphasize the thought process involved. In a minute, we will discuss the causes of pain with mechanical pain as only one of them. I must emphasize that there are mechanical causes of any injury, and just mechanical treatments to help an injury, or both. If we take any injury or pain syndrome, some of our mechanical treatments will be reversing the actual cause of the injury (and these should remain in the patient’s maintenance program), and some of our mechanical treatments will just be helping the phase of rehabilitation that the patient is presently within (like placing a cam walker on a patient during the Immobilization Phase of an injury).

Here A Patient is in the Immobilization Phase with A Removable Boot and EvenUp on the Opposite Side

Practical Biomechanics Question #3: What are the 3 main sources of the actual pain that patients feel?

Practical Biomechanics Question #4: What can be the mechanical cause(s) of lateral ankle pain?

General Book Topics

This book is divided into chapters of varying topics to make the reader more aware of the key points in evaluation and treatment. It is important to note that for an individual patient, one treatment may be more effective for them than with another patient (A cluffy wedge may be helpful for a sesamoid injury in one patient but not help another). This is why your treatments must be tailored to keep the symptoms within a healing range of 0-2 pain level. This forces us to continue to experiment with different treatment options to achieve this goal. We have to follow the patient carefully and make sure our treatments are successful with at least monthly visits. If the patient is not getting better, it is time to make changes, even to go to Plan B if that has been formulated. I always expect to improve month by month as I follow them.

The topics included in this book are:

1. Introduction to the Book and General Principles

2. Basic Approach to Patients (with an emphasis on Biomechanics)

3. Gait Evaluation Findings and their Meaning

4. Basic Components of a Lower Extremity Biomechanical Examination

5. General Mechanical Changes for Various Injuries (Foot to Low Back) from a Podiatrist’s Standpoint

6. Various Theories and Their Role in Treatment

7. Various Mechanical Syndromes

8. Custom Orthotic Designs and Components

9. The Role of Shoes and Modifications

10. Specific Examples of Treatment (Foot to Low Back)

11. Examination Questions for Self Testing

12. Common Office Handouts in a Biomechanics Practice

13. Index

Practical Biomechanics Question #5: What is so sacred about maintaining a patient within a 0-2 pain level?

Practical Biomechanics Question #6: If a patient’s injury necessitates a removable boot (cam walker), but the pain remains around 6-7, what additional steps are needed in this treatment?

What classifies as Podiatric Biomechanics?

The world of biomechanics from a podiatric standpoint has changed in the last 40 years and I hope is well reflected in this book. Biomechanics is more than the foot orthotic devices we place in shoes for some purpose or purposes. Biomechanics from a podiatric standpoint is about custom orthotic devices, shoe gear, numerous shoe inserts like wedges and over the counter arch supports, gait motion whether normal or abnormal, motion performing a certain activity, gait changes from surgery like knee replacements or bodywork or PT guided programs, muscle strength and flexibility issues, good or poor training techniques, training errors, taping, bracing, immobilizing, and so much more. Biomechanics is the understanding of the body’s mechanics and what makes it work and what makes it fall apart and become injured. It is more than just walking, but it's running, dancing, side to side motions on a basketball or tennis court, the landing in ice skating, the edging in downhill skiing, and much much more. Some podiatrists are really interested in the sports side of it, or the various injuries you can treat, or correcting problems seen at a young age. Dr. Merton Root and colleagues developed and tested the early biomechanical principles on only a walking population and had great success. Yet, these principles did not apply to running and other sports. And, there are plenty of activities that still need to be studied extensively. There is plenty to learn. Learning biomechanics takes a serious study into the human body, and a love of what it can do, and a deep respect for its function and vulnerabilities.

The Biomechanics of Running is Complex and Its Treatment can Allow for a Successful and Lengthy Career

Any podiatrist that has an interest can easily learn the biomechanical principles that affect their daily practice in treating patients with injuries or complaints, or with biomechanical deformities like juvenile pes planus, or with special interests in running biomechanics, dance biomechanics, cycling biomechanics, skiing biomechanics, to name only a few. Of course, sports that have repetitive motions can be easier to study then the sports with a marked variety of motions and speeds. When you add sports that include high speeds and/or the possibilities of collision/contact, the epidemiology of injuries can be quite complex. The list of sports that one can specialize, and really make a difference, is innumerable. Sports biomechanics is a fun practice and typically full of very dedicated athletes that will do their treatment plans. Your part of the overall plan of an elite athlete may be to help them walk again after a severe injury, or the mechanics of their golf swing with respect to their foot position. You may even specialize in age groups, like youth or college sports, or the elderly. Every group will have their own demands, their own rules, that you can help and teach. If you want to work with a specific group, become the expert on the mechanics or problems of that group. A podiatrist practicing biomechanics really can become a wonderful beloved teacher as you instruct thousands on staying healthy through sound biomechanical principles. These principles affect every aspect of treatment during the 3 phases of rehabilitation from immobilization, to re-strengthening, and then return to activities. These principles can affect them their whole lives. You have made a positive impact on their health.

Practical Biomechanics Question #7: Why are repetitive motion sports easier to help then continual direction change sports?

Practical Biomechanics Question #8: In a runner, what is the most important area of the foot to stabilize?

Is This A Book About Orthotic Devices or A Specific Theory?

The answer to that question is both yes and no. I am Root trained, whose theories have guided me for over 40 years with great success, yet I have tried to learn what every orthotic technique was attempting to do, and every theory on biomechanics and pain is attempting to explain (like should we be using orthoses at all). Some techniques on the surface seem so off when I first hear them, but someone has a passion for it, and has seen some truth in it, so I try to see what that truth is. Could it be better than what I offer some of my patients and therefore fit into my practice of biomechanics in some way? Where are its weaknesses and strengths? Which type of patient or problem could benefit from this technique or thought process? How do I learn the technique or better understand the theory? Why are other doctors prescribing it? In treating your patients, you will have your standard approach in regards to biomechanics, rehabilitation, and the place for orthotic devices. But if the patient is not improving, can a different orthotic technique help, or just a different way of looking at the problem? One thing you will learn in this book, and in the practice of medicine, is that there are multiple ways of treating someone to get to the same place. This art is in every profession so there is no reason to worry about not having the correct answer to a problem every time. The goal is to get someone better, and then prevent re-occurrences. Some problems require an exactness to scientific principles, while others do not. Some problems only require a slight shift in mechanics here or there. There are too many orthotic techniques for me to get good at as a practicing podiatrist, but that does not mean they do not have great validity. So, when a patient is not improving, I typically will try several other techniques (including more or less correction of motion, more shock absorption, full length vs typical length, etc.), or try to think outside the box for other solutions. Was I treating a neuropathic problem with only mechanical means for example? If my approach does not work, I am happy to refer to someone, or get advice from a lab, with a grasp of something possibly different. The orthotic principle for any podiatrist is that you should have your standard stabilizing orthotic device, one or two modifications for more pronation force, one or two modifications for more supination force, several soft based orthotic modifications for more shock absorption, and a full length design. For many patients I need to make two or three orthotic devices for the right or left or both feet until I can figure them out. I hope every patient understands I will give it my best.

The Soft Based Hannaford Device with Plastazote is the Ultimate Full Length Soft Orthotic Device

Practical Biomechanics Question #9: Why isn’t there one biomechanics theory that governs the discipline of podiatry?

Practical Biomechanics Question #10: What five main types of functional foot orthotic devices are commonly prescribed?

Biomechanics in a Nutshell

I practice a process where slight changes can make a difference in one patient, and only large changes can help another patient. When evaluating and treating a patient, the biomechanics can get to the root cause for both faster rehabilitation, help in the overall prevention of the injury’s re-occurrence, or simply help manage the problem. Biomechanics may have all, some, or nothing to do with the problem, but can be utilized to help in the treatment. Remember to always address the 3 sources of pain: mechanical, inflammatory, and neuropathic. I remember a young female patient with significant bunions around 32 years old, mother of 3. She came in to have her bunions removed since she could only fit 2 of her 75 pairs of shoes, some quite expensive. We talked about her age, the length of time normal bunion surgery lasts before needing a redo, and then I gave her a sheet of ¼ inch adhesive felt to apply just behind the bunion joint to offload it while wearing shoes. We talked about a lot more treatments, but she called me so excited 4 days later telling me with the pad she was able to wear 45 pairs of shoes comfortably. This is the heart of biomechanics where simple ideas, like offloading a sore spot, can start a treatment towards health. Will she eventually need the surgery? For sure! But, there are many things you can learn about a patient, and about what treatments work or don’t, if you start with conservative treatments of mechanics, anti-inflammatory, and neurological.

Here ¼ inch Adhesive Felt Off Weights the Sore Bunion (Simple Biomechanics at its Best)

In practicing biomechanics, with every patient you should do the following:

1. Learn the mechanics of what happened that caused the injury or pain to develop. This can take many visits to see how they function and what treatments help them. In this world of constant videos, sometimes it will take them emailing you a video of what they do in their sport.

2. Get an early sense of their overall biomechanics: flat feet, high arches, duck walk, equinus forces, weak or tight muscles, limb length difference, pronatory or supinatory patterns, poor shock absorption, etc.

3. Learn the more detailed biomechanics of the injured part of the foot (for example, do they have a plantarflexed first ray and a sesamoid injury, early heel off due to short leg causing Achilles tendonitis, pes cavus and tight plantar fascia with fasciitis, etc.)

4. Consider how strengthening or flexibility work can improve the situation (for example how tight achilles can cause more forefoot pain, or how heel valgus with a weak posterior tibial tendon can lead to lateral ankle impingement or sinus tarsi syndrome, etc.)

5. Consider how some common simple biomechanical tools can help an injury (for example, off weight-bearing padding, varus or valgus wedging, taping, bracing, shoe inserts, lifts, heels vs flats, rockers in shoes, more stiffness vs more cushion in shoes, more depth in the toe box, lacing variations, etc.)

6. Learn when problems are either not mechanical, or at the time of the current visit, need more inflammatory or neurological treatments.

7. Early in your treatment (usually within the first 2 visits) get the patient into a healing environment (consistent level 0-2 pain) by properly placing them into the correct phase of rehabilitation. For example, when excessive supination gait pattern causes a fibular stress fracture, you must immobilize before you really address the over supination cause (could be many visits down the line).

Practical Biomechanics Question #11: As you evaluate an injury, it is imperative that you know where the stresses to that injury are coming from with the help of your knowledge of biomechanics. Why must we reduce a tight achilles tendon when the patient has metatarsal symptoms?

Practical Biomechanics Question #12: The KISS principle (Keep It Simple Stupid) is so easily applied in biomechanics on a daily basis. How can you take immediate stress off tarsal tunnel syndrome on your first visit when the heel is everted to the ground using the KISS principle?

The Author’s Personal History

My personal credentials for writing this book include:

•Fellowship Podiatric Biomechanics California College of Podiatric Medicine

•11 years head of the sports medicine class California College of Podiatric Medicine

•Past President, American Academy of Podiatric Sports Medicine

•National and International Lecturer in Podiatric Biomechanics

•Past Special Editor, Sports Medicine, Journal of the American Podiatric Medical Association

•Inventor of the Inverted Orthotic Technique used internationally

•Author of over 50 Published Articles on Biomechanics and Sports Medicine

•Author of 2 books entitled Secrets to Keep Moving and The Inverted Orthotic Technique.

•40 years of teaching at the California College of Podiatric Medicine (San Francisco, Ca) and California School of Podiatric Medicine (Oakland, Ca)

•Diplomate, ABMSP, Podiatric Sports Medicine

The science and art of biomechanics has fascinated me throughout my career. I was trained by some of the best biomechanical thinkers of the 1970s: Drs Merton Root, John Weed, Ron Valmassy, Chris Smith, Robert Phillips, and John Marzelik. This was also an exciting time where new ideas were exploding in the field of sports medicine. As I started developing the Inverted Technique, my contemporaries, including Drs Robert Daryl Phillips, Dennis Burns, Kevin Kirby, Eric Fuller, Jane Denton, David Hannaford, Mathias Fettig, and Raymond Feehery, began to take current concepts and mold them into the new realities such as softer shoes and more elevated heels, and apply them in running mechanics, dance mechanics, and other various sports.

I have been so honored in my life to have friendships with Dr. John Weed, Dr. Merton Root and his son Jeff Root, Dr. Ron Valmassy, Dr. Jane Denton, Dr. Kevin Kirby, and Dr. Doug Richie who has and continues to shape my practice. I strongly recommend in this age of