By: Dr. Stephen Geller, Director, ABPM
Have you ever given someone something you thought would help only to find them using it in a completely unexpected manner? This is exactly what happened when the American Board of Podiatric Medicine provided residency directors with a full-page comprehensive biomechanical examination form. This checkbox form contained hip-to-toe measurements, both non-weight bearing and weight bearing, and in gait. The unexpected outcome was that these forms separated biomechanical examinations from the physical examination performed for most complaints. In reviewing these forms at residency on-site evaluations, there were inadequacies that led to misinterpretations of the examination findings or lack of supporting documentation for the given diagnosis.
CPME 320: Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies, (the document governing residency programs) contains multiple MAVs, including biomechanical examinations. These biomechanical cases are defined as: “…direct participation of the resident in the diagnosis, evaluation, and treatment of diseases, disorders, and injuries of the foot, ankle, and their governing and related structures by biomechanical means. These experiences include, but are not limited to, performing comprehensive lower extremity biomechanical examinations and gait analyses, comprehending the processes related to these examinations, and understanding the techniques and interpretations of gait evaluations of neurologic and pathomechanical disorders.” At no point does this definition state that a biomechanical examination is from the hip to the toe.
Patient’s present with a specific complaint and not all pathology requires a hip-to-toe examination to be comprehensive relative to the causative factors. Residency training is to impart advanced knowledge so that when in practice, the graduated resident will be able to perform pertinent aspects of the biomechanical examination and identify all contributing factors. This information is used to minimize risk of complications in plan of care. First year residents will be less familiar with the presenting pathology and require more guidance through a more thorough exam to identify those causative factors. A senior resident may require less guidance and identifies all causative factors much faster.
With the development of electronic medical records (EMR), the use of forms that are separate from the electronic documents is increasingly difficult. To bring the biomechanical examination into the physical examination where it belongs, EMR templates for pathology specific biomechanical examinations have been created. These templates consist of: Pes Planus; Pes Cavus; Hallux Valgus; Hammertoe, Lesser Metatarsal and Intermetatarsal Pain; and Proximal Examination. The templates are modular being combined to comprehensively evaluate the pathomechanics of a specific patient. For example, a patient complaining of neuroma symptoms with a low arch would begin with the Pes Planus template and where indicated insert the template for Hammertoe, Lesser Metatarsal, and Intermetatarsal Pain. If at the completion of this examination the findings do not fully explain the pathomechanics of the foot, then the Proximal Examination template is added.