A Conversation with Keith L. Gurnick, DPM
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Podiatry, biomechanics, orthotic laboratories, teaching, and the art of treating the whole patient
Interviewed by Kevin Rosenbloom
Edited for length, clarity, and readability from a Zoom conversation.
Dr. Keith L. Gurnick's path into podiatry began as a young runner in Los Angeles. Long before he became known for biomechanics, orthotics, teaching, and a comprehensive approach to patient care, he was a student-athlete dealing with the same kinds of overuse injuries that many patients still bring into podiatry offices today.
A sports podiatrist took the time to watch him run, evaluate his shoes, and treat the larger cause of his pain. That experience left an impression. Decades later, Dr. Gurnick still returns to the same principle: do not treat a diagnosis code; treat the person standing in front of you.
In this conversation, Kevin Rosenbloom speaks with Dr. Gurnick about his entry into the profession, his mentors, his experience with orthotic laboratories, the evolution of biomechanics, his teaching at Cedars, and the lessons he hopes younger podiatrists carry forward.
"You are not treating a wart. You are treating a patient."
From Runner to Podiatrist
Kevin Rosenbloom: Keith, what originally inspired you to become a podiatrist?
Keith Gurnick, DPM: I was a runner in high school, and I actually started running in junior high. A physical education teacher noticed me after I ran a fast time in a 660-yard trial, and that pulled me into running.
By high school I was competing in cross-country and track, mostly middle distance. I was also dealing with soft tissue injuries - shin splints, tendonitis, and the things runners get when they train hard. At one point my shin splints were bad enough that I was taken to see an orthopedist, but the visit did not really help me.
Eventually I saw Dr. Bob Barnes, a sports podiatrist in Burbank. He took me outside, watched me run, looked at my shoes, and gave me practical things to do - stretching, icing, staying off hard surfaces, avoiding sprinting for a while. My shin splints went away and never really came back. That was my first experience with a podiatrist, and it stayed with me.
A few years later, when I was at UCLA, I met another podiatrist, Dr. Jack Taubman, through someone I was dating. I spent time in his office, watched him do surgery, and saw how much his patients appreciated him. I was a biology major looking for a direction, and podiatry gave me that reason to be.
Kevin Rosenbloom: Who were some of the people who influenced you early in your career?
Keith Gurnick, DPM: I was fortunate. After graduating from CCPM, I had the opportunity to do a two-year comprehensive residency program in Los Angeles. Before that, as a senior student, I spent time in the office of Root, Weed, and others. John Weed had lectured to us on biomechanics, so I knew him as a biomechanics authority. But when I spent time in his office, I saw that he was also an excellent general podiatrist. He trimmed corns and calluses, saw children and adults, did surgery, and took care of patients broadly. That made a big impression on me.
During that era, the running boom was taking off, and orthotics were becoming more common. I also learned from people like Harry Hlavac, Steve Subotnick, Sheldon Langer, and others who were helping shape sports podiatry and biomechanics. At school, we worked in what was called the Mechanical Orthopedics Lab, and we learned to make orthotics ourselves. That is where my early interest in biomechanics and orthotic fabrication started.
Building a Practice by Taking Care of Families
Kevin Rosenbloom: Tell us about the way your practice developed.
Keith Gurnick, DPM: When I finished residency, I wanted to be busy. I believed then, and still believe now, that you have to see enough patients and do enough of what you do in order to become good at it and stay good at it.
Early in my career I saw a lot of children. During residency I spent time in clinics in Baja, including crippled children's clinics in Mexicali and Tijuana. We saw clubfoot, metatarsus adductus, spina bifida, orthotics, casting, and many pediatric problems. When I started practice, I realized that if you want to build a busy practice, take care of children. If you take care of the kids, you eventually take care of the parents, the siblings, and later the grandchildren.
That is what happened. I went to pediatricians, introduced myself, and built relationships. Over time, the practice became multigenerational. I still see children, but as I have gotten older, the practice has naturally shifted older too. Today it is a broad general practice. I do not exclude much, but I focus on the areas where I feel I can help patients well.
Kevin Rosenbloom: What do you think separates your approach from a more problem-focused visit?
Keith Gurnick, DPM: I try to treat the whole patient. That was something Sheldon Langer emphasized and something I have always remembered. A patient does not come in with just a heel spur or just plantar fasciitis. A person comes in with pain, and there may be multiple reasons for it.
Insurance companies reduce people to codes. You can have one hundred patients with the same diagnosis code for plantar fasciitis, but they are not the same person. One may be a cashier standing all day, another may be a marathon runner, another may be a truck driver, and another may be a golfer. The diagnosis may be the same, but the person is not.
When I teach residents, I tell them not to say, 'There is a wart in room three.' There is not a wart in room three. There is a patient whose chief complaint may be a wart. Watch them walk. Check pulses. Do muscle testing. Look at limb length. Examine the patient. You may not do everything in one visit, but you should never forget that the person is more than the presenting problem.
Kevin Rosenbloom: You mentioned the first visit as a very important moment. Why?
Keith Gurnick, DPM: I call it the golden visit. For a heel pain patient, for example, the first visit is where you have the greatest opportunity to explain what is happening. Many patients come in looking for one thing - an injection, an orthotic, a tape job, a cream. But heel pain is often not one thing, and it usually is not fixed by one thing.
If you do not take time at that first visit, the patient may leave thinking the treatment failed when really they were never educated about the process. A good first visit sets expectations, builds trust, and helps patients understand why treatment may include several steps.
Career Reflections and Memorable Patients
Kevin Rosenbloom: Looking back, what accomplishments are you most proud of?
Keith Gurnick, DPM: Some of the things I am most proud of may sound unusual. They are not always the most technically complicated procedures. Sometimes they are the moments where being thorough helped someone in a way none of us expected.
I have had patients sent for preoperative evaluations where something serious was discovered before foot surgery. I have had someone in the room with a family member ask me to look at a lesion, and I urged them to see a dermatologist because it looked concerning. It turned out to be melanoma. Those moments remind you that you are a doctor first, and you have to pay attention to the whole person.
It is interesting. Sometimes you receive the biggest thank-you for what seems like a small thing. Patients may bring gifts for something that did not feel complicated medically, while the more complex things may not be appreciated in the same way. But what matters to patients is not always how difficult something was for the doctor. What matters is whether it helped them.
Kevin Rosenbloom: If you could give your younger self one piece of advice, what would it be?
Keith Gurnick, DPM: I would tell myself to have less stress, not to sweat the little things, and never to lose my composure. When you lose your composure, they win and you lose.
In practice, there will always be little things - an orthotic adjustment that takes too many visits, a patient who does not remember the conversation you already had, a beautiful surgery where the patient focuses on something small. You have to learn what matters and what does not. Do good work, treat people well, and let some things go.
Biomechanics, the First Ray, and the Art Within the Science
Kevin Rosenbloom: What do you think clinicians misunderstand about biomechanics today?
Keith Gurnick, DPM: I wish there were more education dedicated to the first ray. Podiatrists, and really anyone who treats people who walk, need to understand how the first ray is supposed to function. We take care of people who move. We are in the movement business.
The first ray has to bear weight during stance and then move properly for propulsion. The first metatarsophalangeal joint is not simply a hinge joint. It is a gliding hinge joint. The sesamoids have to glide forward, and the first metatarsal has to plantarflex in order for the joint to work properly. If that motion is limited, the joint can jam, and patients may develop pain or progressive arthritic changes. Over time, 1st MPJ pathology can also contribute to altered gait as patients compensate for pain or restricted motion.
Kevin Rosenbloom: When you think about biomechanics broadly, what principles have stood the test of time?
Keith Gurnick, DPM: In general, you are trying to improve function and reduce excessive motion where it is contributing to symptoms. If a foot overpronates when it should not, you try to reduce that overpronation. If a foot oversupinates when it should not, you try to reduce that as well. But you have to take into account the patient's symptoms, activity, shoes, joints, and all the mechanical factors you can evaluate.
There are also things that are difficult to treat non-surgically. Equinus and sagittal plane limitations are very challenging. Tight hamstrings influence posture, stance, and gait. Ligamentous laxity can be difficult. Orthotics can be very helpful, but the more you practice, the more you realize that biomechanics is not just a formula. The science has a lot of art in it, and experience matters.
Kevin Rosenbloom: How has your thinking changed over the years?
Keith Gurnick, DPM: I have become less aggressive surgically and more conservative. When you are earlier in practice, you may want to do more surgery because you want to prove yourself. As you gain experience, you become more comfortable doing the cases that need to be done and referring the cases that are better handled by someone else.
The same kind of maturity applies to orthotics. You learn that the least you can do with an orthotic to treat the condition is often better for compliance. The more you add to the device - deep heel cups, full covers, pads, extensions - the more you may limit shoe fit and how many hours a day the patient can use it. Sometimes a frame is enough. Sometimes you can add more later.
Orthotic Laboratories and the Importance of Individualization
Kevin Rosenbloom: You have worked with many orthotic laboratories and even operated your own lab. What did that teach you?
Keith Gurnick, DPM: I started making orthotics in podiatry school to make some money. During residency I had a garage lab, and later my partner and I opened a lab in Los Angeles from 1982 to 1986. At the height of that lab, we were making about 125 pairs of orthotics a day. For a small lab, that was a lot.
The difficulty was that running the lab did not give me enough time to practice. If you want to grow a lab, you have to be committed to the lab. If you want to be a doctor, you have to be committed to being a doctor. It was hard to do both well.
Even after I stopped making the orthotics myself, I continued consulting for labs for many years. I reviewed casts, spoke with doctors, and helped with prescriptions. The doctors who took good casts, did good examinations, and still wanted input were the ones where you could really make the product better.
Kevin Rosenbloom: What mistakes do laboratories commonly make?
Keith Gurnick, DPM: One of the biggest problems is symmetry. Feet are not symmetric. They are often different in length, width, shape, and function. Yet many labs have a tendency to make left and right devices look like mirror images because symmetry looks clean and reduces remakes.
But if one foot is different from the other, the orthotics should reflect that. If a patient needed a left AFO for drop foot, no one would assume the right side should match. I have always believed that left and right orthotics should be treated as individual prescriptions, not simply two halves of the same order.
Kevin Rosenbloom: What makes you trust a laboratory?
Keith Gurnick, DPM: Consistency matters. So does having people you can talk to. A good lab has people who understand materials, shoes, activities, and patient needs. They can help a doctor choose polypropylene, polyethylene, carbon, leather, a particular top cover, or a specific accommodation for a specific reason.
The lab should not just manufacture what is checked on a form. The best labs support the doctor and help the patient get a better device.
Kevin Rosenbloom: How has orthotic manufacturing changed?
Keith Gurnick, DPM: The improvements have been dramatic. Anything that can reduce waste, reduce unnecessary labor, eliminate plaster when appropriate, and make communication more efficient can be positive, as long as quality and individualization are maintained.
I am not excited about technology just because it is fast. For example, I am not excited about 3D printing if the only benefit is that the patient gets an orthotic quickly. Most patients do not need an orthotic immediately. The orthotic is not usually the acute treatment. It is part of the long-term management plan that holds correction and helps maintain function. If 3D printing allows better rigidity, flexibility, torsion control, and individual design, that is a different discussion. But speed alone is not the goal.
Shoes, Technology, and the Reality of Injury
Kevin Rosenbloom: You have lived through a major evolution in athletic footwear. What stands out to you?
Keith Gurnick, DPM: Shoes today are far superior to what we had years ago. I ran my first marathon in Adidas Gazelles, which today would be considered more of a fashion shoe. Earlier running shoes were often simple and unforgiving. Materials, torsional stability, flexibility at the metatarsophalangeal joints, and overall shoe construction have improved tremendously.
At the same time, people will still get injured. A better shoe can help, but it does not eliminate injury. Not every injury is caused by a severe biomechanical abnormality, and not every foot that is not perfect needs to be corrected. There is a difference between perfect, normal, and within normal limits.
Teaching the Next Generation
Kevin Rosenbloom: You have taught many students and residents. What has teaching meant to you?
Keith Gurnick, DPM: The greatest pleasure is one-on-one teaching and small workshops with residents. At Cedars, I have been involved with teaching for a long time. We have residents who can go through a structured set of workshops - biomechanics, casting, prescription writing, and dispensing.
A biomechanical evaluation includes gait analysis, non-weight-bearing and weight-bearing examination, range of motion, muscle testing, stance measurements, and limb length evaluation. Everybody gets a limb length check. I also measure feet often, because many people wear shoes that do not fit properly. Patients like when you measure their feet. It shows that you are paying attention.
Kevin Rosenbloom: Do former students still reach out to you?
Keith Gurnick, DPM: Yes, and I am proud of that. We have had excellent residents who have gone all over the country. They will email x-rays, ask about a complication, ask about a wart in an immunocompromised patient, or ask for advice on something that may not even be biomechanics.
One of the nice things about our profession is that we can be eclectic. We can learn from everybody. I still reach out to colleagues when I want opinions. Nobody is the best at everything. Some people are very good at many things, and some people are exceptional at a few things. You should be willing to learn from all of them.
Kevin Rosenbloom: What should young podiatrists understand that may not be emphasized enough?
Keith Gurnick, DPM: They are bright and they get a good education, but I wish there were more emphasis on bread-and-butter podiatry. Many young doctors come out wanting to be surgeons or wound care specialists, and there is nothing wrong with that. But the profession is broader than surgery and wound care.
A podiatrist is the neurologist, radiologist, vascular doctor, orthopedist, dermatologist, and biomechanist of the foot and ankle. None of those things are exclusive to us, so we have to do them better than anyone else. We should be better at trimming a corn, doing an ingrown nail procedure, taping a foot, reading the foot x-ray in context, and making orthotics. That is how the profession maintains its value.
The Future of Podiatry
Kevin Rosenbloom: Where do you think podiatry will be in ten years?
Keith Gurnick, DPM: I think podiatry will be in a similar place clinically, but the practice model will continue to change. More podiatrists will work in the VA, large medical groups, HMOs, and multispecialty organizations. There may be fewer independent doctors practicing in the style I have practiced - one doctor taking care of patients one-on-one in a community office where people know you.
But there will always be podiatry because podiatry is hands-on. You can try to do podiatry through AI, Zoom, or remotely, but you cannot do it well that way. We touch our patients. They take off their shoes, and we examine their feet, legs, gait, shoes, and sometimes posture and back. When a patient lets you touch them, you develop a relationship. That is central to what we do.
Kevin Rosenbloom: What advice would you give young practitioners entering the profession?
Keith Gurnick, DPM: It takes a long time to get busy. Always do what you believe is right. Never do what you think is wrong. Never do what a patient wants you to do when you know it is not the right thing to do.
People often say to treat every patient like family. I would go one step further: treat them better than family. Patients appreciate what you do when you take care of them well. And when it is all said and done, try to balance your practice with your family life, your social life, and your own enjoyment of life. You want to look back and feel that you did good for people.
Rapid Fire
Kevin Rosenbloom: Custom orthotics or prefab?
Keith Gurnick, DPM: Individualized for the patient. Some patients do well with prefabs, and some absolutely need custom prescription orthotics. There are decent prefabs today that we did not have years ago, but the decision should be based on the patient.
Kevin Rosenbloom: Favorite biomechanics book?
Keith Gurnick, DPM: The Compendium, also called The Compendium of Podiatric Biomechanics, by Tom Sgarlato. People do not read it as much anymore, but it was important. I was fortunate to meet and work with people from that era, and younger clinicians do not always get that opportunity.
Kevin Rosenbloom: Coffee or tea?
Keith Gurnick, DPM: Neither, really. If I drink coffee, it is decaffeinated. I do not do well with caffeine. If you think I talk a lot now, imagine me on caffeine.
Kevin Rosenbloom: Beach or mountains?
Keith Gurnick, DPM: Mountains. I was in the Boy Scouts and worked at camp for many summers teaching camp craft, hiking, tents, fires, and outdoor skills. My long answer is mountains.
Kevin Rosenbloom: Morning person or night owl?
Keith Gurnick, DPM: Morning person. My father was in the wholesale produce business, and it was not unusual for him to work at midnight. My brothers and I worked in that business when we were kids, so I learned to get up early.
Legacy
Kevin Rosenbloom: After everything you have accomplished, what do you hope people remember about you?
Keith Gurnick, DPM: That, for the most part, I was a nice, decent guy who never claimed to be better than anybody else. I tried to work hard and do good for my patients. I also hope my family knows that the hard work was part of giving them a good life.
Kevin Rosenbloom: If someone wrote a chapter about your contribution to podiatry, what would you hope it said?
Keith Gurnick, DPM: I am hard on myself. Part of me would say I did not do enough. There are only so many hours in the day, and there is always more you could give. But at some point, you also have to know when enough is enough. You give what you can, you try to help people, and you try to do it the right way.
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