Biomechanical Intelligence:

How Great Doctors Measure Their Patients and Get Extraordinary Results

As any doctor knows, medicine is both art and science

For some conditions there are precise tests that lead to a definitive diagnosis, but for many other ailments, it is a combination of multiple tests, coupled with the doctor’s past experiences and intuition that ultimately lead to diagnosis and identification of the etiology. In podiatry, the latter occurs more often than the former. Patients often have visited multiple medical providers and physical therapists, and tried over-the-counter relief before ultimately receiving a targeted treatment plan that addresses the functional etiology and successfully treats the pathology.

"Biomechanical Inteligence"

Article for podiatrym.com by Kevin B. Rosenbloom

Root Theories

In 1971, Merton Root et al published the seminal, “Clinical Examination of the Foot volume 1” and in 1977 published “Clinical Biomechanics Volume II Normal and Abnormal Function of the foot”. These works established podiatry as a validated clinical field within the medical community with millions of patients treated successfully using Root Theories.

Over recent years, the focus of podiatry education changed from biomechanics to surgical procedure. While educators still claim that understanding biomechanics is the foundation for understanding the “why” of surgical procedures, there is a shortage of podiatrists who are confident and capable of assessing patients’ biomechanics whether normal and efficient, or pathological and inefficient. Surveys and discussions have confirmed a significant lack of education in biomechanics and a similar lack of understanding of the related subjects of physics and engineering among podiatrists.

For two years, I shadowed and assisted the revered Lowell Weil Sr., DPM in clinic and surgery. I carefully observed the surgical procedures and conservative therapies provided to patients and the latest literature in various journals. It was evident that the biomechanical underpinnings behind conservative therapy, which had a stronghold during the 1970’s-1990’s, were largely overlooked by new fellows and podiatry residents who were focused on the latest surgical techniques, not the underlying biomechanical roots of pathology. Considering the growing hole I observed in biomechanical competency and understanding by new and young podiatric physicians, I shifted my career path from surgical treatments to conservative treatments believing there was a place for functional orthopedics and biomechanics to rise again, and began focusing on developing technology that could help physicians treat patients better.

For the past 15 years, I’ve worked on creating the Biomechanical Intelligence Quotient™ (BIQ™) as a Root 2.0 so to speak, a new way of evaluating patients to help doctors more effectively and efficiently identify many podiatric and biomechanical conditions by honing in on the etiologic biomechanical issues underlying the pathology.

Our research & development teams have produced methods of measuring and supporting your prescriptions that will assess your patients' entire biomechanics

The utility of BIQ

The utility of BIQ is well-demonstrated with plantar fasciitis, a painful inflammation that typically occurs from overuse or ripping / tearing of tissue. By doing a thorough BIQ exam, the clinician may discover that a limitation of internal rotation at one hip is creating an imbalance resulting in overuse of a kinetic chain that ultimately involves the plantar fascia tissue on the bottom of the foot. The diagnosis of plantar fasciitis was made using physical examination. The root cause of plantar fasciitis (limited internal rotation of the hip resulting in equinus, and ultimately plantar fasciitis) is discovered with a thorough BIQ exam. Addressing and treating the symptoms and pain of plantar fasciitis with calf stretches, ice water soaks, anti inflammatory medication and orthotics does help, but failure to identify and resolve the root cause limit the patient’s ability to find permanent relief. Using BIQ allows treatment aimed at the underlying biomechanical imbalance rather than the symptom alone, and tends to produce more definitive, long-lasting results and reveals to the patient a clear explanation of why they suffer from plantar fasciitis. In this case modifying patient gait and precise orthotic therapy provides mechanical neutrality from the hip to the foot and the foot to the hip. It’s important to understand that mechanics work in both directions, from hip to foot and foot to hip.

The Biomechanical Intelligence Quotient (BIQ) was born from my desire to help doctors better relieve their patient’s pain

This tool allows identification segment by segment of the tissue structures and biomechanical features underlying the pain and thus facilitates restoration of a more optimal alignment using gait training, shoe recommendation, orthotics, physical therapy and surgery.

The BIQ is an effective tool to assess the root cause of a wide range of conditions including complaints like plantar fasciitis, ankle and foot arthritis, tendon dysfunctions, hallux rigidus, and plantar plate pathology, knee pain, hip pain, shin splints, sesamoiditis, and Lisfranc injuries.

The Biomechanical Intelligence Quotient (BIQ) collects data about the patient’s lower extremities with the goal of providing comfortable ambulation and positive outcomes. The information collected includes the most crucial measurements of the bones, tendons, ligaments, and muscles comprising each joint, as well as the key measurements of the range and fluidity of each joint’s motility. When all measurements are completed, this data is then used to decide on an individual treatment plan.

The Old Way of Doing Things

While The American Board For Podiatric Medicine does provide a standard biomechanical exam template, there is no standardization for the values or ranges the examining clinician should use. As a result, there are no normative values, nor is there a way that responses can be collectively grouped together to produce data sets for research or artificial intelligence (AI) learning algorithms. With the data produced from BIQ, doctors will eventually be able to use AI to assist even further in diagnostic assessment. BIQ is designed to be a new standard to collect biomechanical data using a universal protocol.

The need for an updated standard protocol for biomechanical evaluation is evident considering the lack of standardized data collection. Other examination modalities (X-ray, CT, MRI, NCV lab tests) allow universal methods of data collection, organization, and analysis which have been adopted for AI. On the other hand, biomechanical data (bone shape, available joint excursions, quality of range of motion/flexibility) collection lacks standards, making high quality scientific analysis impossible.

BIQ incorporates established scientific ideas from the biomechanical literature along with clinical experience, ideas and practice. By normalizing data collection, BIQ will facilitate large-scale data analyses that may allow new correlations and patterns to emerge.

As more data is obtained, the analyses using BIQ data will become more reliable and validated, thus aiding our understanding of biomechanics and contributing to improved diagnosis, treatments, and outcomes.

The New Way-BIQ

BIQ is not a theory, hypothesis or a presumption. It uses the laws of physics, geometry, and engineering to reveal how tissue stress is applied throughout the body. Further, it facilitates identification of actionable changes that can be accomplished through lifestyle modifications, therapies, surgeries and environmental adaptations such as shoes and orthoses.

Prior to development of BIQ, patients were at the mercy of a wise physician, relying solely on a trained eye to evaluate a physical exam without standards. BIQ measures and analyses the phenotypic uniqueness of the human body. BIQ identifies the particular variables that affect loads and forces, helping to explain individual musculoskeletal pathology such as overuse or underuse conditions. BIQ allows doctors to target the root cause, not simply the symptoms.

“Using BIQ has made prescribing orthotics easy and has helped me better explain to my patients their pathology,” said James Judge, DPM. “It also serves as great documentation for follow-up and sharing notes with referring physicians.”

We combat pathology with functional strategy. Our philosophy is to focus upstream and eliminate pathology at the root cause.

KevinRoot Medical team

The BIQ Exam

The BIQ Exam is not only designed to create universal standards, but to also take into account the realities of running a profitable practice. The current American Board For Podiatric Medicine biomechanical exam requires about thirty minutes for a doctor to administer. The new BIQ Exam can be conducted in five to seven minutes. Additionally, a clinician can take that data along with scans or a cast of a foot and send it without a formal order form to an orthotics lab, allowing the lab to make decisions on orthosis design and construction based on the biomechanical and demographic data provided, saving the doctor even more time.

Prior to conducting the BIQ exam, clinicians record the patient’s height, weight, past pathological tissue. The clinical BIQ Exam has the doctor perform assessments that determine the structural morphology and available range of motion of a patient’s lower extremities.

The test can be performed sitting or standing in a standard exam room, and requires nothing more than a protractor, a non-gravitational goniometer, a measuring tape and, if available, a caliper. The acquisition of biomechanical data must be rigorous, with strict adherence to the established protocols. It is only with universal application that this growing data source can be used to to establish normative data, and to recognize patterns and correlations. That said, application of this data can, and should, be modified based on clinician experience and judgment.

Assessment Elements of the BIQ Exam

CONTENT BIQ 10 BIQ 24

ASIS Width (cm)

External Hip Excursion

Internal Hip Excursion

Genu Valgum/Varum

Tibial Varum

Foot Dorsiflexion Excursion

Foot Plantar Flexion Excursion

Subtalar Joint Eversion Excursion

Subtalar Joint Inversion Excursion

Talonavicular Joint Excursion

Cuneonavicular Joint Excursion

Metatarsocuneiform Joint Excursion

Metatarsal Head Mean Alignment

Midfoot Flexibility Test

1st Metatarsophalangeal Joint Excursion

Locate Subtalar Joint Axis

Mark Callus

Weight-bearing Foot Anatomical Structure

Foot Heritage Type

Morton's Foot (Longer 2nd metatarsal)

Kevin's Angle

ASIS to Distal Hallux (cm)

Genu Recurvatum

Brannock Shoe size

ASIS breadth and the AAA

The anterior superior iliac spine (ASIS) is the central point of reference for the BIQ. ASIS width demonstrates how the core of the body resets on the locomotive lower extremities and sets the biomechanical foundation for an individual's lower extremities by defining the origination of all ipsilateral downstream bones and muscles. ASIS width is analogous to the axle width of an automobile, demonstrating how the chassis of the vehicle sits on the wheels. Just as the axle and chassis width sets the foundation for the mechanical character of the vehicle, the ASIS width sets the foundation for the mechanical character of the person.

Another key reference point for all BIQ measurements is the ASIS-achilles alignment (AAA), which is a line drawn downward from the ASIS on each side, at a 90o angle to the line connecting the right and left ASIS. The AAA is uniform for all individuals, and is the reference point for many subsequent BIQ measurements. That is, BIQ measurements are measured as their angle of deviation from the AAA.

External and Internal Hip Excursion

External and internal hip excursion measure the amount of movement available at the hip in the transverse plane. It measures the degree to which the foot can be turned out or in by the clinician. An individual's optimal hip position is defined by the midpoint between the external and internal measurements.

An individual whose gait results in excursion that falls outside of his or her optimal range is at risk of strain and damage to skeletal tissue at the hip, knee, ankle, and foot.

Genu Valgum/Varum

When the bones of the lower extremity are stacked like well-aligned building blocks, the knee joint is in line with the AAA. In most individuals, however, the bones are not perfectly aligned. Measurements of deviation from the AAA at the knee joint quantify the degree of genu valgum or genu varum in an individual. Any deviation from the AAA can indicate unstable positioning. Regaining stability requires additional work by the muscle and soft tissue to stabilize the knee and leg.

When severe, this can cause excessive tensile, shearing, and compressive forces on the leg tissues (musculature, ligaments, and tendons), which may be overused and ultimately result in injury /pathology.

Foot Dorsiflexion Excursion

Foot dorsiflexion excursion measures the degree to which the ankle can bend upwards toward the shin when held in AAA alignment. This test quantifies the degree of dorsiflexion. Limited dorsiflexion, known as equinus, results in compensatory mechanisms such as flattening of the arch, early heel rise with walking, and increased pressure on the ball of the foot, all of which can result in foot, leg, and back pathology. Hyperflexibility, on the other hand, may also be problematic by shifting loads in a manner that the lower extremity is not optimized to handle.

Subtalar Joint Eversion and Inversion Excursions

The subtalar joint in the foot is responsible for movement of the foot away from the AAA in the coronal plane. Subtalar joint eversion and inversion excursions measure this deviation outwards and inwards, respectively. Movement and rotation at the subtalar joint is essential for walking. Insufficient eversion results in inadequate untwisting of the plate, i.e. shock absorption, resulting in excessive compressive forces on the upstream tissues. Insufficient inversion i.e twisting the plate, results in poor coordination of the movements of the subtalar joint with upstream and downstream joints and bones, ultimately producing inefficient ambulation. On the other hand, excessive eversion or inversion, twisting or untwisting the plate requires the stabilizing muscles and tendons of the foot to work excessively, resulting in strain and overuse pathology throughout the lower extremity and back.


Midfoot and Reverse Midfoot Flexibility

Midfoot and reverse midfoot flexibility measurements take into account movement of the talocalcaneonavicular, calcaneocuboid, naviculocuneieform, cuboideonavicular, interecuneiform, cuneocuboid, tarsometatarsal, and intermetatarsal joints. Just as under- and over-flexibilty of the subtalar joint can result in lower extremity pathology, under- and over-flexibility of the midfoot and reverse midfoot can confer similar problems. Rigidity of the midfoot or reverse midfoot results in problems twisting and untwisting the plate, whereas hyperflexibility requires that the structures stabilizing the foot need to work too hard, again resulting in strain and overuse.

Metatarsal Head Mean Alignment

Metatarsal head mean alignment studies the relationship of the metatarsal heads to the AAA. To obtain this measurement, the practitioner determines the average protrusion of the plantar aspect of the five metatarsal heads, and compares this vector to the AAA in the coronal plane.

The metatarsal heads are the distal segment in the closed chain. Normal alignment is, on average, 2 degrees of varus. An alignment that strays excessively from this norm requires compensation by muscles, tendons, and ligaments during ambulation, again resulting in extra work to stabilize the body.

Functional Limb Length Discrepancy

The functional limb discrepancy measures right-left differences in leg and foot length. This measurement is taken from the ASIS to the hallux with the patient standing in their natural angle of gait. Most important here is the fact that the limb measurement takes into account not just the length of the leg (as would be obtained by measuring from the ASIS to the heel on the floor), but also the length of the foot.

This is critical because the foot is an important lever while walking, and discrepancies in the length of the two feet (in addition to those between the two legs) may impact the forces generated on the two sides of the body and the location of the center of mass while walking.

Weight-bearing Foot Anatomical Type

The Weight-bearing Foot Anatomical Type assesses the arch of the foot. It is a qualitative appraisal of the shape of the arch: flat-footed, high arch, etc based on graphical representation of common arch shapes.

The shape of the arch contributes to the overall structure of the foot and its ability to transfer loads between tissues and structures,, so this assessment affects the interpretation of other metrics within the BIQ 10.

Kevin's Angle

Kevin's Angle is the final test in the BIQ 10 exam. It examines the efficiency of the achilles tendon by measuring the angle of the tendon from the center of the plantar aspect of the calcaneus.

A tendon that is perfectly aligned with the AAA is maximally efficient, whereas deviation from this reference line results in loss of efficiency.

Conclusions

The BIQ exam is a new way of collecting and documenting biomechanical data that aids in understanding patients' mechanics. And planning for treatment by helping doctors identify and treat the root cause of the pathology manifested by the patient.

The BIQ Assessment should aid clinicians in diagnosing many podiatry issues by providing a data-driven, visual model with universal standards. With the data derived from BIQ assessments, future AI tools can be developed to further help doctors with diagnostic assessments. For more information on BIQ and and information on becoming a Certified BIQ provider email hello@kevinrootmedical.com

Biomechanical Intelligence:

How Great Doctors Measure Their Patients and Get Extraordinary Results

As any doctor knows, medicine is both art and science

For some conditions there are precise tests that lead to a definitive diagnosis, but for many other ailments, it is a combination of multiple tests, coupled with the doctor’s past experiences and intuition that ultimately lead to diagnosis and identification of the etiology. In podiatry, the latter occurs more often than the former. Patients often have visited multiple medical providers and physical therapists, and tried over-the-counter relief before ultimately receiving a targeted treatment plan that addresses the functional etiology and successfully treats the pathology.

"Biomechanical Inteligence"

Article for podiatrym.com

Root Theories

In 1971, Merton Root et al published the seminal, “Clinical Examination of the Foot volume 1” and in 1977 published “Clinical Biomechanics Volume II Normal and Abnormal Function of the foot”. These works established podiatry as a validated clinical field within the medical community with millions of patients treated successfully using Root Theories.

Over recent years, the focus of podiatry education changed from biomechanics to surgical procedure. While educators still claim that understanding biomechanics is the foundation for understanding the “why” of surgical procedures, there is a shortage of podiatrists who are confident and capable of assessing patients’ biomechanics whether normal and efficient, or pathological and inefficient. Surveys and discussions have confirmed a significant lack of education in biomechanics and a similar lack of understanding of the related subjects of physics and engineering among podiatrists.

For two years, I shadowed and assisted the revered Lowell Weil Sr., DPM in clinic and surgery. I carefully observed the surgical procedures and conservative therapies provided to patients and the latest literature in various journals. It was evident that the biomechanical underpinnings behind conservative therapy, which had a stronghold during the 1970’s-1990’s, were largely overlooked by new fellows and podiatry residents who were focused on the latest surgical techniques, not the underlying biomechanical roots of pathology. Considering the growing hole I observed in biomechanical competency and understanding by new and young podiatric physicians, I shifted my career path from surgical treatments to conservative treatments believing there was a place for functional orthopedics and biomechanics to rise again, and began focusing on developing technology that could help physicians treat patients better.

For the past 15 years, I’ve worked on creating the Biomechanical Intelligence Quotient™ (BIQ™) as a Root 2.0 so to speak, a new way of evaluating patients to help doctors more effectively and efficiently identify many podiatric and biomechanical conditions by honing in on the etiologic biomechanical issues underlying the pathology.

Our research & development teams have produced methods of measuring and supporting your prescriptions that will assess your patients' entire biomechanics

The utility of BIQ

The utility of BIQ is well-demonstrated with plantar fasciitis, a painful inflammation that typically occurs from overuse or ripping / tearing of tissue. By doing a thorough BIQ exam, the clinician may discover that a limitation of internal rotation at one hip is creating an imbalance resulting in overuse of a kinetic chain that ultimately involves the plantar fascia tissue on the bottom of the foot. The diagnosis of plantar fasciitis was made using physical examination. The root cause of plantar fasciitis (limited internal rotation of the hip resulting in equinus, and ultimately plantar fasciitis) is discovered with a thorough BIQ exam. Addressing and treating the symptoms and pain of plantar fasciitis with calf stretches, ice water soaks, anti inflammatory medication and orthotics does help, but failure to identify and resolve the root cause limit the patient’s ability to find permanent relief. Using BIQ allows treatment aimed at the underlying biomechanical imbalance rather than the symptom alone, and tends to produce more definitive, long-lasting results and reveals to the patient a clear explanation of why they suffer from plantar fasciitis. In this case modifying patient gait and precise orthotic therapy provides mechanical neutrality from the hip to the foot and the foot to the hip. It’s important to understand that mechanics work in both directions, from hip to foot and foot to hip.

The Biomechanical Intelligence Quotient (BIQ) was born from my desire to help doctors better relieve their patient’s pain

This tool allows identification segment by segment of the tissue structures and biomechanical features underlying the pain and thus facilitates restoration of a more optimal alignment using gait training, shoe recommendation, orthotics, physical therapy and surgery.

The BIQ is an effective tool to assess the root cause of a wide range of conditions including complaints like plantar fasciitis, ankle and foot arthritis, tendon dysfunctions, hallux rigidus, and plantar plate pathology, knee pain, hip pain, shin splints, sesamoiditis, and Lisfranc injuries.

The Biomechanical Intelligence Quotient (BIQ) collects data about the patient’s lower extremities with the goal of providing comfortable ambulation and positive outcomes. The information collected includes the most crucial measurements of the bones, tendons, ligaments, and muscles comprising each joint, as well as the key measurements of the range and fluidity of each joint’s motility. When all measurements are completed, this data is then used to decide on an individual treatment plan.

The Old Way of Doing Things

While The American Board For Podiatric Medicine does provide a standard biomechanical exam template, there is no standardization for the values or ranges the examining clinician should use. As a result, there are no normative values, nor is there a way that responses can be collectively grouped together to produce data sets for research or artificial intelligence (AI) learning algorithms. With the data produced from BIQ, doctors will eventually be able to use AI to assist even further in diagnostic assessment. BIQ is designed to be a new standard to collect biomechanical data using a universal protocol.

The need for an updated standard protocol for biomechanical evaluation is evident considering the lack of standardized data collection. Other examination modalities (X-ray, CT, MRI, NCV lab tests) allow universal methods of data collection, organization, and analysis which have been adopted for AI. On the other hand, biomechanical data (bone shape, available joint excursions, quality of range of motion/flexibility) collection lacks standards, making high quality scientific analysis impossible.

BIQ incorporates established scientific ideas from the biomechanical literature along with clinical experience, ideas and practice. By normalizing data collection, BIQ will facilitate large-scale data analyses that may allow new correlations and patterns to emerge.

As more data is obtained, the analyses using BIQ data will become more reliable and validated, thus aiding our understanding of biomechanics and contributing to improved diagnosis, treatments, and outcomes.

The New Way-BIQ

BIQ is not a theory, hypothesis or a presumption. It uses the laws of physics, geometry, and engineering to reveal how tissue stress is applied throughout the body. Further, it facilitates identification of actionable changes that can be accomplished through lifestyle modifications, therapies, surgeries and environmental adaptations such as shoes and orthoses.

Prior to development of BIQ, patients were at the mercy of a wise physician, relying solely on a trained eye to evaluate a physical exam without standards. BIQ measures and analyses the phenotypic uniqueness of the human body. BIQ identifies the particular variables that affect loads and forces, helping to explain individual musculoskeletal pathology such as overuse or underuse conditions. BIQ allows doctors to target the root cause, not simply the symptoms.

“Using BIQ has made prescribing orthotics easy and has helped me better explain to my patients their pathology,” said James Judge, DPM. “It also serves as great documentation for follow-up and sharing notes with referring physicians.”

We combat pathology with functional strategy. Our philosophy is to focus upstream and eliminate pathology at the root cause.

KevinRoot Medical team

The BIQ Exam

The BIQ Exam is not only designed to create universal standards, but to also take into account the realities of running a profitable practice. The current American Board For Podiatric Medicine biomechanical exam requires about thirty minutes for a doctor to administer. The new BIQ Exam can be conducted in five to seven minutes. Additionally, a clinician can take that data along with scans or a cast of a foot and send it without a formal order form to an orthotics lab, allowing the lab to make decisions on orthosis design and construction based on the biomechanical and demographic data provided, saving the doctor even more time.

Prior to conducting the BIQ exam, clinicians record the patient’s height, weight, past pathological tissue. The clinical BIQ Exam has the doctor perform assessments that determine the structural morphology and available range of motion of a patient’s lower extremities.

The test can be performed sitting or standing in a standard exam room, and requires nothing more than a protractor, a non-gravitational goniometer, a measuring tape and, if available, a caliper. The acquisition of biomechanical data must be rigorous, with strict adherence to the established protocols. It is only with universal application that this growing data source can be used to to establish normative data, and to recognize patterns and correlations. That said, application of this data can, and should, be modified based on clinician experience and judgment.

Assessment Elements of the BIQ Exam

CONTENT BIQ 10 BIQ 24

ASIS Width (cm)

External Hip Excursion

Internal Hip Excursion

Genu Valgum/Varum

Tibial Varum

Foot Dorsiflexion Excursion

Foot Plantar Flexion Excursion

Subtalar Joint Eversion Excursion

Subtalar Joint Inversion Excursion

Talonavicular Joint Excursion

Cuneonavicular Joint Excursion

Metatarsocuneiform Joint Excursion

Metatarsal Head Mean Alignment

Midfoot Flexibility Test

1st Metatarsophalangeal Joint Excursion

Locate Subtalar Joint Axis

Mark Callus

Weight-bearing Foot Anatomical Structure

Foot Heritage Type

Morton's Foot (Longer 2nd metatarsal)

Kevin's Angle

ASIS to Distal Hallux (cm)

Genu Recurvatum

Brannock Shoe size

ASIS breadth and the AAA

The anterior superior iliac spine (ASIS) is the central point of reference for the BIQ. ASIS width demonstrates how the core of the body resets on the locomotive lower extremities and sets the biomechanical foundation for an individual's lower extremities by defining the origination of all ipsilateral downstream bones and muscles. ASIS width is analogous to the axle width of an automobile, demonstrating how the chassis of the vehicle sits on the wheels. Just as the axle and chassis width sets the foundation for the mechanical character of the vehicle, the ASIS width sets the foundation for the mechanical character of the person.

Another key reference point for all BIQ measurements is the ASIS-achilles alignment (AAA), which is a line drawn downward from the ASIS on each side, at a 90o angle to the line connecting the right and left ASIS. The AAA is uniform for all individuals, and is the reference point for many subsequent BIQ measurements. That is, BIQ measurements are measured as their angle of deviation from the AAA.

External and Internal Hip Excursion

External and internal hip excursion measure the amount of movement available at the hip in the transverse plane. It measures the degree to which the foot can be turned out or in by the clinician. An individual's optimal hip position is defined by the midpoint between the external and internal measurements.

An individual whose gait results in excursion that falls outside of his or her optimal range is at risk of strain and damage to skeletal tissue at the hip, knee, ankle, and foot.

Genu Valgum/Varum

When the bones of the lower extremity are stacked like well-aligned building blocks, the knee joint is in line with the AAA. In most individuals, however, the bones are not perfectly aligned. Measurements of deviation from the AAA at the knee joint quantify the degree of genu valgum or genu varum in an individual. Any deviation from the AAA can indicate unstable positioning. Regaining stability requires additional work by the muscle and soft tissue to stabilize the knee and leg.

When severe, this can cause excessive tensile, shearing, and compressive forces on the leg tissues (musculature, ligaments, and tendons), which may be overused and ultimately result in injury /pathology.

Foot Dorsiflexion Excursion

Foot dorsiflexion excursion measures the degree to which the ankle can bend upwards toward the shin when held in AAA alignment. This test quantifies the degree of dorsiflexion. Limited dorsiflexion, known as equinus, results in compensatory mechanisms such as flattening of the arch, early heel rise with walking, and increased pressure on the ball of the foot, all of which can result in foot, leg, and back pathology. Hyperflexibility, on the other hand, may also be problematic by shifting loads in a manner that the lower extremity is not optimized to handle.

Subtalar Joint Eversion and Inversion Excursions

The subtalar joint in the foot is responsible for movement of the foot away from the AAA in the coronal plane. Subtalar joint eversion and inversion excursions measure this deviation outwards and inwards, respectively. Movement and rotation at the subtalar joint is essential for walking. Insufficient eversion results in inadequate untwisting of the plate, i.e. shock absorption, resulting in excessive compressive forces on the upstream tissues. Insufficient inversion i.e twisting the plate, results in poor coordination of the movements of the subtalar joint with upstream and downstream joints and bones, ultimately producing inefficient ambulation. On the other hand, excessive eversion or inversion, twisting or untwisting the plate requires the stabilizing muscles and tendons of the foot to work excessively, resulting in strain and overuse pathology throughout the lower extremity and back.


Midfoot and Reverse Midfoot Flexibility

Midfoot and reverse midfoot flexibility measurements take into account movement of the talocalcaneonavicular, calcaneocuboid, naviculocuneieform, cuboideonavicular, interecuneiform, cuneocuboid, tarsometatarsal, and intermetatarsal joints. Just as under- and over-flexibilty of the subtalar joint can result in lower extremity pathology, under- and over-flexibility of the midfoot and reverse midfoot can confer similar problems. Rigidity of the midfoot or reverse midfoot results in problems twisting and untwisting the plate, whereas hyperflexibility requires that the structures stabilizing the foot need to work too hard, again resulting in strain and overuse.

Metatarsal Head Mean Alignment

Metatarsal head mean alignment studies the relationship of the metatarsal heads to the AAA. To obtain this measurement, the practitioner determines the average protrusion of the plantar aspect of the five metatarsal heads, and compares this vector to the AAA in the coronal plane.

The metatarsal heads are the distal segment in the closed chain. Normal alignment is, on average, 2 degrees of varus. An alignment that strays excessively from this norm requires compensation by muscles, tendons, and ligaments during ambulation, again resulting in extra work to stabilize the body.

Functional Limb Length Discrepancy

The functional limb discrepancy measures right-left differences in leg and foot length. This measurement is taken from the ASIS to the hallux with the patient standing in their natural angle of gait. Most important here is the fact that the limb measurement takes into account not just the length of the leg (as would be obtained by measuring from the ASIS to the heel on the floor), but also the length of the foot.

This is critical because the foot is an important lever while walking, and discrepancies in the length of the two feet (in addition to those between the two legs) may impact the forces generated on the two sides of the body and the location of the center of mass while walking.

Weight-bearing Foot Anatomical Type

The Weight-bearing Foot Anatomical Type assesses the arch of the foot. It is a qualitative appraisal of the shape of the arch: flat-footed, high arch, etc based on graphical representation of common arch shapes.

The shape of the arch contributes to the overall structure of the foot and its ability to transfer loads between tissues and structures,, so this assessment affects the interpretation of other metrics within the BIQ 10.

Kevin's Angle

Kevin's Angle is the final test in the BIQ 10 exam. It examines the efficiency of the achilles tendon by measuring the angle of the tendon from the center of the plantar aspect of the calcaneus.

A tendon that is perfectly aligned with the AAA is maximally efficient, whereas deviation from this reference line results in loss of efficiency.

Conclusions

The BIQ exam is a new way of collecting and documenting biomechanical data that aids in understanding patients' mechanics. And planning for treatment by helping doctors identify and treat the root cause of the pathology manifested by the patient.

The BIQ Assessment should aid clinicians in diagnosing many podiatry issues by providing a data-driven, visual model with universal standards. With the data derived from BIQ assessments, future AI tools can be developed to further help doctors with diagnostic assessments. For more information on BIQ and and information on becoming a Certified BIQ provider email hello@kevinrootmedical.com

How Great Doctors Measure Their Patients and Get Extraordinary Results

As any doctor knows, medicine is both art and science

For some conditions there are precise tests that lead to a definitive diagnosis, but for many other ailments, it is a combination of multiple tests, coupled with the doctor’s past experiences and intuition that ultimately lead to diagnosis and identification of the etiology. In podiatry, the latter occurs more often than the former. Patients often have visited multiple medical providers and physical therapists, and tried over-the-counter relief before ultimately receiving a targeted treatment plan that addresses the functional etiology and successfully treats the pathology.

Root Theories

In 1971, Merton Root et al published the seminal, “Clinical Examination of the Foot volume 1” and in 1977 published “Clinical Biomechanics Volume II Normal and Abnormal Function of the foot”. These works established podiatry as a validated clinical field within the medical community with millions of patients treated successfully using Root Theories.

Over recent years, the focus of podiatry education changed from biomechanics to surgical procedure. While educators still claim that understanding biomechanics is the foundation for understanding the “why” of surgical procedures, there is a shortage of podiatrists who are confident and capable of assessing patients’ biomechanics whether normal and efficient, or pathological and inefficient. Surveys and discussions have confirmed a significant lack of education in biomechanics and a similar lack of understanding of the related subjects of physics and engineering among podiatrists.

For two years, I shadowed and assisted the revered Lowell Weil Sr., DPM in clinic and surgery. I carefully observed the surgical procedures and conservative therapies provided to patients and the latest literature in various journals. It was evident that the biomechanical underpinnings behind conservative therapy, which had a stronghold during the 1970’s-1990’s, were largely overlooked by new fellows and podiatry residents who were focused on the latest surgical techniques, not the underlying biomechanical roots of pathology. Considering the growing hole I observed in biomechanical competency and understanding by new and young podiatric physicians, I shifted my career path from surgical treatments to conservative treatments believing there was a place for functional orthopedics and biomechanics to rise again, and began focusing on developing technology that could help physicians treat patients better.

For the past 15 years, I’ve worked on creating the Biomechanical Intelligence Quotient™ (BIQ™) as a Root 2.0 so to speak, a new way of evaluating patients to help doctors more effectively and efficiently identify many podiatric and biomechanical conditions by honing in on the etiologic biomechanical issues underlying the pathology.

The utility of BIQ

The utility of BIQ is well-demonstrated with plantar fasciitis, a painful inflammation that typically occurs from overuse or ripping / tearing of tissue. By doing a thorough BIQ exam, the clinician may discover that a limitation of internal rotation at one hip is creating an imbalance resulting in overuse of a kinetic chain that ultimately involves the plantar fascia tissue on the bottom of the foot. The diagnosis of plantar fasciitis was made using physical examination. The root cause of plantar fasciitis (limited internal rotation of the hip resulting in equinus, and ultimately plantar fasciitis) is discovered with a thorough BIQ exam. Addressing and treating the symptoms and pain of plantar fasciitis with calf stretches, ice water soaks, anti inflammatory medication and orthotics does help, but failure to identify and resolve the root cause limit the patient’s ability to find permanent relief. Using BIQ allows treatment aimed at the underlying biomechanical imbalance rather than the symptom alone, and tends to produce more definitive, long-lasting results and reveals to the patient a clear explanation of why they suffer from plantar fasciitis. In this case modifying patient gait and precise orthotic therapy provides mechanical neutrality from the hip to the foot and the foot to the hip. It’s important to understand that mechanics work in both directions, from hip to foot and foot to hip.


The Biomechanical Intelligence Quotient (BIQ) was born from my desire to help doctors better relieve their patient’s pain

This tool allows identification segment by segment of the tissue structures and biomechanical features underlying the pain and thus facilitates restoration of a more optimal alignment using gait training, shoe recommendation, orthotics, physical therapy and surgery.

The BIQ is an effective tool to assess the root cause of a wide range of conditions including complaints like plantar fasciitis, ankle and foot arthritis, tendon dysfunctions, hallux rigidus, and plantar plate pathology, knee pain, hip pain, shin splints, sesamoiditis, and Lisfranc injuries.

The Biomechanical Intelligence Quotient (BIQ) collects data about the patient’s lower extremities with the goal of providing comfortable ambulation and positive outcomes. The information collected includes the most crucial measurements of the bones, tendons, ligaments, and muscles comprising each joint, as well as the key measurements of the range and fluidity of each joint’s motility. When all measurements are completed, this data is then used to decide on an individual treatment plan.


The Old Way of Doing Things

While The American Board For Podiatric Medicine does provide a standard biomechanical exam template, there is no standardization for the values or ranges the examining clinician should use. As a result, there are no normative values, nor is there a way that responses can be collectively grouped together to produce data sets for research or artificial intelligence (AI) learning algorithms. With the data produced from BIQ, doctors will eventually be able to use AI to assist even further in diagnostic assessment. BIQ is designed to be a new standard to collect biomechanical data using a universal protocol.

The need for an updated standard protocol for biomechanical evaluation is evident considering the lack of standardized data collection. Other examination modalities (X-ray, CT, MRI, NCV lab tests) allow universal methods of data collection, organization, and analysis which have been adopted for AI. On the other hand, biomechanical data (bone shape, available joint excursions, quality of range of motion/flexibility) collection lacks standards, making high quality scientific analysis impossible.

BIQ incorporates established scientific ideas from the biomechanical literature along with clinical experience, ideas and practice. By normalizing data collection, BIQ will facilitate large-scale data analyses that may allow new correlations and patterns to emerge.

As more data is obtained, the analyses using BIQ data will become more reliable and validated, thus aiding our understanding of biomechanics and contributing to improved diagnosis, treatments, and outcomes.


The New Way-BIQ

BIQ is not a theory, hypothesis or a presumption. It uses the laws of physics, geometry, and engineering to reveal how tissue stress is applied throughout the body. Further, it facilitates identification of actionable changes that can be accomplished through lifestyle modifications, therapies, surgeries and environmental adaptations such as shoes and orthoses.

Prior to development of BIQ, patients were at the mercy of a wise physician, relying solely on a trained eye to evaluate a physical exam without standards. BIQ measures and analyses the phenotypic uniqueness of the human body. BIQ identifies the particular variables that affect loads and forces, helping to explain individual musculoskeletal pathology such as overuse or underuse conditions. BIQ allows doctors to target the root cause, not simply the symptoms.

“Using BIQ has made prescribing orthotics easy and has helped me better explain to my patients their pathology,” said James Judge, DPM. “It also serves as great documentation for follow-up and sharing notes with referring physicians.”

The BIQ Exam

The BIQ Exam is not only designed to create universal standards, but to also take into account the realities of running a profitable practice. The current American Board For Podiatric Medicine biomechanical exam requires about thirty minutes for a doctor to administer. The new BIQ Exam can be conducted in five to seven minutes. Additionally, a clinician can take that data along with scans or a cast of a foot and send it without a formal order form to an orthotics lab, allowing the lab to make decisions on orthosis design and construction based on the biomechanical and demographic data provided, saving the doctor even more time.

Prior to conducting the BIQ exam, clinicians record the patient’s height, weight, past pathological tissue. The clinical BIQ Exam has the doctor perform assessments that determine the structural morphology and available range of motion of a patient’s lower extremities.

The test can be performed sitting or standing in a standard exam room, and requires nothing more than a protractor, a non-gravitational goniometer, a measuring tape and, if available, a caliper. The acquisition of biomechanical data must be rigorous, with strict adherence to the established protocols. It is only with universal application that this growing data source can be used to to establish normative data, and to recognize patterns and correlations. That said, application of this data can, and should, be modified based on clinician experience and judgment.


Assessment Elements of the BIQ Exam

CONTENT BIQ 10 BIQ 24

ASIS Width (cm)

External Hip Excursion

Internal Hip Excursion

Genu Valgum/Varum

Tibial Varum

Foot Dorsiflexion Excursion

Foot Plantar Flexion Excursion

Subtalar Joint Eversion Excursion

Subtalar Joint Inversion Excursion

Talonavicular Joint Excursion

Cuneonavicular Joint Excursion

Metatarsocuneiform Joint Excursion

Metatarsal Head Mean Alignment

Midfoot Flexibility Test

1st Metatarsophalangeal Joint Excursion

Locate Subtalar Joint Axis

Mark Callus

Weight-bearing Foot Anatomical Structure

Foot Heritage Type

Morton's Foot (Longer 2nd metatarsal)

Kevin's Angle

ASIS to Distal Hallux (cm)

Genu Recurvatum

Brannock Shoe size

ASIS breadth and the AAA

The anterior superior iliac spine (ASIS) is the central point of reference for the BIQ. ASIS width demonstrates how the core of the body resets on the locomotive lower extremities and sets the biomechanical foundation for an individual's lower extremities by defining the origination of all ipsilateral downstream bones and muscles. ASIS width is analogous to the axle width of an automobile, demonstrating how the chassis of the vehicle sits on the wheels. Just as the axle and chassis width sets the foundation for the mechanical character of the vehicle, the ASIS width sets the foundation for the mechanical character of the person.

Another key reference point for all BIQ measurements is the ASIS-achilles alignment (AAA), which is a line drawn downward from the ASIS on each side, at a 90o angle to the line connecting the right and left ASIS. The AAA is uniform for all individuals, and is the reference point for many subsequent BIQ measurements. That is, BIQ measurements are measured as their angle of deviation from the AAA.


External and Internal Hip Excursion

External and internal hip excursion measure the amount of movement available at the hip in the transverse plane. It measures the degree to which the foot can be turned out or in by the clinician. An individual's optimal hip position is defined by the midpoint between the external and internal measurements.

An individual whose gait results in excursion that falls outside of his or her optimal range is at risk of strain and damage to skeletal tissue at the hip, knee, ankle, and foot.


Genu Valgum/Varum

When the bones of the lower extremity are stacked like well-aligned building blocks, the knee joint is in line with the AAA. In most individuals, however, the bones are not perfectly aligned. Measurements of deviation from the AAA at the knee joint quantify the degree of genu valgum or genu varum in an individual. Any deviation from the AAA can indicate unstable positioning. Regaining stability requires additional work by the muscle and soft tissue to stabilize the knee and leg.

When severe, this can cause excessive tensile, shearing, and compressive forces on the leg tissues (musculature, ligaments, and tendons), which may be overused and ultimately result in injury /pathology.


Foot Dorsiflexion Excursion

Foot dorsiflexion excursion measures the degree to which the ankle can bend upwards toward the shin when held in AAA alignment. This test quantifies the degree of dorsiflexion. Limited dorsiflexion, known as equinus, results in compensatory mechanisms such as flattening of the arch, early heel rise with walking, and increased pressure on the ball of the foot, all of which can result in foot, leg, and back pathology. Hyperflexibility, on the other hand, may also be problematic by shifting loads in a manner that the lower extremity is not optimized to handle.


Subtalar Joint Eversion and Inversion Excursions

The subtalar joint in the foot is responsible for movement of the foot away from the AAA in the coronal plane. Subtalar joint eversion and inversion excursions measure this deviation outwards and inwards, respectively. Movement and rotation at the subtalar joint is essential for walking. Insufficient eversion results in inadequate untwisting of the plate, i.e. shock absorption, resulting in excessive compressive forces on the upstream tissues. Insufficient inversion i.e twisting the plate, results in poor coordination of the movements of the subtalar joint with upstream and downstream joints and bones, ultimately producing inefficient ambulation.

On the other hand, excessive eversion or inversion, twisting or untwisting the plate requires the stabilizing muscles and tendons of the foot to work excessively, resulting in strain and overuse pathology throughout the lower extremity and back.


Midfoot and Reverse Midfoot Flexibility

Midfoot and reverse midfoot flexibility measurements take into account movement of the talocalcaneonavicular, calcaneocuboid, naviculocuneieform, cuboideonavicular, interecuneiform, cuneocuboid, tarsometatarsal, and intermetatarsal joints. Just as under- and over-flexibilty of the subtalar joint can result in lower extremity pathology, under- and over-flexibility of the midfoot and reverse midfoot can confer similar problems. Rigidity of the midfoot or reverse midfoot results in problems twisting and untwisting the plate, whereas hyperflexibility requires that the structures stabilizing the foot need to work too hard, again resulting in strain and overuse.


Metatarsal Head Mean Alignment

Metatarsal head mean alignment studies the relationship of the metatarsal heads to the AAA. To obtain this measurement, the practitioner determines the average protrusion of the plantar aspect of the five metatarsal heads, and compares this vector to the AAA in the coronal plane.

The metatarsal heads are the distal segment in the closed chain. Normal alignment is, on average, 2 degrees of varus. An alignment that strays excessively from this norm requires compensation by muscles, tendons, and ligaments during ambulation, again resulting in extra work to stabilize the body.


Functional Limb Length Discrepancy

The functional limb discrepancy measures right-left differences in leg and foot length. This measurement is taken from the ASIS to the hallux with the patient standing in their natural angle of gait. Most important here is the fact that the limb measurement takes into account not just the length of the leg (as would be obtained by measuring from the ASIS to the heel on the floor), but also the length of the foot.

This is critical because the foot is an important lever while walking, and discrepancies in the length of the two feet (in addition to those between the two legs) may impact the forces generated on the two sides of the body and the location of the center of mass while walking.


Weight-bearing Foot Anatomical Type

The Weight-bearing Foot Anatomical Type assesses the arch of the foot. It is a qualitative appraisal of the shape of the arch: flat-footed, high arch, etc based on graphical representation of common arch shapes.

The shape of the arch contributes to the overall structure of the foot and its ability to transfer loads between tissues and structures,, so this assessment affects the interpretation of other metrics within the BIQ 10.


Kevin's Angle

Kevin's Angle is the final test in the BIQ 10 exam. It examines the efficiency of the achilles tendon by measuring the angle of the tendon from the center of the plantar aspect of the calcaneus.

A tendon that is perfectly aligned with the AAA is maximally efficient, whereas deviation from this reference line results in loss of efficiency.

Conclusions

The BIQ exam is a new way of collecting and documenting biomechanical data that aids in understanding patients' mechanics. And planning for treatment by helping doctors identify and treat the root cause of the pathology manifested by the patient.

The BIQ Assessment should aid clinicians in diagnosing many podiatry issues by providing a data-driven, visual model with universal standards. With the data derived from BIQ assessments, future AI tools can be developed to further help doctors with diagnostic assessments. For more information on BIQ and and information on becoming a Certified BIQ provider email hello@kevinrootmedical.com