Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

Yes.

No.

No, because neither are a `condition`. They are just subjective descriptions of parts of the foot in a given position.

Yes, along with casting the foot in other positions to achieve the desired orthoses prescription to offload what`s hurting.

To prescribe is; "the form of instructions that govern the plan of care for an individual patient" So, one type, whether that be Root or any other will not fit all. Patients are individual and present with unique pathologies. We manufacture according to that individual need. I`ve never understood the term `functional orthosis`? It`s a bit of plastic that can reduce the load on a part of the foot, that`s all.

By teaching us to identify what hurts, why and how we can help it to heal?

Respectfully,
John

 

Rear and forefoot varus are not conditions but subjective descriptions? Wow. SMH.

 

To Doogle and/or any other TST advocates on this board. Please describe the following weight bearing AP and lateral radiographs in tissue stress terms. I know, the lines on the AP give some of it away...but what the heck...hints like this are much like the circle sign.

 

When I taught biomechanics by the final year of my teaching

we taught Root theory in a historical perspective, explained what went on East verse West coast, looked at the list of Normal and biomechanical exam process.

it must be noted that this may have been my basterdised Root theory.

we then discussed using normal or a diagnosis of tissue damage as a starting point, looked at the work of Kevin re STJ axis and Nester re MTJ and of course the bone pin studies, we also looked at sagittal plane theory and then discussed cause or result. Etc etc etc.

Yes we did casting, not Root though, but a modied version, but we also discussed casting the foot in*different positions depending on what you needed, to show them or as an exampleThey cast a foot, then added a low dye strap (with my own modifications) and re cast the foot to see the difference .

Did they learn Root device I did not teach this section and it was a few years ago but I don't think so.

FWIW before I started the course I explained my roll was not to teach them, but to explain the theory and get them to think what makes sense, I explained it like this

if we say Biomechanical theory is a big room with many doors in it , my roll was to explain what behind each door, their roll was to research and open each door to investigate more over their careers, if they decide 1 door fits their working future then ok or mutiple then ok.

 

You need to provide more information Xrays while helpful do not provide the full picture

 

The problem with Root theory is that once you scratch the surface many things do not make sense

say we have a " pronated " foot in whatever language you want to describe it in

Root theory would have us build a device a certain way ( control the excessive pronation in whatever language you want to describe it )

Tissue stress would ask what was the problem or what tissue was broken

if that stressed tissue is Medial OA of the knee with lateral wedge device ( in whatever language you want to describe it )

which is what scientific research shows us will work

The root device will in most cases lead to increased loads on the medial Knee

The above shows why working from normal is not a way forward.

Jeff you keep saying you need Root theory to understand Tissue stress theory you don´t , you do not even have to heard the Name Root .

 

Jeff asked; "Do podiatry schools outside the U.S. teach The concept of the neutral position of the STJ?"

I answered his questions honestly; whilst discussing all paradigms, we are taught at Huddersfield to critique the conceptof whether the position of the rearfoot in relation to the forefoot is clinically relevant. In some patients it may be, in others it will not be. It depends on the patients presenting complaint. Radiographs in isolation will not inform an effective treatment plan to help reduce symptoms of any foot pathology.

 

BS....but nice duck, (quack, quack). Just comment on the forefoot to rear foot relationship then. You have ALL the info you need. It appears to me you don't shoot and/or read a lot of film, do you? There's a LOT one can determine about that patient when simple, weight bearing plain film radiographs are taken. For those Podiatrists that can't/don't shoot film, I'm not sure how they determine pathology. It would be analogous to an ortho trying to determine DJD without the same, or a PT doing the same.

 

That was the one comment you made that I didn't disagree with. In the future, try to address what I specifically targeted with my quote, (I actually highlighted it). It was the rest of your comments, particularly about fore and rear foot varus not being a condition but a description that was really over the top. And you have dismissed my article determining the source of GPs and the connection to RLS? Perhaps I should consider the source from those that object.

 

I wish doctors would use proper terminology when describing arthritis of the knee. OA implies a systemic disease. DJD implies that the arthitis is joint specific. My understanding is that orthos are moving away from lateral wedging for medial knee DJD...which is a good thing. They(you) believe it is a frontal plane problem...it is not.

 

"Rearfoot Varus" and "Forefoot Varus" are not conditions/diagnoses/pathologies Matt. End of.

 

Did I write that these were pathologies? Even though they can be, that's not what I wrote. But they are not just "descriptions", and certainly are not subjective. Care to comment on my x-rays in post 443?

 

Dr Hunt

Please can you tell me what `SMH` stands for?

John

 

So in one sentence you manage to defend your position by stating what you did and did not say yet at the same time completely affirm what I suspected your actual position to be: that you feel descriptions such as "forefoot Varus" or "rearfoot Varus" are pathologies....Er....ok. You're still wrong obvs.

Do I care to comment on a static 2D image of an individual who I know nothing else about? Nah not really. Treat the man not the scan Matty...

 

In the future, why dont you try to engage with your peers with some respect? Your attitude is one of like so many before you that come here thinking they are the next big thing and when their work is critiqued by their peers they respond with personal attacks. I did read your article and so did my colleagues but i dont feel inclined to engage with you any more so you will never know whether we liked, dismisssed or objected to it or not. your loss.

 

Just as I suspected. Playing word games, eh Griff? Yes...FF and RF varus ARE conditions that can lead to pathologies...to deny that is an example of: head, sand, stuck. It is NOT a subjective finding...nor should anyone here attempt to portray it as a subjective description.

That "2D photograph" shows EXACTLY what I'm stating. That 17 y.o. patient has an obvious FF varus deformity...and it was/is staring you in the face. Heck, I even drew lines bisecting the rear foot, midfoot and forefoot on the AP and you still didn't "get it" when determining the effect on his structural problems, which in your mind are purely subjective. Nothing subjective about radiographs...is there? Look at the lateral view, Griff...how much overlap is there between the 4th and the 5th? Look at the MPE...what should these WB, static findings tell you? Oh, there's a lot more, Griff...when discussing that "2D photograph...a lot more indeed.

 

I treat those with respect that offer the same to me. No big deal, Doogle. I already responded to Angela Evans in her genuflexed letter-to-the editor to PMM...really...nothing more needs to be stated as she obviously holds me to a higher standard then she holds herself. Do not let personalities come before principles.

 

Oh I got your point Matty. Please don't mistake the lack of interaction you are getting from myself or others as anything close to approaching the possibility that you are thinking on a different level to others. You are not. It's just most of us have dismissed this approach; having decided to move on and replace it with a more scientifically supportable, biologically plausible, theoretically coherent approach. It's ironic that we are still having to highlight this less than a week after the father of evidence based medicine has just passed away... Nothing changes for some people I guess

 

Matty? How very British of you.

"It's just most of us have dismissed this approach; having decided to move on and replace it with a more scientifically supportable, biologically plausible, theoretically coherent approach."

That's the problem with academics...high up in their ivory towers they can't possibly address real problems and find real solutions. I would rather take the approach that benefits my patients...you can do whatever you want...but flailing away on a public forum, such as you are, when I repeatedly expose you and dismiss what you write, does not achieve better patient outcomes. If I were you...I'd think about that.

 

The only exposure throughout this entire thread is that of your xenophobic, ignorant and callow behaviour, whilst constantly blowing smoke up Jeff Root`s....

Whilst maybe only a few colleagues have taken the time to indulge you, remember; for every `poster` there are many `lurkers` following discussions such as these. You`ve certainly made a lasting impression on the podiatric community here. Don`t bother replying with your usual wit and charm;

Bel

 

Ha! whare ye gaun, ye crowlan ferlie!
Your impudence protects you sairly:
I canna say but ye strunt rarely,
Owre gawze and lace;
Tho’ faith, I fear ye dine but sparely,
On sic a place.

Ye ugly, creepan, blastet wonner,
Detested, shunn’d, by saunt an’ sinner,
How daur ye set your fit upon her,
Sae fine a Lady!
Gae somewhere else and seek your dinner,
On some poor body.

Swith, in some beggar’s haffet squattle;
There ye may creep, and sprawl, and sprattle,
Wi’ ither kindred, jumping cattle,
In shoals and nations;
Whare horn nor bane ne’er daur unsettle,
Your thick plantations.

Now haud you there, ye’re out o’ sight,
Below the fatt’rels, snug and tight,
Na faith ye yet! ye’ll no be right,
Till ye’ve got on it,
The vera topmost, towrin height
O’ Miss’s bonnet.

My sooth! right bauld ye set your nose out,
As plump an’ gray as onie grozet:
O for some rank, mercurial rozet,
Or fell, red smeddum,
I’d gie you sic a hearty dose o’t,
Wad dress your droddum!

I wad na been surpriz’d to spy
You on an auld wife’s flainen toy;
Or aiblins some bit duddie boy,
On ’s wylecoat;
But Miss’s fine Lunardi, fye!
How daur ye do ’t?

O Jenny dinna toss your head,
An’ set your beauties a’ abread!
Ye little ken what cursed speed
The blastie’s makin!
Thae winks and finger-ends, I dread,
Are notice takin!

O wad some Pow’r the giftie gie us
To see oursels as others see us!
It wad frae monie a blunder free us
An’ foolish notion:
What airs in dress an’ gait wad lea’e us,
And ev’n Devotion!

http://www.theguardian.com/books/booksblog/2008/oct/13/poem-of-the-week

 

John,

Thanks for answering my questions. By answering yes to some of my questions it demonstrates the simple point that I have attempted to make numerous times on this and other threads, that "Root Theory", a meaningless label at best but one that seems very popular here on the PA, is still being taught and that portions of "Root Theory" are used by those practicing Tissue Stress Theory. Why is that so difficult for some to accept or admit? There seems to be a lot of denial going on.

There are elements of "Root Theory" (note: I have decided to always put quotation marks around the term "Root Theory" because the term is invalid as there is no such thing as "Root Theory") that are very useful academically and clinically, such as having a structural classification system. Although this system could probably be improved upon, there is no denying the significant benefit that exists which enables clinicians to discuss structure and structural variation in a more meaningful manner than would be possible with it.

Tissue Stress is not a new concept. Wolff's law has long been a key element of podiatric biomechanics. Tissue Stress Theory as a treatment approach certainly has merit. But it is not unique and new except it is now being used as a label for a form of treatment that combines elements of a number of clinical theories and approaches. As a treatment approach, the primary problem with Tissue Stress Theory is that there are no standards or standard techniques and practices. Where is the written protocol for prescribing custom foot orthoses using the Tissue Stress Approach? Each practitioner implements their own, unique approach to reducing stress on injured tissue. Without standards, Tissue Stress is not a treatment approach but rather a treatment philosophy.

Jeff

 

Matt, you should re-read your John Weed 2nd year sylabus where he discussed the x-ray findings of forefoot varus. This radiograph is the exact opposite of what John Weed said was a forefoot varus. What he said was that in a forefoot varus, in the lateral view, there would be maximum overlap of the metatarsal bases. There is almost no overlap of the first and fifth met bases.

One reason that I did not comment earlier was that all you said was that this was a weight bearing x-ray. You did not say if it was a weight bearing neutral positoin x-ray or resting positoin x-ray. Not knowing the condition under which the x-ray was taken makes it impossible to make any conclusions about the foot.

Were you just trolling us with this quiz? The only way that foot has a forefoot varus as described by John Weed is if the STJ was markedly supinated when film was shot. Which is entirely possible as there are many signs on the film of a more supinated position of the STJ which would be inconsistant with a forefoot varus. (Open sinus tarsi, intact cyma line)

I'm sure anyone is capable of taking that foot and putting a tractograph to that foot and getting an inverted forefoot rearfoot measurement if you drew your heel bisection everted enough and didn't load the lateral column very hard.

Eric

 

Eric-then I disagree with Dr. Weed, (that is, if he was referring to ALL FF varus deformities). If the STJ has adequate ROM, then a lateral view would be as he describes. If you look at the lateral I posted, it almost looks like an oblique...no overlap between 4 and 5, very little overlap between 3 and 4, and the obvious MPE. But the key, at least for me, is the MTJ accommodation on AP view. This kid has a skewfoot deformity, ie., he also has a rearfoot varus deformity as well. I'll be sure to take pics and a video when he comes back for orthotic casting. I'll draw a posterior calcaneal bisection to demonstrate RCSP vs. NCSP and the fact that he has zero eversion left at static stance available. This is another point I'm trying to make...and it's a "definitional" one. We have, IMO, a problem with definitions of "what is". More on that later. Once I get the videos and pics, I'll be sure to share them along with a brief history.

 

Eric-Let me illustrate what I wrote above by posting a drawing my illustrator drew. Imagine a lateral X-Ray of the following two feet. There's a big difference between compensated and uncompensated....and that's my point. More on this later. Oops...used the wrong illustration...look at the second, larger pic...it should read uncompensated FF varus...the first should read simply FF varus. I had the illustrator correct the wording.

 

Jeff, I have to disagree here. Identify the injured structure. Model the injured structure to predict which orthotic modification(s) will reduce stress on the injured structure. Make those modifications and then evaluate the results. Take posterior tibial tendon dysfunction. That is modeled in Kevin's rotational equilibrium paper. The prediction is that an orthotic should increase supination moment from the ground. A medial heel skive should shift the center of pressure under the ground. I don't know of any tissue stress advocate who would think differently in that scenario. Jeff, how would a standard improve the above thought process? What do you mean by not having any standards?

What differences are you referring to? The vast majority of the time tissue stress advocates will agree on examination methodology. Where we disagree, we would probably agree on the research question/ design that would address our difference in opinion. Jeff the criticisms you have given here are ones that have been used against neutral position theory. Can you give an example of where tissue stress proponents have disagreed?

Eric

 

Eric,

In your example for treating PTTD, TST has no agreed upon casting technique, no agreed upon casting position, no agreed upon cast modification techniques, no agreed upon method for positioning the cast in the frontal plane because as you TST advocates have pointed out many times, you don't believe in heel bisection because it is "inaccurate", etc. So two people using the TS treatment theory may come up with radically different devices because there is no standard orthotic prescription protocol involved with TST. As a result, we could use a Root Type Functional orthosis and potentially get the same or a better result. But the reality is, many, but not all people treating this foot using the TST approach would probably be using a modified Root Type Functional Orthosis (using heel bisection to orient the cast in the frontal plane, intrinsic FF correction, medial heel skive, and reduced medial arch fill). We have been using these modified Root Type Functional Orthoses long before anyone mentioned TST.

I have seen many situations where TST proponents don't agree but you won't and don't engage each other here on the PA because if would conflict with your alliance, which is more important to the cause (advancing TST) than the truth is. Occasionally I can get Simon and Kevin to express there different treatment approaches but it just gets swept under the rug for the most part.

Jeff

 

Yeah? And? So? What? You seem to be making the assumption that there is only one way of casting the foot, one cast modifcation etc which will allow us to design and manufacture an efficacious foot orthosis- this just isn't true. It's all about load management, and we can manage the load in many ways, with several different orthosis design solutions. Why do you desire for there to be a single rigid recipe?

 

look I understand I am not Eric , Kevin or Simon Jeff but I do think you are stretching the truth a lot in you last statement, but my point of getting involved is more the 1st

i reads as though Root invented the Medial skive , it may not be your meaning

But sure I would use a medial skive, with EVA fill to increase the surface area and increase stiffiness under the medial heel, high heel cup, increased arch contour ( read no or very little arch fill , plus having plantarflexed the 1st MTPJ head during casting etc etc , but I don´t use bi section lines .

but what makes this a modified Root device ? the molding of heated plastic over a postive cast?

and if mine is not a modified Root device what makes this

a Modified Root device specifically ?

 

Simon,

Simply stated, TST has no orthotic Rx protocol.

Jeff

 

Mike,

The medial heel skive is a modification that was added to the Root Type Functional Orthosis. Interestingly enough, Merton Root et al patented the triplane heel wedge, which is essentially an extrinsic medial heel skive.

Jeff

 

Simply stated, it does- design an orthosis to place the stress on the injured tissue within its zone of optimal stress (ZOOS). Since we now have a far better understanding of how foot orthoses work, we recognise that there will be multiple design permutations for foot orthoses within the positive solution set that will place the loading on the tissue back within it's ZOOS. We recognise that the position the foot is cast in is merely a starting point, that the surface contour of the device at the foot-orthosis interface is only one of the three design characteristics which ultimately determine the direct mechanical effects of the foot orthosis and that there are many, many ways of managing loads and skinning cats. From this we glean the fact that the concept of a single prescription protocol that tells you that you must cast the foot in a single certain position, you must balance the cast to a single certain number of degrees etc etc, is unnecessary.

I'll ask again, why do want a single rigid protocol?

 

I don't want a single protocol. The protocol can be situational as long as you identify the various conditions and how it changes your approach. Root had multiple Rx protocols, depending on the ROM of the STJ, the presence of spasm, the position of the tibia, etc. For example, he recommended a pronated casting technique if there was a peroneal spasm, and the degree of pronation was dependent on the point of spasm. He recommended inverting or everting the positive cast in certain, very specific situations. He had specific criteria to guide users which TST clearly lacks.

Does it matter what position or what technique we use to cast the foot in TST? Let's start with casting technique. Is a full weigthbearing, a semi-weightbearing or a non-weightbearing casting technique the preferred technique? Forget for now what position we might cast the foot in using these techniques. Which technique is used when applying TST and why?

The definition of protocol is:
:a system of rules that explain the correct conduct and procedures to be followed in formal situations
: a plan for a scientific experiment or for medical treatment

The definition of system is:
a set of principles or procedures according to which something is done; an organized scheme or method.


TST has no rules and is not an organized treatment system.

Jeff

 

It doesn't really matter because all a cast provides is a starting shape. Certain casting techniques may make the process quicker, but in reality you could start with a cube of plaster and carve it into the desired shape. Moreover, you might not need a cast at all, because a non-casted or OTC device might suffice.

 

And how do these casting techniques influence shape. Let's limit this discussion to custom orthotics for now. Which technique is advocated in TST?
JefF

 

All of the techniques are advocated.

 

So how does TST indicate to the practitioner which technique to use on a given patient and when?

 

The practitioner is free to choose which ever technique they feel most comfortable with. Personally, I choose the technique which I think will provide me with the least amount of additional work to create the shape of the device at the foot-orthosis interface that I wish to achieve in the finished device. Like I said, we could start with a cube of plaster and carve it into the shape that we want, but that would be a ball-ache.

So, let me ask you a more interesting question: how does the shape of the foot orthosis at the foot-orthosis interface influence kinetics at the afore mentioned interface?

 

So there is no established protocol for casting using TST. Practitioners are free to choose any technique and cast the foot in any manner or position they choose. However, because the shape of the cast will different with each casting technique, and given that this will influence the shape of the resulting orthoses (i.e. NWB casts will have greater contours than WB casts), then the casting technique should have an influence on orthotic reaction forces. However, TST doesn't have a system or protocol for casting the foot or for any of the orthotic modifications or specifications. Practitioners are free to choose because there is no basic guideline when using TST.

 

Nope nor does there need to be because the shape of the initial "negative" cast doesn't determine the shape of the finished device. Rather, the shape of the finished positive cast determines the shape of the device at the foot-orthosis interface, if you are vacuum forming; otherwise the initial model just gives you a starting point in your CAD system. Nothing more nor less. But then we go on and realise that the shape is only one component... I can see you are finding this a difficult concept, but like I've said before, (for the third time now in as many posts) we could start with a cube of plaster and carve it into whatever shape we wanted to form our "positive" mould. There is no single "rigid recipe" for casting the foot, Why do you think that a single "rigid recipe" is necessary, is it because of the lens that you view your world through?

I'll ask again, how does the shape of the foot orthosis at the foot-orthosis interface influence kinetics at the afore mentioned interface?