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Forefoot Varus Predicts Subtalar Hyperpronation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Dec 17, 2014.

  1. Jeff Root

    Jeff Root Well-Known Member

    May I suggest we keep the focus on Podiatry and biomechanics? Let's discuss and debate the content, validity and quality of the comments and not resort to personal attacks that detract from the purpose of this forum. Please!

    Thank you,
    Jeff
     
  2. admin

    admin Administrator Staff Member

    Yes; what Jeff said:
     
  3. rdp1210

    rdp1210 Active Member

    The ZOOS is a qualitative concept that is not presently quantitated in any clinical practice. The simple fact is that the sinus tarsi is not the only restraining mechanism of the PEROM for the STJ. If it was, then failure of the deltoid ligament would not result in the subluxation of the STJ in static stance and PTTD would not be the devastation on the foot that it is. I have always agreed with the concepts of looking at the stress within the restraining mechanisms. Different people become symptomatic with different amounts of stress. I deal daily with this concept in the high number of diabetics that I treat. Reserve of pronation becomes important because of what happens when you want to use that reserve. It's like when I was driving on the Autobahn, doing 140Klicks, but my pedal was to the metal in that little Fiat. Did I have any reserve of acceleration? No, but the Mercedes passing me did. If a person is standing in static stance with no reserve or pronation in the STJ, what happens when he wants to make a movement that requires more STJ pronation? We would first ask how much and how fast he wanted to use the reserve. For some, little symptoms if there is little plastic deformation in the tissues, for others a lot of symptoms if the plastic deformation is great. Also we need to know what the reserve of pronation is available in other joints. Again, currently ZOOS is a concept, not highly developed, but thrown in our faces by those who are looking for a "anything-but-Root-argument." I realize that Root also only vaguely referred to ZOOS concepts, but he wasn't oblivious to it.



    As you may have guessed, I have limited time to read every comment and write replies. I have almost 2 hours into this particular reply. (You are the most prolific in this forum and I wonder if you have any other life besides treating patients 50-60 hr/week and reading and writing on this forum) I have pretty well ignored most of Dr. Hunt's comments and have not waded through a lot of his comments, so I did miss his derogatory nationalism. He claims I know him, but I'm not recognizing him here. My failure in not calling him out for his anti-Brit comments should not be construed as acceptance of such as being appropriate. So to any American pod who may be looking down their nose at any non-American professional -- I say enough is enough! Quit it! If anyone wants to do some flag waving in this forum of any type, go somewhere else and wave your flag. I don't consider anyone's nationality when I decide the validity of their work -- I don't care if Root came from California or Sussex, he continues to have a tremendous influence on the world-wide pod community. I believe that his number one addition is his adaptation of the twisted plate to orthotic making, which I have come to call "The Root Postulate." I haven't heard Kirby or Fuller argue that it is wrong, just that there is more. The see that the big problem has not been Root, but the arrogance of many of his disciples and their evangelistic attitudes that the Root-canon came from God's lips and is now closed. The problem with the anti-Rootians has been their dogma that any research that tears into Root must be good research, that either Root is all-right or all-wrong, and that any additions to the biomechanics canon means that Root was wrong. What disturbs me the most is the way some people are quick to characterize others' intelligence in proportion to what parts of Root they accept.

    BTW I am a big fan of Chris Nester's, and appreciate his methodological approach. It's important, though, that you be as critical of Nester's work and Kirby's work as you are of Root's. I have all of Kirby's published papers, but I don't have his books. I try to keep up with the latest foot kinematic and kinetic literature but my pub-med weekly notifications are in the diabetic foot literature. I didn't have Nester's latest paper published in November, and really appreciate the reference. Feel free to send me other references that you feel are important. I'm a great proponent to Nester's multisegment approach (see my paper 1996 with Law and Ward which was a crude early attempt at such, but which seems to agree with the more sophisticated work of Nester et al.). The most interesting part of the paper is that it appears that the MTJ has very little contribution to the twisted plate, and most of the function is distal to the MTJ. Good stuff! I will be digesting it more. It will be interesting to look at the difference in the intersegment motions in various foot types in his future papers. I also appreciate your finite-element analysis of orthotic function - good stuff! In all the research papers that use human subjects, it is important that we remember that there are two definitions of normal (see Eric Lee's paper).

    With best wishes,
    Daryl
     
  4. rdp1210

    rdp1210 Active Member

    I'm always glad to hear about others' positive experience with people, e.g. Chris Smith. I don't want you to think I was denigrating his intelligence. My experiences with Chris were not as numerous nor as positive as yours, in his willingness to listen and question his own ideas. But then again, I was just one student. One of the good things about this forum is that I get some mirror of how I may appear to others. When others question me, then I try to sit down and evaluate my own ideas before I reply. I hope that others find me willing to change, though I don't want to just shift in the wind.

    I am not criticizing Eric for the value of what he has done, especially in detailing more the application of basic tissue biomechanics principles to the lower extremity. What I am criticizing is more style. We (including myself) need to be more complimentary of each other, and do less patting our own backs. Matt has not written much, though I hope to see more from him as he does have potential. Let's encourage him to develop. Hopefully I've got a few more papers in me to publish, though my time in the VA has left me very limited time to do things I want.

    Again best wishes this year. Looks like we'll have a little time to get together in Vancouver.

    Daryl

    Robert D. Phillips, DPM
    Professor Podiatric Medicine
    College of Medicine, University of Central Florida
    Orlando, FL
    ph: 407-629-1599 ext 1099
    email: Robert.Phillips9@va.gov
     
  5. Well said, Jeff. A concurrent theme in this thread laments the current and emerging cohort of podiatric clinicians for not giving sufficient weight to lower limb biomechanics and orthotic management in their practice - and there is suggestion that it has become too complicated to understand. I don't agree with that - if someone has the intelligence to gain a doctorate or degree in podiatry, then understanding fairly basic physics and engineering principles shouldn't prove too difficult a hurdle - but that will depend on how they are taught. Obviously there are deficiencies in the undergraduate programs - and many podiatrists will try and gain an explanation and further knowledge through these pages - but if their experience here is unpleasant and derogatory - professionally and personally, then we will lose them and the profession will be poorer as a result. In the last few weeks some public posts have been malicious and grossly unprofessional and could quite easily come under the banner of "misconduct". Some private comments have been libellous and defamatory.

    As a regular nominee for Quote of the Year - usually for some derogatory remark about rhubarb - I'm in no position to preach, but can I suggest that before posting comments can we all just pause and think about its impact and how it might be regarded by others and whether it adds or detracts from the conversation as a whole.

    Never one for New Year resolutions, but it seems like a reasonable one to try.
     
  6. Daryl:

    Most of what I have written on Tissue Stress Theory is contained within my four books so I understand now why you might make the statement:

    To learn more about Tissue Stress Theory, my last three books contain the most information. In fact, in my latest book, just published last year, I devoted a whole chapter to designing prescription orthoses using Tissue Stress Theory. This should provide you with the current thought on these subjects.

    In addition, we have had very many discussions on the concept of Tissue Stress right here on Podiatry Arena. You should become more involved here since I know I value your input, ideas and criticisms as I'm sure Simon Spooner, Eric Fuller and many others here also do.

    I really don't think we are too far apart in our ideas and the way we do things, Daryl. The biggest difference I see between us is that you place more emphasis on subtalar joint neutral measurements than I do and you are more of a "Root-disciple" than I am. With those thoughts in mind, it would be nice to have you more involved here on Podiatry Arena since I think your contributions could be very valuable to helping to advance the knowledge of the international podiatric biomechanics community.

    Happy New Year!:drinks

    Below: ACFAOM Conference, Orlando, Florida, October 28, 2011: (L to R) Daryl Phillips, Kevin Kirby, Bruce Wiulliams, Simon Spooner
     
  7. Since earlier in this discussion we were talking about foot animations, I thought it might be helpful to also point out that Nicholas Giovinco (DrGlass) and I worked for about 6 months on producing a three-dimensional video of closed kinetic chain pronation and supination with the subtalar joint axis included for educational purposes. One of the best things about this video is that it allows the motions of the subtalar joint and other pedal joints to be viewed from all three cardinal body planes to help show the three-dimensional motions of the pedal joints during closed kinetic chain pronation and supination. Dr. Giovinco did all the animation and I helped him tweak it so it was more anatomically and functionally accurate. The YouTube video below includes our animation but Dr. Giovinco alone wrote the script for the video narration.

    Dr. Giovinco is now Director of Education and an Assistant Professor of Surgery at the University of Arizona in Tucson.

     
    Last edited by a moderator: Sep 22, 2016
  8. rdp1210

    rdp1210 Active Member

    Eric,

    I'm not criticizing any of your statements in this post. I indeed practice, daily, exactly what you're preaching in qualitatively assessing my patients. What makes you think that the STJA assessment is not a part of my daily assessments of patients? What makes you think that I'm not thinking about how much stress each soft tissue is being subjected to during gait and stance?

    What I'm criticizing is the insistence that Root has been replaced by Tissue Stress, or that Root has been replaced by STJA theory. What I'm advocating is adding it all together, I find that it all can be fit together. I think that you will find in Hetherington's first podiatric medicine book that I wrote about stress on tissues, and the need to understand the stress-strain curve of all tissues as well as the force-velocity and force-length curves for the muscles. That's why I spent a couple of years trying to break down the Achilles force during gait into its active and passive components. I explained in Hetherington's text the need to understand moments of inertia of each segment, both bending and polar. I continue to try to test soft tissue strain curve on many of my diabetics by using a durometer on the fat pads forefoot and rearfoot. I have written NSF grant proposals for further testing such. STJA theory is an essential component of the full biomechanical exam and modifying orthotic prescriptions. But its not the only part. If I had my way, I would get isokinetic muscle testing on each patient. I have also advocated developing many other measurements that I hope to see become reality. In summary, I say bully-for-you in writing about these important applications, and in preaching the need to know. I think you and I both agree that the identification of the fully pronated foot that has a vertical calcaneus or even inverted calcaneus (if you accept that a calcaneal bisection is possible) is important, and trying to treat a "partially compensated rearfoot varus" as a supinated foot is not advisable. I don't recall anyone before Root writing about what Root called "the partially compensated rearfoot varus", though someone out there may know more.

    What I'm also criticizing is the insistence that we only treat syptoms and that we don't need to develop the quantification of tissue stresses. Such attittudes are as antiprogressive as the idea that Root wrote the final scripture on biomechanics. We have few longitudinal studies and few A-B-A-B intervention studies. We have still to quantify the shape of orthotics into a mathematical equation. I hope to see the day that a pod writes a Rx for orthotic shape, in the same way that an optomotrist. We did learn that the Kilmartin version of the Root orthotic seemed to accelerate Hallux valgus development, though a giant chasm was jumped in a single bound by those who took this to mean all orthotics accelerate hallux valgus development.

    In response to Kevins criticism that I was totally devoid of knowledge about your writings I again reviewed your chapter in Steve Albert's book. I have no criticisms of the chapter itself and find it well written. I've been doing everything you talk about for years. One thing that did catch my attention in better detail was your drawings of the varus-valgus moments on the knee joint. The drawings are correct, in which the forces aligned at the two ends, and do not pass through the center of the knee joint surface nor through the CoM of the segments, thus putting a frontal plane bending moment at the knee. What I've been arguing with youu is that this also applies to the ankle and STJ. That we not only have to look at the axis of the STJ, but we also want the center of the ground reaction force under the heel to align with the center of mass of the lower leg and the center of mass of the heel and talus to prevent these same rotational moments at the ankle and STJ. That's why I don't understand your resistance to getting a better understanding of where the CoM of the calcaneus is and trying to make sure our posterior calcaneal bisection overlies it.

    Now to address your questions about the hypothetical patient. First, pushing the STJ toward neutral position does not in itself create more stability. Mert never said it does, that's only his disciples representing Mert's position. Mert maintained that the foot is most stable when the MTJ is fully pronated. i.e. "The Root Postulate". As to your measurement that the forefoot can maximally get 2 degrees off the ground, first I have to question what your measurement techniques are? I read into the problem that the patient is standing 50% between full pronation and neutral position. You don't tell me whether the patient is trying to lift the forefoot off the ground, or whether you, the practitioner are doing the lifting. So noting some inconsistencies between the NWB and the WB exam, I start looking for reasons. I don't just toss the baby out with the bathwater. However I do agree that you need to put a wedge between the ground and the forefoot to pronate the MTJ to its EROM, no more and no less. One of the problems I had as a student was my arm got soooo tired when trying to take an orthotic cast. Then I went and took lessons directly from Mert, and discovered what a light touch he was using to maximally pronate the MTJ compared to what everyone in the biomechanics department was doing. No wonder everyone at CCPM was claiming that 90% of the population had forefoot valgus, whereas Mert was estimating about 33%. So force against the rearfoot is still a confounding variable that has to be solved. That's why I have started calling for development of a measurement system that creates a FF to RF relationship curve, that is a plot of angle against the amount of forefoot eversion force being applied. And it really should be a surface plot with the third axis being the STJ position. For the same reason we need an Achilles tendon force-tension curve for every patient rather than defining the magical 10 degree mark that separated equinus from non-equinus dx. I think I addressed this Achilles tendon issue in Alberts new book.

    In summary then, I'm a little bit tired of everyone who tries to box me into being a nonprogressive Root evangelist, and I'm tired of those who want to eliminate his mark on the world. I have expressed more ideas on where I think we need to go in the future than I have seen expressed by my critics. I think we all could be a little more humble and try to give more credit where credit is due. All of us have tried to build on the shoulders of giants.

    Best wishes,
    Daryl
     
  9. Daryl:

    In all the conferences I attended where Dr. Root lectured, and in all of his writings, Mert Root seemed to indicate that the subtalar joint (STJ) neutral position was the most stable position of the foot. At least that was the impression I got from reading all of his published work at least twice and attending many of his seminars.

    While I agree with you Dr. Root thought the midtarsal joint (MTJ) was most stable when the midtarsal joint was "fully pronated", from what I remember, he lectured that the STJ neutral position was the position of maximum stability and the STJ maximum pronated position was the position of least stability.

    Maybe you can point to where Dr. Root said that the neutral position of the STJ does not create more stability. Why else would Dr. Root want everyone to cast a foot in the STJ neutral position if he didn't feel the STJ neutral position had the most stability? Are you saying Dr. Root thought the STJ maximally pronated position was the STJ rotational position with the most stability?

    I hope we're not trying to rewrite history and place the blame on others and not on the original author himself, all for the sake of protecting the memory of one man.
     
  10. I didn't say that the floor of the sinus tarsi was the only restraining mechanism, I merely used that as an example of one potential restraining mechanism.


    Yep and since position does not in isolation predict stress... P= G + E + (GxE), where P = tissue stress, G = genotype, E = Environment (all non-genetic factors). Now, partition the Environmental variance... Then have a stab at the Genetic variance (we know there are genetic markers for various musculoskeletal conditions, for example Achilles tendinopathy)

    They use a different kinematic solution. I'm playing Devil's advocate, lets say we clone your person: one of them we send training for a marathon, the other we provide with an X-box, a large sofa and sufficient amounts of food and drink... which one is more likely to get a running related injury? What causes running related injuries? Running-right? Both have the same foot posture, the differentation lies elsewhere.


    Actually, I doubt whether these authors have even heard of Root, yet the idea seems to be catching on. http://www.physicaltherapyjournal.com/content/82/4/383.full

    Although these authors were talking about spinal position and "posture", I think the following should ring some bells here:

    "Rather than emphasizing an ideal standard of posture and hypothesizing that there is a large relationship among specific postures, impairments, and pain patterns, the [physical stress theory] PST proposes that pain is caused by excessive tissue stress and that postural deviations are one of many potential variables that contribute to the excessive stress levels that result in pain. We commonly observe people with “poor” posture who are pain-free and other people with “good” posture who have pain. The types of activities performed by people varies widely, resulting in different stress demands on tissues of the body.

    The PST predicts that no one ideal posture exists for all people because tissues will adapt to meet the unique stress demands of each person. Injury occurs when tissues are unable to adapt to meet the demands of a given posture or task. Therefore, rather than comparing a person's posture to an ideal standard, the therapist's examination should focus on the postures or movements that cause pain.26,32,38,39 Within this context, postural deviations become one of many potential factors that may place stress on injured tissues. In some people, the postural deviation may be the primary factor contributing to excessive tissue stress (see “Implications for Physical Therapist Practice” and “Implications for Research” sections). In our view, the PST expands upon the Kendalls' theory by proposing that postural deviations are one important component of musculoskeletal pain; however, pain patterns should be evaluated in a broader context that considers other potential sources of tissue stress."

    For Kendall read Root. Some years ago you advocated "not throwing the baby out with the bathwater"; I advocate passing both through a scientific sieve then taking a look at what's left. To achieve that we need to be critical.
     
  11. drhunt1

    drhunt1 Well-Known Member

    Quote:


    Originally Posted by rdp1210 View Post

    rdp1210-"If a person is standing in static stance with no reserve or pronation in the STJ, what happens when he wants to make a movement that requires more STJ pronation?"

    Simon-"They use a different kinematic solution."

    That is just flat wrong!
     
  12. Is it really? And you know this because? The foot is designed with built-in redundancy. For example, we know from the work of Nester and others that pronation like motion can occur in many joints of the foot, not just the subtalar joint. So lets say we need some frontal plane motion and the subtalar joint is at its end of rom for the force being applied, yet the talo-crural joint is not at it's end of rom for that given force and is currently more compliant to the applied load. What's going to happen? Given that when forces are applied across multiple joints of the foot simultaneously, the joints with the lowest stiffness characteristics will deform greatest... this is basically what has been called "compensation" in Root's and others publications, viz. it's a different kinematic solution. Or, are you now denying that this exists in order to attempt another poorly aimed personal "pop" at me, Michael?

    This doesn't even begin to touch on motor-control and the "preferred-movement pathway" model of Nigg and the metabolic cost models which seem to suggest that the body is programmed to move in the most metabolically efficient way whilst attempting to avoid injury.

    You may not like me, Michael- I really don't care, but I do know my subject field- don't attempt to play me for a fool. And that's as far as I'll rise to this tool- ignore list it is.
     
  13. efuller

    efuller MVP

    Daryl, I don't recall saying anywhere that you do not assess STJ axis position. From your writings and lecturing, I had always assumed that you did incorporate STJ axis position and tissue stress into your thinking. It is important that we understand what the other person is saying.



    Daryl, I'm mostly in agreement with you here. The major exception is the need for the replacement of some of the Root ideas. I'll say it again. We need to keep the good parts and discard the bad parts. I think one the reasons that Root theory is on the wane is that there are some internal inconsistencies that make the paradigm confusing. When I was teaching, there were many overheard conversations around graduation that were similar to this. "I'm really beginning to understand surgery now, but I don't really understand biomechanics. I got A's in class, but I don't really understand it." The students were able to figure out what the professors wanted to hear in terms of test answers. However, they were unable to study it enough to see the internal inconsistencies. A good example of this is the explanation of how orthotics work. In this very thread I was told that Mert Root did not profess that pushing the foot toward neutral position was not one of the explanations of how an orthotic worked. Can someone point out to me where Mert Root explained how an orthotic works. If we can't find that, can someone who is a Root disciple, explain to me their understanding of how an orthotic works. I would like someone to fill in the blank. We cast the foot in neutral position because...... It's really hard to be critical of theory when it keeps changing. It's also really hard for students to grasp a theory if it is never clearly articulated. There are more internal inconsistencies, but this one, how does an orthotic work, I feel, is the big question.



    Daryl, I think I better understand our disagreement here. I do agree that we need to examine all anatomical structures and understand the forces acting on them. Gravity acting on the center of mass will sometimes be relevant. The moment of inertia of individual structures will be relevant. I think our disagreement about the importance of the center of mass of the calcaneus comes from an error in your free body diagram analysis. So, when you want to do a free body diagram analysis of the calcaneus you isolate the calcaneus by removing all the contacting structures and then apply the forces that come from the removed structures. You cannot just look at the center of mass without looking at the forces from the forefoot applied to the calcaneus. In stance, most of the time, upward ground reaction force on the heel is going to be between 50-70% of body weight. The force on the forefoot will be transferred to the rearfoot (talus and calcaneus) so the forefoot is applying 30-50% of body weight to the calcaneus and talus. The calcaneus weight is probably less than 1% of body weight. So in our calculations it can be ignored because it is so small in relation to the other forces.

    Daryl, I don't think that having a frontal plane line that goes through the center of mass of the calcaneus will be useful in determining how the foot functions. If you believe that it does can you lay out your reasons for thinking so. Which physics equations do you want to plug the value of the moment of inertia of the calcaneus into to help understand foot function?


    Daryl you are correct the hypothetical patient numbers do not add up. But the big question is, how is a neutral position orthotic going to help a patient with peroneal tendonitis?

    Daryl, perhaps the reason that you are feeling boxed into a corner is that you and Jeff are the only defenders who come onto podiatry arena. Daryl, I really appreciate your depth of knowledge in physics. I know how it can feel. I've been the only person in a room who is being critical of Root. Daryl, I will say it again. I am not trying to eliminate Mert's mark on the world. I'm trying to separate the wheat from the chaff. We are disagreeing on what is wheat and what is chaff.

    Eric
     
  14. drhunt1

    drhunt1 Well-Known Member

    Simon-one sentence answers to rdp1210's question will never suffice...not in any meaningful way. If no STJ eversion is available at static stance or at mid-stance during the gait cycle, then ANY closed chain force applied to that individual, from either above or below will result in that individual NOT being able to compensate...they are laterally unstable. These patients are prone to inversion sprain injuries, feel like a "klutz" and do not excel at sports...and that's just for starters.

    There is no other alternative kinematically. You again bring up Nester...the same guy that mentioned he had found 3-4 cadavers that demonstrated greater axial and coronal plane motion in the ankle joint than in the STJ...that Nester? Even his references didn't support his "findings". Please. And we're supposed to accept what you write as gospel? I don't think so.

    It doesn't matter if I "like you or not"...I don't even know you. But I don't like your boorish, insulting, rude, pedantic and dogmatic approach to dealing with contrarian opinions to yours...even attempting to denigrate an outdoor sport as if you are some authority to point fingers elsewhere. Frankly, you and Kevin deserve each other...your approaches are quite similar, your egos equally fragile.

    rdp1210 asked you a plain, simple, yet fundamental question which you tried to dismiss with a one sentence answer that is, for all intents and purposes wrong. Instead of looking at serial plain film radiographs for trabecular reorganization, perhaps you should be more focused on similarities between patients' radiographs that demonstrate lateral instability. You might discover patterns on lateral views that would help those in private practice be able to treat these types of patients. When you and Kevin get together at the next conference, be sure to extend your pinkie fingers while sipping from your demitasse.
     
  15. Yeah, baby.
     
  16. rdp1210

    rdp1210 Active Member


    Interesting how we seem to have both heard many lectures from Root and gleaned different concepts. I remember one interesting debate between Mert and John at one seminar in which they had different concepts about the positioning of the MTJ when one needed to take a fully pronated cast. I never did hear how they resolved their differences on that. I will look it up in the "Root Foundation Notes" from 1985, but I believe that Mert usually believed in pouring the heel vertical, even for most fully compensated rearfoot varus deformities. I'll get back to you on that. Jeff may be able to shed a little more light. I believe that Jeff has said many times that Mert felt that heel vertical was the point of maximal stability. I wish I could get Bill Orien to participate in these discussions, as he is the closest to the original source as we have. Maybe I've had too many discussions with Bill, and I may be giving you more his concept than Mert's.

    I believe that protecting the proper memory of every person is important. I don't like to see any great thinker rubbished, even if some things he believed turned out to not be accurate. It's interesting that no physicist rubbishes Einstein over his opposition to quantum theory. Maybe I've been a little harsh on Chris Smith, so I'll recognize his great intelligence and see some academic differences as just that. What you may not know is that my real biomechanics hero at CCPM was a man of little recognition, Bud Collins. Now there was a intellect! Pat Laird was also a heavyweight in my book who gets little credit. And a person I have come to really appreciate in the past several years is Dave Skliar. Root was indeed a man of many warts, just as any other high impact person has had. I have the greatest respect for many of the high impact people over the years, and Root is just one of many. None of these high impact people were perfect. I hope that you find I have the same respect for many of the other past thinkers, like Dudley Morton, Royal Whitman and Sir Arthur Keith, as well as Russel Jones, Paul Lapidus, John Manter, Vern Inman, John Hicks, etc. You and I both know the philosophical impact that Mert had which may be looked on by history as his greatest contribution. His 1964 article on An Approach to Foot Orthopedics might his best in the annals of history. Right now in my office, I have over 400 hours of reel-to-reel tapes of Mert speaking, that my father made. Need to find equipment, time and money to have them all digitized so that they are not lost. I believe that much of the antipathy for Root has developed over the actions and attitudes of his zealous disciples. I remember that you did do a good job of identifying Mert's contributions, and maybe we can reprint those. I'm also in favor of identifying truly Mert's ideas and those who came before him. That's why I'm really in favor of allowing the idea of STJ neutral really pass to Lovett and Cotton, though it seems that Mert may have "rediscovered" on his own their basic concept of the foot having a position of being neither pronated nor supinated. The one thing that I believe is truly unique to Root is what I have come to call "The Root Postulate".

    Anyway, will try to detail better what the man said and what he didn't. Eric Lee, if you're on this, please give us your input as you have probably done the best historical research to date.

    Thanks for your comments,
    Daryl
     
  17. David Wedemeyer

    David Wedemeyer Well-Known Member

    Jeff Interesting thoughts. I took the Cped course in 2007 and at that time nearly the entire training and accompanying manual was Root theory based in evaluation, design and treatment. It could be that the CPed programs in countries such as Canada where they are baccalaureate degrees and university affiliated could progress to that level. In the US last I checked there were only two schools offering the CPed course and one is proprietary to a retail franchise. I feel the CPed program is dying a slow death in the US.

    I am seeing growing interest in the chiropractic and physical therapy fields and much less so in podiatry sadly. Some of the posters here are truly the old guard of modern podiatric biomechanics.
     
  18. Daryl:

    I am not trying to "rubbish" Mert Root. Like Eric, however, I believe we need to keep his good ideas and throw out his bad ideas in order to move forward intellectually as a profession.

    When you get a chance, I would be interested in what you feel is "The Root Postulate". Maybe we can start another thread here on Podiatry Arena to discuss this further since I am very interested in hearing what "The Root Postulate" actually is.

    And, if you need any help getting those tapes published, please let me know. I'll bet that some foot orthosis lab(s) wouldn't mind donating some money to get these tapes available for download/purchase and/or transcribed.
     
  19. rdp1210

    rdp1210 Active Member

    Dave, who you calling "old guard". I'm still in my youth and Kevin has hardly passed puberty. I'm not sure if he shaves yet. ;)
    Take care,
    Daryl
     
  20. Good idea, Simon. To the ignore list drhunt1 goes!

     
  21. Daryl is old. Eric and Craig Payne are right behind me. Simon is a kid.

    I still haven't gotten over the time when lecturing at the Biomechanics Summer School in Manchester a few years ago when one of the seminar attendees said that I was teaching "traditional biomechanics". Ouch!! :rolleyes::drinks
     
  22. David Wedemeyer

    David Wedemeyer Well-Known Member


    First post of 2015 and a faux pas! Errrr...what I meant to say was "established and esteemed luminaries of podiatric biomechanics" :) As for Kevin's pubescence or lack thereof, I cannot unsee that comment!
     
  23. Yeah, I'll take that. When we were in Florida in 2011, Ray Anthony said something along the lines of: "now that you're part of the old establishment of podiatric biomechanics, who is young and exciting now in the UK? I told him Ian Griffiths. But for the record, Griffiths has less hair on his head than me and I'm better looking. As for his regional dialect... it's incomprehensable.
     
  24. At least Ray didn't call you "traditional". As far as Griff is concerned, we will see at BSS 2015 in Manchester in June just how exciting he is....no pressure at all, Ian.;):drinks
     
  25. Jeff Root

    Jeff Root Well-Known Member

    I thought Rob was the only Kid(d) here! ;)

    Jeff
     
  26. Rob Kidd

    Rob Kidd Well-Known Member

    Rob is an old man - 60 next birthday. His knees may be failing, but his neurones are still 110%
     
  27. While Simon used ZOOS a little while ago.

    I like the term Physiological window. Same same really I read an article on the term which I posted a few years ago on here will look for it when I have a little more time. But a quick search came across the beloow page of a book, which I found interesting given the discussion

    Can across this though, Modelling in Medicine and Biology VI




    ps Happy new year everyone
     
  28. rdp1210

    rdp1210 Active Member


    Thank you Kevin.

    Contrary to popular belief, I myself have been trying to sort out what is wheat and chaff for 35 years. And as I've contemplated Root and my interactions with him and his followers and detractors, I've come to realize that he was indeed a complex and also dynamic person and personality. Few other people in the history of our profession evoke such emotion in almost every pod on all sides of the ponds. Interestingly enough that name of Root evokes in some the idea of enlightenment while in others it evokes the idea of cult-like superstition. Anytime a person's name alone evokes such a spectrum of emotions, they become an extremely important person to study. While on a microscale, comparing the total numbers in our profession worldwide with the entire worldwide population, I would say that percentage-wide within our profession, the name of Root has the same attention paid to him as more globally the names of Hitler, George Washington, Winston Churchill, Henry Tudor (VIII), Abraham Lincoln, Sigmund Freud. Almost everyone in our profession has an opinion on Root. On the other hand if we mention the names of Dalt McGlamry or Irv Kanat, who in the U.S. has really had as great effect as Root on the ways we practice, there is very little emotional reaction.

    I believe that if you read the biomechanics chapter I wrote for Levy & Hetherington in their Principles and Practices of Podiatric Medicine, I approached understanding biomechanics starting with forces and moments. I tried to help people remember muscle function in terms of the need for concentric, isometric and eccentric contractions to create accelerations, stabilizations and decelerations. I tried to include Root's ideas that I felt could be supported by good mechanical principles and to explain those ideas.

    With any such controversial person, we search for every scrap of evidence to support our opinions. And of course throughout the annals of time, it is almost impossible to find a historian who doesn't pick and choose those evidences, to support their own personal biases. Unfortunately, with Root, trying to find the scraps of evidence has been difficult, because, unlike Dudley Morton, he left so little written evidence. From my own limited interactions with him I am under the impression that he did this on purpose because he didn't want to be put in a box and not allowed to change his own mind. As has been pointed out throughout these and other discussions, almost everyone has had some degree of direct or indirect interaction with Root, and those interactions are indeed varied.

    With this in mind, I tried to approach the chapter I wrote for Steve Albert in terms of understanding the ideas that were in the world before and during the Root period. In trying to read the historical papers, I find that most of the Root thoughts about the function of the foot and lower extremity were already there. Indeed forefoot varus had already been addressed in many forms on both sides of the Atlantic. Maybe, Simon, you could get your hands on a pair of those Thomas Wrenches that George Perkins used to correct forefoot varus (see Perkins paper in 1948 in Proceedings). And the concepts of Wheeler Haines in the development of hallux valgus were very consistent with Root descriptions. As I've pointed out previously, Lovett & Cotton in 1898 proposed an ideal position of the STJ that they said was neither pronated nor supinated, and they built a device of leather straps and steel strips to pull the foot toward that position. Interestingly they did not use the word "neutral position." In considering all the historical papers, I find very little in Root that is unique to Root. Harris and Beath were writing about Equinus conditions creating flatfoot. Many pre-Root authors were trying to prove that flatfoot caused hallux valgus and hammertoes. Getting to know Dave Skliar has been a great source of personal information because from him I have gained insight into the mind of the great Dick Shuster. Interestingly enough, Mert's group and Dick's group in the early days of both got together frequently to discuss ideas. But after a while, those meetings waned and we started to hear more rhetoric that became known as the great East Coast - West Coast debate that was at its height in the 70s-80s. Unfortunately, some are now trying to make a rekindling of this debate into a U.S.-non U.S. format. If Mert and Dick had sat down together to decide how to resolve their differences instead of each retreating to their own corners and standing on their own soapboxes, a lot more progress would have been made and a lot fewer words of angst would have been spoken.

    With this all said, I have come to the conclusion that the one truly unique idea that Mert Root had, that I really don't find in the pre-Root literature, is what I have come to call, "the Root Postulate". This one idea seems to be core and crux of the Root-Schuster debate and the fork that divided their clinical practice of orthotic fabrication. What is that postulate? There may be a number of ways of phrasing it, but in essence it states that the foot in stance is maximally stable when the midtarsal joint is fully pronated." Off of this postulate Root based clinically measuring the varus or valgus of the forefoot and also in developing his casting technique. He also even chose "rigid" thermoplastics for orthotics materials with this concept in mind. I really don't like to tell this story, and have not done so before because I don't like to drop names or necessarily pat myself on the back (though I love adoration as much as anyone on this forum), but I do so in support of my proposition to adopt the term, "Root Postulate". In 1983, before I published my first forefoot-rearfoot paper, I sent Mert a copy of my initial submission to the Journal. He wrote back, with a few ideas for clarification and a little bit of encouragement that I see it all the way to publication. However it came back to me about 3 years later, after the paper was published, that he had commented to some of his friends that he thought that the paper was the best paper of the decade. When I heard this through a secondary source I was totally befuddled, because I thought the paper was simple and straight forward and really didn't have much to say. In retrospect, though, I now realize that the paper could have been seen by him to support his postulate and also to support the exponential unwinding of the twisted plate in the pronated foot that even today is gaining in evidence. Indeed, twisted plate theory and the Root Postulate intertwine and it is difficult to say that they can really be separated.

    With this in mind, I would be happy to start a new thread devoted to the idea of everyone coming to an agreement of defining and discussing "The Root Postulate". We need to discuss the following:
    1. Have I correctly identified the Root Postulate?
    2. Is there literature before Root that put forth Root Postulate ideas? The closest one I know of is Steindler (1929)

    If it decided by a majority that we will adopt term, "the Root Postulate", then we can turn our attention to:
    1. Arguments that the Root Postulate fit with known principles of mechanics
    2. Arguments that the Root Postulate is contrary to known principles of mechanics.
    3. That there is literature since 1977 (the last major Root writing) that supports the Root Postulate as being correct.
    4. That there is literature since 1977 that will show the postulate to be incorrect.
    5. Clinical experiences that would support and also clinical evidence that would not support the use of the Root Postulate.
    6. Possible modifications of the Root Postulate that could make it agreeable with all known evidence.

    We really have to make some rules for such a thread.
    1. No nationalistic comments. As I noted before, this is not a discussion about whether Root was from California, New York, Isle of Wight or Padagonia. We can all pick our favorite authors from the community we love most.
    2. No broad statements about everyone else. Such comments as "all the other literature shows ... to be invalid..." are not acceptable. If you want to quote a specific author, that's OK, but be prepared to defend the quoted author's research, its strengths and weaknesses. No author should be accepted by reputation alone. I'm willing to admit the weaknesses of my own published studies (which weaknesses are numerous) and everyone else should be willing too.
    3. A willingness of the commentators to admit their own biases and even agendas, even if it hurts. I will admit that I have some biases due to my personal experiences with my father and also with Milt Wille, both of whom I greatly admire. My father because he wanted to be known as the most progressive podiatrist, and Milt Wille because he showed me that it's OK to question even the most authoritative expert if there are flaws in their thinking. Some of you may feel that some Americans are trying to shove Root down your throat and that you would like to see those in your community better recognized. Some may feel that their own contributions are going unnoticed, and want more personal recognition. Some may feel that certain principles violate their own world-views. Besides my devotion to the two people above, I will admit to having an ego that drives me to be the best podiatrist. It's OK to admit these biases as we all have them. Only when we face such can we really get to the truth.
    4. Avoidance of accusations of motive of others. Such comments are only counterproductive. I have to say, that much of the East-Coast-West-Coast debate got caught up in rhetoric and personality. I heard Mert himself use a few expletives when talking about the other side. I'm not really sure that he tried to boil down the differences to find the fork-in-the-road. Also avoidance of glib, sarcastic, ambiguous and generalized statements.

    So with this said, I will start a new thread and look forward to comments,
    Best wishes,
    Daryl
     
  29. Jeff Root

    Jeff Root Well-Known Member

    Speaking of nationalism, I found a website last year that enabled me to trace my family roots (no pun intended) back to John Roote (1576-1664) of England. After John, the letter e was dropped from the last name. John is buried at the Church of Saint Virgin Mary Cemetery, Badby, Daventry, Northamptonshire, England. John's son Thomas Root was a colonist who is one of the original founders of Hartford, Connecticut, USA. So if Thomas had not come to the colonies, perhaps we would be blaming an Englishman named Root for all this controversy in biomechanics!
    http://www.myarnolds.com/individual.php?pid=I88182&ged=Arnold.ged

    My great grandfather was Merton Root the first, and he is at the end of the family tree that I found:http://www.myarnolds.com/individual.php?pid=I109922&ged=Arnold.ged

    Jeff
     
  30. I lived a couple of miles down the road from Daventry when I was mid-way through my PhD and was working for a commercial orthotic lab.
     
  31. drhunt1

    drhunt1 Well-Known Member

    rdp1210-you are the calm in the storm, in a manner of "speaking". I have read no one else's contributions on this site, that are as respectful and calculated to be 'mindful of others', as yours. But now that Simon and Kevin have me placed on ignore, I can write comments without their acerbic and ego-centric interventions. I applaud your willingness to drive to the heart of the matter here, and will wait with keen interest to see what transpires from the new thread. In essence, your parameters for this new thread gets to the bottom of the material problems that others have with Root biomechanics. But you've done this before, rdp1210, on this thread alone...asked very simple, straight forward questions that essentially "peel away" the wheat from the chaff, and the answers you received are as illuminating in their avoidance as any I read.

    Example #1: You asked Simon a straight forward question about a patients' ability to move when the STJ is maximally pronated. His response in post #170 was a simple one sentence answer until I called him out on that, so he edited it with a hypothetical question that STILL doesn't answer your question...one question that drives to the heart of the argument. Avoidance and bombastic irrelevance is his answer.

    Example #2: His exchange with me in post #135, he brings up a study performed by Nester that discusses dynamic cadaver measurements. In that study, Nester suggested that he found 3-4 examples of cadaver ROM in the AJ that demonstrated greater frontal and transverse plane motion than in the STJ...then goes on to reference another study that doesn't support his findings at all.

    Example #3: Simon in post #118 basically dismisses any relevance for bisecting the posterior aspect of the calcaneus because, as he writes, it is meaningless for anyone to determine NCSP vs. RCSP...it just doesn't matter in his world. Really? So...how does the tissue stress model resolve these issues...he never really discusses any of that. He's quite good at deconstructive criticism of anyone's technique, but seriously lacking in producing that which can further our efforts as a profession.

    Example #4: In post #110, after extending an "olive branch" to Kirby, (after Lab Guy intervened), Kevin states that if I posted my real name, (which he thought was TOTALLY unprofessional that I didn't provide that originally), he could then address me in a "professional" manner. He asked me to do just that..provide my name, which I did. So what does Kevin immediately do with that information? Precisely what I KNEW he would...attempt to smear my name on a legal issue I resolved 7 years ago and triumphed over the Board of Podiatric Medicine/AG's office etc. In other words, Kevin descended into the sewer in THE most unprofessional manner he could in his failed attempt to discredit me. This is a post he will have to live with, for quite some time. Big mistake. Copy, pasted and archived.

    There are many other examples of the self-anointed "Gods of Podiatric Biomechanics" failures to address the REAL issues that we face as practitioners while treating patients...but I think you get the message. And fwiw, I heard Kevin's lecture on Tissue Stress Model at CCPM at Samuel Merritt college and walked away learning nothing...zip, nada, zero. Ron Valmassy was there as well...and we talked right after that lecture on his way out the door to leave. Not a word was spoken about it between the two of us...not one. One would think that such landmark research and epiphanies would have been on both of our minds...it was not. What did we discuss? My animation.

    No matter what "theory" is utilized or which approach is taken, what is the end point? What should be, in the final analysis, the result of all our efforts? Improved patient care...something that seems entirely lost on the "Gods of Biomechanics". That is where my yet-to-be-published article fits in...the discovery of the root cause of growing pains in children and the connection to RLS in adults. One of the Big Kahuna's in biomechanics of the lower extremity. Oh, there's more on the way, but this shall be a start. Biomechanics doesn't operate in a vacuum...neither does kinematics. There are people attached to these legs, ankles and feet that come into our offices will real complaints...the patterns that are formed by the overlap in presentations and symptoms are staring us in the face, yet many of us are ignoring them, instead being more concerned with, and squabbling about minutiae, IMO.

    In a Precision Intracast newsletter written by Kirby in August 2003, Kevin mentions the work he and Green published in 1992 indicating that pes planus was the causative factor for growing pains in children. He also mention A. Evans article published in 2003 based on the findings of 8 children also concluding that pes planus was the problem. He stated that her study along with his work with Green was "more than enough evidence" for him to conclude that a biomechanical eval should be the first line of treatment along with triplane wedges, orthotics, stretching and/or mechanical therapy, (whatever that means). Thus...the issue was never fully resolved and was further obscured when in 2008, A. Evans did a follow-up study and concluded that pes planus was NOT a causative factor. Kirby concludes...again, that this is an overuse syndrome. Balderdash! If Evans' study/conclusions in 2003 using 8 patients is "good enough for Kevin", then he should be thrilled with my pilot study. Who wants to bet he won't?

    The end point...that's what we ALL need to focus on...patient care.

    rdp1210-please link the new thread to this blog topic. I will lurk in the background, keep my opinions to myself, but read with interest those that are willing to take on your epic topic. Separating the wheat from the chaff is always a good thing.
     
  32. efuller

    efuller MVP

    Matt the majority of your post is whining about how you were treated or complaining about what other people do. When you complain about what other people are doing, you do not provide a reason why what they are doing is wrong. You do say that people are making things too complicated, but this is not a valid criticism of why something would not work. You have been a champion of critical thinking yet you do not show us your reasoning. You can continue to write about personalities or you can start writing on what you claim is important, improving patient care.

    Explain why your video is an important advance.

    Explain what you do with the information you get when you compare RCSP versus NCSP.

    Answer the question that I posed: Why should people cast the foot in neutral position?

    Why do you think orthotics casted in neutral position work?

    Let's see some of that critical thinking that you are so proud of.

    Eric
     
  33. drhunt1

    drhunt1 Well-Known Member

    First, Eric, my "whining" was limited to example #4...did you not read the first 3? Care to comment on those and retract your statement that my post was all about "whining"? Was my example #4 not a legitimate concern, and a prime example of unprofessional behavior?

    Second, animation could be a VERY useful tool in allowing practitioners and students the ability to visualize biomechanical concepts. Simon and Kevin both ridiculed my efforts, but only Kevin provided an example of something he and "Dr. Glass" worked on eons ago. Notice the lack of accurate depiction of STJ motion in Glass' video? Mine is better...not perfect by any stretch, but much better. In fact, up until I produced this video, I had not seen talar plantarflexion/adduction reproduced to any degree. Mine is a step in the right direction. Further, what did you think about the modeling portion? Did not "light bulbs go off in your head"? When viewing that simple video segment, attention should be drawn to the STJ, as the medial and lateral columns are distracted from each other. Remember, this was a video segment I designed to be used for gatekeepers...MD's. The one's I have shown it to, plus my two peer review docs, plus an architect as well as some of my patients, they were all very impressed and appreciative. Good enough for me.

    Third, the value of comparing RCSP and NCSP is for the practitioner to get an idea of how much correction at the rear foot and forefoot might be necessary to achieve the goal of holding the foot in a more corrected position. It's just one of several static measurements that I perform in order to gain a better understanding of the patient's foot type and possible strategies to correct them. Gait analysis is also an important tool. While everyone else is arguing about the value of static measurements, I am being rewarded with resolution of patient complaints. So if arguing is your focus, or redesignation of what theory we should be looking at, then continue with what you're doing. Thus, the value of posterior calcaneal bisections...it's just a reference line in my practice. Sure, I try to be as accurate as possible, but that's not always achievable. Now, one can argue about how inaccurate that task is, or one can plow through that, and use that information to create better patient outcomes. Your choice.

    Fourth, I try to cast and order orthotics to hold the patients' foot closer to neutral position because that results in the best patient outcomes. I realize that joints function best when they function close to neutral, with the knee a possible outlier to that theory. But an analogy I give to my patients is the following: imagine if I forced a patient to run a series of 100 yard dashes without being able to bend their knee, ie., straight legged. How would their knee feel later that night or the next day?

    It wasn't until the "light bulb went off in my head" about putting together the patterns I was witnessing in my office with my patients in re to GP, that I began to research the issue. That's when I first began reading about it on Google Scholar. When I first began my pilot study, and I began to research this topic there were 182K hits on GS on it. When I concluded there were over 200K hits...now there's >322K. I thought to myself...how did we miss this...where did we go wrong, and how has no one ever put this puzzle together? Then, as my research was furthered, I came across articles where MD researchers tried to describe GP in children as the adolescent form of RLS. That's when I broadened my research and pilot study to include RLS. With just a few additional past medical and family history questions being asked in my office, of the patient and family members...I started to put the pieces together. Since that time that I wrote the article, I have been even more convinced of the connection and my hypothesis...which is that GP and RLS are a continuum of the same problem. I just hope that the article is published sooner then later. Then we can discuss more germane ways to treat these maladies which will ultimately provide better patient outcomes. Hope this helps.
     
  34. efuller

    efuller MVP

    Matt, I thought you wanted to contribute to improving clinical outcomes. Ok I can see a video as a teaching tool. The flouroscopy video Don Green Produced in the 1980's would serve the same purpose without the concern of artist's misconceptions. An article that might help you make a more accurate video is Van Langelaan E. J. van, A Kinematical Analysis of the Tarsal Joint an Radiographic Study. Acta Orthopaedica Scandinavica Suppl #204. 1983. Vol. 54

    What light bulbs were supposed to go off. I already understand the motions of the foot.

    So, this is a sales tool to market to gatekeepers..... How is this supposed to improve clinical outcomes?


    So you've rasied some interesting points. What do you mean by correction? How do you know your correction is correct? Can you give an example of RCSP versus NCSP is used to change the yet undefined term of correction. You have accused folks here on the arena of not thinking critically. Have you thought critically about terms like correction?

    We all get resolution of patient complaints. Blood letters got resolution from patient complaints, even the ones that lived.


    So, why do you think that casting in neutral position results in the best outcomes? There is certainly no literature that states that. Why is it better to function in neutral position? When you put patients in NCSP, what percentage of patients have their first met head on the ground? Is it better to function with the first met head up in the air as opposed to on the ground. Have you ever looked at the amount of STJ position change on top of an orthotic versus not on an orthotic? Have you every thought critically about why a joint would function better in neutral position?

    Eric
     
  35. drhunt1

    drhunt1 Well-Known Member

    Eric-thanks for the link and I already addressed the problems inherent with using fluoroscopy in an earlier post...did you not read it? It's called radiation! Heavy rems given to the patient or subject. DO NO HARM!

    The "light bulb" that goes off when most others view the modeling segment is the major articulation between the medial and lateral column at the STJ. Sure, there is the buttressing effect between the lateral cuneiform and cuboid, but it's the STJ that brings those two separate entities of the foot together. It's the "money" joint of the foot. The video wasn't designed to be a "sales tool" for the gatekeepers, (it has since turned out that way), but when increased business comes your way secondary to the dissemination of this information are you going to turn them away? Will you send them my way, telling the patient's parents that you don't believe in the manner I discovered this, or don't agree with my "critical thinking"? I haven't offered the last video I produced, (which is actually the best), after the very warm reception I received from some of the blog members, I realized what a waste of time it was.

    Static measurements aren't taken in a vacuum. There are taken together. After or before measuring NCSP and RCSP, a measurement of the ROM of the patients' MTJ and STJ's needs to be determined. The hardest foot to treat, IMHO, is the patient with low ROM of the STJ and MTJ that also presents with a forefoot varus deformity. (Couple those items with a rear foot varus position, something I call skewfoot, and it's very difficult to control that patient). Sometimes, the forefoot deformities can be 'casted out', sometimes they cannot.

    The original paper we wrote is 42 pages long, (10K words), complete with jpegs, illustrations, pictures etc., and discusss these foot types. The revised edition is only 3K words and doesn't delve into the treatment to any great extent. The original paper would be very informative to those interested in how they would/could approach the problem, and would produce better clinical outcomes.

    Perhaps one of the reasons I discovered this problem and the resolution is that I didn't cloud my vision with too much of the research oriented papers out there and let my own costly mistakes of reordering orthotics lead me to that final destination. Patterns...look for the patterns in your own patient group and put those patterns together...you might be surprised what you find. Hope this helps.
     
  36. efuller

    efuller MVP

    Matt, I did read what you wrote then and I thought it would have been petty and you might accuse me of being unprofessional if I pointed out the flaw in your logic. However, since you repeated it....
    Your video is an instructional video, done by artists. It has nothing to do with any individual patient. Matt, when I viewed Don Green's film in 1987 I didn't pick up any radiation exposure. I believe it's available digitally and if someone were to watch it today, they would not be exposed to the radiation.


    You discovered this??? Ok personal discovery. I guess I discovered this in 1987 by watching a video made by someone else.

    Matt, I asked you to provide an example of what you would do with the information you got from comparing NCSP to RCSP. The above paragraph, when viewed critically, would lead one to believe that there is no information gained from that comparison. Do you want to try again?

    Matt, I would agree that people who look for patterns and also learn from their mistakes will tend to get better results than those who don't. However, the statement that you don't let research cloud your vision is troubling. The published research will help you learn from others' experience as well as your own. No one knows so much that they still can't learn from others. I learn from people who can support their arguments with logic and research.

    Eric
     
  37. drhunt1

    drhunt1 Well-Known Member

    Eric-it appears that you're of the Tissue Stress Theory School of thought, so anything I write, like with Spooner and Kirby, you're going to dismiss and/or attempt to punch holes into. Am I wrong? Is my engagement of your questions a complete waste of my time? Prove me wrong. Simon and Kevin have buried their heads in the sand by placing me on ignore..."out of sight, out of mind"...and "ignorance is bliss" comes to mind. Several Podiatrists that saw the video acknowledged how helpful it is in visualizing the importance of the STJ in the relationship between the two columns. Don't you think students would appreciate that info? How about others outside of our profession? Listen to the audio portion of the video sequencing again in the second youtube video I posted. Have any problems with the narrative?

    You wrote: "Matt, when I viewed Don Green's film in 1987 I didn't pick up any radiation exposure. I believe it's available digitally and if someone were to watch it today, they would not be exposed to the radiation." I can't believe you wrote that...and you were an instructor? Here...try this link:

    http://www.webmd.com/cancer/news/20100331/faq-radiation-risk-from-medical-imaging

    Fluoroscopy imparts 50% to 25 times the dosage of radiation of a CT scan...and one abdominal CT itself delivers the equivalent of 2.7 years of radiation as living on this planet. I WASN"T REFERRING TO THE VIEWER...it's the patients/subjects that are receiving whopping dosages of rems. Did Dr. Green place dose cards on the subjects prior to his fluoroscopy study? OK, that info is good stuff, like I wrote...for that individual patient. Everyone is different...every foot functions slightly different...every foot, because of these individual differences adapts to the terrain differently. Did it ever occur to you that markers could be placed on the overlying skin to pinpoint osseous prominences throughout the gait cycle to produce more accurate animated representations?

    After comparing RCSP to NCSP, and taking static measurements of the ROM of the ST and MTJ's, then I have a pretty good idea if I can "cast out" the forefoot deformity, (if that's where the problem lies), or how many degrees of correction I need to prescribe in order to get the patient functioning closer to neutral.
     
  38. Griff

    Griff Moderator

    Hi drhunt1

    Just a few comments based on your above post from someone who has been following along over the Christmas break with interest.

    1. Calcaneal position has not been shown to be predictive of lower extremity overuse injury

    2. As already stated, the drawn bisections exhibit poor reliability (particularly inter-rater) and it is also unlikely they are reflective of true bony position and movement

    3. The available scientific literature does not support the contention that foot orthoses will exert a consistent kinematic effect (they may not exert any kinematic or angular change whatsoever)
     
  39. Jeff Root

    Jeff Root Well-Known Member

    Eric,

    Let me respond to this question. Root theorized that a joint was most stable when compression forces were greatest and rotational forces were lowest and that greater muscle and ligamentous function would be required to stabilize a joint when the bones were not linear because rotational forces would be potentially greater. He theorized that when the stj was in the neutral position, the joints of the foot would have lower rotational moments or in other words, the angles between the osseous members would be lower than in the pronated foot.

    Root wrote: "Static stance stability of the foot is of minor clinical significance. In most feet that function abnormally during kinetic conditions, the static stance periods are probably not very traumatic to the foot. Therefore, static stance can be considered to be clinically insignificant except in feet that are severely subluxed and pronated". (page 105 Normal and Abnormal Function of the Foot).

    Root also wrote: "The two components of force which interact at a joint are compression (linear) force and bending (tension or rotational) force. Compression forces contribute to joint stability, and bending forces contribute to joint instability. Compression forces tend to stabilize a joint by compressing one bone against the other across the joint. Bending forces produce instability at a joint because they tend to produce rotation between two articulating bones. Therefore, all bending (rotational) forces must be resisted by tension exerted by soft tissue which is extrinsic to the bony articulation in order to maintain normal joint stability".
    some cut:
    Bone is the primary tissue that supports the forces of locomotion. Muscle contraction contributes to stability by resisting only the varying rotational moments of force that develop as the bones move relative to each other. Ligament tension develops only if forces acting upon a joint tend to move the joint in a direction contrary to its normal plane of motion or if they move if they move it beyond its total range of motion. Therefore it seems reasonable to assume that in a normal functioning foot, very little ligament function is necessary to maintain joint stability during the stance phase of gait.

    In a foot that functions in an abnormally pronated position, rotational forces increase at most joints. This occurs because the angles between the bones increase, and the angles at which forces interact across the joint also increases proportionately".(page 109).

    Root also went on to explain that a supinated foot is more stable then the neutral foot and is necessary during the propulsive phase of gait in order to make the foot a rigid leaver for propulsion.

    So you asked "Why do you think orthotics casted in neutral position work"? They don't always work. However, when they don't work there can be a number of reasons that have nothing to do with the neutral position. A better question would be, what is the reasoning behind casting the foot in the neutral position and how does this contribute to orthotic treatment success?

    Simply stated, a properly made orthotic from a neutral position cast can reduce pathological forces to help alleviate symptoms. In some cases it may be necessary to cast the foot in a pronated position or in a supinated position to achieve better symptom resolution. However, the neutral position has proven to be a very effective position to cast feet when making functional orthoses. But it isn't just the stj neutral position that contribute to this history of success. Pronation of the midtarsal joint is also a fundamental component of Root's neutral position casting technique, and as Daryl has pointed out, perhaps more important than having the stj in the neutral position.

    The goal of the orthosis is not to hold the foot in the neutral position at the stj, it is to reduce pathological forces to the greatest extent possible. Ideally that means the orthosis should contribute to supination and pronation of the foot during the gait cycle and is should resist extremes of motion (extreme forces) that are associated with pathology. Since as Root pointed out the foot is not typically traumatized during bipedal stance, whether the foot is in the neutral position or not at this time is usually of little consequence. However, we do see that orthoses can, in some case, alter the position of the rearfoot to reduce the degree of supination or pronation at the stj during relaxed stance.

    So if well educated and skilled practitioners use casting positions other than neutral and have good outcomes, then great. If they can provide the criteria by which they make their treatment decisions like root did so we can teach others, including the students who are the practitioners of tomorrow, and if in so doing those future practitioners prove to demonstrate a history of good outcomes, then that would be progress.

    Jeff
     
  40. Jeff Root

    Jeff Root Well-Known Member

    Ian,

    Please explain why and how the heel bisection with the orthosis under the foot is so much more vertically oriented than the RCSP picture with no orthosis in place in pictures Matt posted, if this is not due to a change in the frontal plane position of the calcaneus.

    Thanks,
    Jeff
     
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