Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

Thanks for cleaning up this thread, Admin.

Now maybe we can stop insulting each other and keep the discussions professional and educational so the thread won't eventually need to be closed to further postings.

 

Apologies, a manic few weeks with little time. I think Mike’s point is well made regarding trying to detail what specific modifications achieve. This discussion thread has started to allow some clarification of terminology and a basis for moving forward. Providing information on what orthoses can achieve and how as he outlines, would provide a baseline both for practice and teaching and allow individualisation. The recent Australian paper (http://www.jfootankleres.com/content/7/1/49) has tried to provide criteria for prescription writing for flat feet.

I do believe there should be some clarification as to how the effects of a tissue stress approach (I am divorcing this from SALRE) are assessed other than symptom relief – how do we know we have not unduly increased stress to another tissue?

For medial knee OA, it has been demonstrated that laterally wedged orthoses reduce the external knee adduction moment (EKAM) which is believed to be important in reducing symptoms. However, a meta-analysis shows that there is little consistent change in pain compared to ‘neutral’ orthoses and a study by Chapman et al has shown:

1. Laterally wedged orthoses shift the CoP laterally
2. Increase rearfoot eversion and eversion moment
3. In 1/3 of subjects EKAM increases
4. Whilst there was a trend for those with baseline higher eversion / eversion moment to reduce EKAM, there was no clear cut threshold.

In a recent editorial, Creaby notes that the knee flexion moment is a factor in this condition and the degree to which EKAM and knee flexion influence knee load, perhaps not surprisingly, varies between individuals.

Clinically I have had two recent patients who demonstrated excessive tibial rotation (assessed with 3d gait and statistically high value compared to an uninjured database). When observed clinically, the tibial rotation correlated with navicular drop / drift (as per the recent work from Nester’s group). A simple OTS device to reduce this motion reduced pain.

So we can determine specific treatment regimens for patients but how do we assess the outcome? If in the case of medial knee OA we provide laterally wedged orthoses, we could make the assumption that we are reducing the load when in fact, it has been shown that there is a 30% risk of increasing the load? We would only know that this was the case IF they had increased symptoms - they may not but the increased load could be negative in the long term. Similarly, if we provide a patient orthoses with increased lateral wedging for say a peroneal or lateral ankle problem, how do we know we have not increased the force through the knee?


Chapman GJ, Parkes MJ, Forsythe L, Felson DT, Jones RK, OA & Cart, 2015 – in press

Creaby MW, Editorial: It’s not all about the knee adduction moment: the role of knee flexion moment in medial knee joint loading, Ost & Cart, IN Press, 2015:1-3

Dubbeldam R, Nester C, Nenee AV, Hermens HJ, Buurke JH, Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects, Gait & Posture 2013, 37:159-164

Parkes MJ, Maricar N, Lunt M, LaValley MP, Jones RK, Segal NA, Takahashi-Narita K, Felson DT, Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis, JAMA, 2013, 310(7):722-730

 

Trevor, thanks for your thoughtful response. Let me comment on a few of these thoughts.

Using the Tissue Stress Model, we of course don't know that we have "unduly increased stress to another tissue" until the patient complains of symptoms. However, this is also true of any other approach used for prescribing foot orthoses, and is not a problem with just the Tissue Stress Model. Using the Sagittal Plane Facilitation or Root Model, how do we know that we have not "unduly increased stress to another tissue"? We don't until the patient complains of symptoms, just as in the Tissue Stress Model.

I'm not so sure about your above conclusions, Trevor. There are now numerous studies which show valgus wedged insoles not only decrease the external knee adduction moment, but also decrease the medial compartment compression force within the knee and decrease patient symptoms in medial knee OA versus controls. I just finished writing a 3,000 word article for Podiatry Today with over 60 references on this subject. I can provide my reference list if anyone wants it. The article won't be published until October 2015.

You can assume using biomechanical modelling that anytime a patient changes their shoes, puts on a different insole, has an orthosis adjustment, or does a different weightbearing activity that the forces and moments will be altered in each of the joints of the lower extremity. You also assume that anytime a patient changes their shoes, puts on a different insole, has an orthosis adjustment, or does a different weightbearing activity that the central nervous system (CNS) will respond to these alterations in forces and moments and change make small "corrections" in the efferent activity of the muscles of the body in order to accomplish the weightbearing task using less metabolic energy, with the minimum amount of pain and in a manner which prevents injury.

In addition, an increase in "force through the knee" is not always a bad thing. Internal loading forces build stronger bone, stronger muscles, stronger ligaments and stronger tendons. The body is strengthened by optimal repetitive loads being applied loading to it's structural components but is also injured by excessive magnitudes of repetitive loads being applied to it's structural components.

We, as clinicians, must understand the biomechanics and physiology of the human body, and realize that what happens internally within the body is governed by exceedingly complex processes that we, most times, have little knowledge of. Therefore, we must not only observe, examine, test, and image our patients, but we must also ask and listen to our patients of their complaints since, in many instances, the perception of discomfort by the patient is not measurable by any objective means so that their subjective complaints may be most sensitive measure of the changes in internal loading patterns that we accomplish with our orthosis and shoe modifications.

 

I cannot disagree with you here but there must be some criteria you use to limit where or what you do so as to reduce the risk of injury elsewhere. Calf inflexibility may be an example that we might offset against the resistance provided by any orthosis – we may provide less resistance, include a heel raise etc. The pronation and supination moments acting on the foot will be a summation of the whole leg function, the activity etc. If I have someone with reduced hip adduction or limited tibial rotation, there is a risk that providing an orthosis to increase supination moments will limit these motions further – it may help a specific injury in the foot but at the risk of load elsewhere.

These were the conclusions from the papers quoted. These papers indicate that the result in terms of pain is at best mixed ( the conclusion of a meta analysis)and, in some, the EKAM is increased (about 30% in the study quoted).

[QUOTEIn addition, an increase in "force through the knee" is not always a bad thing. Internal loading forces build stronger bone, stronger muscles, stronger ligaments and stronger tendons. The body is strengthened by optimal repetitive loads being applied loading to it's structural components but is also injured by excessive magnitudes of repetitive loads being applied to it's structural components.[/QUOTE]

Agreed, but in the case of medial knee OA, the aim of the treatment is to reduce the moment whereas it increases in a not insignificant number.

[QUOTEWe, as clinicians, must understand the biomechanics and physiology of the human body, and realize that what happens internally within the body is governed by exceedingly complex processes that we, most times, have little knowledge of. Therefore, we must not only observe, examine, test, and image our patients, but we must also ask and listen to our patients of their complaints since, in many instances, the perception of discomfort by the patient is not measurable by any objective means so that their subjective complaints may be most sensitive measure of the changes in internal loading patterns that we accomplish with our orthosis and shoe modifications.[/QUOTE]

Again agreed but this does not stop us considering methods to reduce the risk of patients developing other problems. If we institute a treatment to reduce stress but demonstrate it makes function elsewhere worse, then perhaps this would be an indication to either use this as a temporary measure or advise the patient that there is a risk or they may have to reset their training programme or activity goals, much depending on the complexity of the individual.

Lost in all of this was the excellent suggestion of trying to get some commonality with terminology and methods for altering loading. I wonder if there is a desire / method to take this forward?

 

Assessing stress on tissue is a very difficult thing. You could put a strain gauge on the structure that you are concerned about. However, that might do more damage than the treatment. That is why we resort to modeling. You can model the external forces that you would think would increase stress on the anatomical structure that you are concerned about. If you reduce the external force where you in intend to, and the pain decreases, you have some rationale that there is cause and effect.

The thing about tissue stress is that you can attempt to predict what problems you will create. For example, when you model sinus tarsi pain, you would predict that decreasing the pronation moment from the ground would decrease the interosseus pressure in the sinus tarsi. A patient with tibial varum will tend to have little eversion range of motion available and be more likely to get sinus tarsi pain. The treatment for sinus tarsi pain is to shift the center of pressure more medially. As you shift the center of pressure more medially, you will be increasing the external adduction moment on a knee with tibial varum. So, you should warn your sinus tarsi patient that they might get medial knee pain. If you understand how your treatment should alter forces you can look for areas where there may be more potential for pathology.

I agree with Kevin here. You have some studies that show that a valgus wedge helps and others that say there is no effect. So, what do you do when there is conflict in the literature? There was one study mentioned recently here on podiatry arena that showed that amount of eversion range of motion was related to the effect of the valgus wedge. I makes perfect sense. Not all feet have the same amount of eversion range of motion. So, not all feet will respond the same to the same amount of valgus wedge. Which could lead to masking the effectiveness of the wedge in a study.

Trevor have you ever stood on a very large valgus wedge? I can feel the valgus moment on my leg with a small amount of wedge. It sure feels like a valgus wedge should create that effect.

Trevor, when you discuss tibial rotation, are you talking about rotation in the transverse or frontal plane?

Tibial rotation is a nice objective measurement. You can correlate it with navicular drop. Now if you have a correlation between navicular drop and pathology you would have a nice empirical indicator of pathology. You give someone and arch support and the navicular drop decreases and the pain goes away then you have a good rationale for giving people with a large amount of navicular drop arch supports. (In regards to your points about tissue stress: How do you know if your arch support is going to cause pathology elsewhere? Where would it cause the pathology?) With the empirical approach you don't have a good explanation of why the pathology occurs. All you have is a correlation. It would be nice to look carefully at the empirical success and try explain why it successful. When I say look closely, I mean model anatomical structures. Tissue stress does need to incorporate empirical results. When tissue stress does incorporate empirical results, we can know why pathology is occurring and know why the treatment is helping. This will allow us to better devise, or use, other treatments that use the same means to reduce stress on an anatomical structure.

Eric

 

Those that are adhering to valgus wedged extensions for treatment of medial knee DJD, must believe that the problem exists in the frontal plane. I don't believe it is a frontal plane problem...and my aim is to prove that.

 

Where is the evidence that adding a 1/8 inch soft top cover will help reduce ground reactive forces (GFRs) more than the hunk of wedged foam it is sitting on? And will that 1/8 of extra top cover be enough to mitigate the very large impacts our very large patients produce? Are they placing probes in the tendons and fascia of walking people and measuring the effectiveness of their prescriptions vs Root-based or other newer gait systems?

Aloha Jeff,

I do not understand how we should walk away after your father worked so hard to put some science and math fundamentals into our orthotic designs. He had us make biometric measurements and off those measurements design our orthosis. How does this unsupported Tissue Stress Theory enhance that? Is it better and more scientific than what your Dad proposed.

Where is the proof that it is now most accepted-correct theory?

It sounds like you are also having inside-outside shoe testing issues as well.

"we don't necessarily have the technology to measure the forces generated by the orthoses" ok but what if we can make orthotics that do?

Kevin is not responding to my posts and questions so perhaps you can answer this for him?

Mahalo,
Steve

 

This is a nice example of how you can use a structural position, combined with joint range of motion to try and predict the effect of your intervention. This is why I believe we need to be cautious with our criticism of looking at underlying structure as part of our assessment. It helps to determine how our interventions may alter function in both a positive and negative way. I suspect that those with years of experience do this automatically, it is how it is taught so that it fits in with the wider balanced approach that would benefit from development.

I would agree with the sensation. The Chapman study I quoted indicated that those with more eversion were more likely to respond but there was no clear threshold. In reality, it is likely that, in a percentage of people the EKAM is the relevant factor and a lateral wedged insole will help. In others, there may be other factors such as rotation or flexion and thus a lateral wedge insole is not effective and may be one reason why the EKAM increases. I would suggest that there is enough evidence out there that EKAM and laterally wedged insoles are not the answer for all.

Transverse plane rotation

In the example I gave, we could correlate the arch drop with the tibial rotation and get a positive result. I can still marry this to the SALRE approach as the navicular drop / drift indicates a pronation moment and the support provided increased supination moments. However, the pathology (medial knee OA), as we have discussed above, can be treated by increasing pronation moments about the STJ axis to try and manipulate the knee moment. Yet both can be successful.

I believe this is because, for any given condition, it is how the triplanar motion of the individual interlinks and which segments couple. It is my opinion that this varies so that in some, it will be more of a transverse plane issues, others frontal etc. Similarly, I suspect that tibial rotation couples with arch height in some but others may demonstrate coupling with the rearfoot. In the cases I provided, we were able to assess relative motion and determine the direction of the treatment provided hence the application of supination rather than pronation moments.

In terms of trying to determine the effect elsewhere, when I analyse the 3d gait kinematics (unfortunately, I cannot measure the moments at this stage), I can see whether or not, when I introduce orthoses, it increases or decreases motion at the pelvis, hip, knee or ankle. This gives me an indication of the potential global effect of my intervention. Is it better or worse, what are my aims and duration of intervention, does the individual have to sacrifice motion in one plane or another site in order to be comfortable with the presenting complaint and perhaps modify their desired activity levels etc.?

I appreciate that not all have access to this equipment so it strikes me that there are levels at which people can practice:

1. “I” know how to reduce the stress to that tissue, I will do so and as long as it gets better and nothing else hurts, we are helping the patient. I would suggest, this is relatively straight forward to teach although I have deliberately not touched on orthoses design. It does of course run the higher risk of causing problems, particularly for those with less experience.

2. By modelling the structural alignment / muscular control and co-ordination, “I” can make a judgement of the more global effect of my intervention and modify my management / advice accordingly. This is an area that would benefit from discussion and development and would advance practice. It would of course have to be validated but it would be a start and, by being based on clinical assessment, cost effective.

3. “I” can utilise further evaluation tools (video / inshoe / 3d gait / moments) to try and asses the global affects. I would suggest that video has limited benefit in the assessment of the effect of orthoses as one cannot measure rotations. Plantar pressure analysis can at least demonstrate the overall effect of the interventions and give an idea of symmetry. 3D gait, provides more global data and, if we can get to a stage where it is cost effective to assess joint moments with the kinematics in the clinical environment, would provide greater information.

Better go and do some work!!

 

You would be assuming a lot then. I do not believe medial compartment osteoarthritis to be a frontal plane problem. However, to address the symptomology of the degeneration while one awaits knee replacement (which at times can be held off for as much as ten years by the way) the patient is in need of maintaining as much moveemnt as they can. It is difficult when it hurts. I have done valgus wedging on a great many over the years and even progressed them to unloading knee orthoses after that. The patients are always happy with symptom control and are always wondering why it was not suggested earlier. I have followed many of these patients for as much as 15 years. There were no ill effects from the valgus wedging that was done to aid them in their plight.

Do not assume to know what someone you do not know believes. It says more about you than it does about anything else.

 

There a multitude of reasons why a valgus extension "might" help the patient...one of which is placing the knee in a position where the previous degenerated area on the medial tibial plateau no longer rubs. In 2010, there were 720K prosthetic knees replaced in the US, at a cost > than $8B. Factor in the arthroscopic surgeries that precede these procedures, and one can gain an appreciation of the totality of the problem. Prevention, therefore, is the key. That's my aim. And whom wants to doubt my veracity on this topic after solving the mystery of GP/RLS? Regards...

 

once this this is your claim you have no scientific proof of it

 

How does the tibia rotate in the frontal plane?

 

Certainly not according to you. But will you use my method to test my hypothesis for diagnoses? I seriously doubt it. After all...personalities before principles in your world...right, Mike?

 

No science most important in my world

 

I'm not sure why you are asking. The tibia rotates in the frontal plane when an unbalanced moment is applied to it. If you apply a moment to the tibia and it does not rotate then there are some other forces acting preventing the rotation. Those other forces are the ones that could cause medial knee OA. Matt, you said you read my and Kevin's chapter. There are some nice pictures in there explaining this concept.

Eric

 

Then tell me how was Angela Evans' 2003 article so much different? How was hers "more scientific", and mine less so? If you can't handle the method, then at least test the hypothesis... or is that too much to ask? Obviously so.

 

And the thread was about:
Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

And now the topic is about drhunt....

Moving on...yawn

 

Please re-read posts #570 and 571. Take your issues up with Mike, but I answered your question.

 

Todd:

I have been using valgus forefoot and rearfoot wedging for patients with medial knee osteoarthritis (OA) now for over 20 years. I learned about valgus wedging for medial knee OA from one of the older orthopedic surgeons I practiced with for many years who has since passed away (I have been practicing with orthopedic surgeons now for 30 years). I have also followed these patients over the years and they don't seem to have any ill-effects from these wedges as long as the valgus wedge isn't too large. Valgus orthoses/insoles work very well for the relief of the pain of mild medial knee OA, work fair to good for moderate medial knee OA and don't seem to work at all for moderate severe to severe medial knee OA.

I do believe that the valgus wedges work on the frontal plane and, as Eric stated, our chapter includes a lengthy discussion of frontal plane knee kinetics as it relates to the compression loads within the medial and lateral knee compartments (Fuller EA, Kirby KA: Subtalar joint equilibrium and tissue stress approach to biomechanical therapy of the foot and lower extremity. In Albert SF, Curran SA (eds): Biomechanics of the Lower Extremity: Theory and Practice, Volume 1. Bipedmed, LLC, Denver, 2013, pp. 205-264).

I was heavily influenced back in my Biomechanics Fellowship in 1984-1985 on frontal plane knee biomechanics by reading the book on knee biomechanics by Maquet. His book, which has excellent mechanical illustrations and photographs of the forces acting within the frontal plane within the knee, is still an great read. Any clinician who has an interest in treating knee pathology with orthoses should thoroughly read and understand the concepts put forth by Maquet from over three decades ago (Maquet, Paul G.J.: Biomechanics of the Knee. Springer-Verlag, New York, 1984).

 

I look forward to reading the article. However, there are quite a few studies that indicate otherwise. One of the problems is not only a definitional one, but also a 'descriptional' one as well. The actual foot type(s) that lend to development of medial knee DJD is not addressed in the studies I have read.

http://journals.lww.com/ajpmr/Abstr..._Knee_Varus_Moment_Reduction_Caused_by.4.aspx

http://www.sciencedirect.com/science/article/pii/S0268003311001914

http://onlinelibrary.wiley.com/doi/10.1002/jor.1100120314/abstract

http://www.tandfonline.com/doi/abs/10.1080/03093640802613237

There is a lot more that needs to be done in this area of study. I'm on it.

 

Eric-I slugged my through that chapter, yes...but that doesn't mean I agree with what you wrote. It is theoretical, IMO, at best in the area you're referring to. Frontal plane motion of the tibia is not responsible for medial tibial plateau DJD. That is my theory, and now it is up to me to prove it. I'm on it.

 

Fair enough Todd it is just that making claims and being able to prove are not that same thing.

A bit like some of or a lot of what was in the Normal and abnormal biomechanics of the foot Root et al
all well and good to claim something but it is just opinion until you can prove it

 

That isn't really how one should approach research Matt....oh never mind...

 

Bingo! And therein lies the rub.

 

Suit yourself.

 

There are none so blind as those who do not wish to see.

It would appear that drhunt1 is living within his own 'Matthewcentric' universe. :deadhorse:

 

LOL! Even if that were true, it would take a huge effort on my part to counter-balance the TST adherents on this board.

 

Sadly, it is true Matt. :deadhorse:

 

I noticed that Kirby thanked you for your post, yet you appear as an alias, without divulging your full name. So does that mean Kevin is a hypocrite?

Considering the fact that I'm a graduate of UC Davis, I'm well aware of the scientific method...which means that the investigator does not work backwards from a conclusion, nor does he/she cherry pick the articles that only support that hypothesis. Further, one must address those contrarian findings, either in the methods section, or in the discussion...they simply cannot be dismissed or ignored. After years of observing gait cycles on a plethora of patients and being able to look at plain film radiographs at the time of observation, (something I realize is not timely for Podiatrists in the UK or Australia), while taking static measurements on these patients, I have begun to "see patterns". This is how I resolved the mystery of growing pains in children, and not sloughing the pathology off as being "an overuse syndrome".

Let's see what references Kevin uses in his article for Podiatry Today. The answer to medial knee DJD is actually quite simple...much like GP's in children and RLS in adults. Clues to this pathology lie not only within the prodigious patient population that we see every day/week/month/year, but are found in Root et al's work which I tried to consolidate into a shortened version for PCP's:

https://www.youtube.com/watch?v=7BSetRI_UH4&feature=youtu.be

Now...tell us about your qualifications and contributions....

 

Short term memory loss?


http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=360185&postcount=145

 

There has been a bit of a tissue stress love fest going on on the PA for years now. The theory has been described as something like this:
1. Identify the anatomical structure that is the source of the patient’s complaints.
2. Determine the structural and/or functional variables that may be the source of the pathological forces acting on the injured structure.
3. Reduce the pathological forces without creating other pathological forces.


I'm glad to see Trevor Prior asking some critical questions that echo some of the problems and concerns I have with the simplicity and lack of structure and detail to the tissue stress theory and related treatment paradigm. Let me use cancer treatment to demonstrate my concerns with tissue stress theory. Here is a cancer disease theory paradigm that parallels tissue stress theory:
1. Identify the the anatomical location of the cancer.
2. Determine the pathological implications of the cancer cells.
3. Remove or eradicate the cancerous cells without harming healthy cells.

Treating cancer sounds very simple, when in reality, it is not always so simple and easy. In cancer treatment, there are protocols for surgical, radiation and chemotherapy. It too is not an exact science, but there are many established treatment methods and techniques depending on the nature and location of the cancer.

As I have attempted to point out, in tissue stress theory there seem to be no standard methods of examination and treatment. From what I have seen here on the PA, each tissue stress practitioner uses their own methods and prescribes orthoses in a somewhat to significantly different manner than the next practitioner. Hence, we are all practicing tissue stress theory when we put any device in the shoe.

Root developed a standard biomechanical examination technique and a form for recording examination results. I just don't see any formal structure to tissue stress theory and see it more as a concept than a form of practice.

Jeff

 

I do not like to feed narcissists but in this case I will make the exception due to some of the things said..

According to your note there drhunt you in looking down from your ivory tower there believe that there is a "simple solution" to medial compartment osteoarthritis and you believe that the type of foot is the genesis?

So you are not looking at other causatives? why? That is rather limiting is it not?
other factors that come to my mind based on the patients I have seen over these years are but not limited to: rheumatoid arthritis, septic arthritis, gout, paget's disease, hyperthyroidism, avascular necrosis, acromegaly, hypermobility, trauma, meniscectomies, and then there is the list of developmental disorders like perthes.

But for you it seems from what you wrote it is a simple matter of the right functional foot orthosis RX? Hmmmmm. tut tut Perhaps you are looking at solving the simple ones with foot typing them and saving the world in your mind but I beg to differ for the list I have provided of some of the other factors are definitely to be considered and not thrown out in favour of a one solution fits all approach..

Otherwise it might appear that one has blinders on in order to support ones argument or theory. Just saying....

Oh one more little tidbit. If the entire problem can be wrapped up nicely with the right foot orthosis then tell me how that foot orthosis stops the OA of the wrists and fingers that just happened to begin at the same time as the knee?

 

Jeff:

We have been around this stump so many times, I don't know what to say any more. I will try, however, to summarize.

The Root theory taught to us at CCPM, and taught around the world for that matter, where nearly all foot orthoses were vertically balanced and ended at the metatarsal necks is simply outdated, doesn't make sense biomechanically, and is, in some cases, just plain wrong. In fact, there is not one piece of scientific research which supports the Root theory of orthosis prescription. It is time to move forward, not continue living in the past.

Yes, Tissue Stress theory is not perfect, but it certainly makes more biomechanical sense than the Root theory method of orthosis prescription I was taught at CCPM. In addition, it allows the foot-health clinician, who has a good knowledge of foot biomechanics, foot and lower extremity anatomy, physics and physiology to very effectively prescribe and modify foot orthoses, and not being brain-washed into believing that the restrictions of the "Root Functional Orthosis" and "preventing compensations for foot deformities" and "locking the midtarsal joint" are the way forward to more effectively treat patients using prescription foot orthoses

In other words, Tissue Stress Theory is a work in progress and is not perfect. However, considering that Root theory is being taught less and less (if at all) and Tissue Stress Theory is being taught more and more around the world at podiatric biomechanics seminars, that should say something to the objective observer who is trying to decide which direction the worldwide podiatric biomechanics community is leaning as to what theory seems to be more accurate and useful when prescribing foot orthoses for their patients.

 

Popularity is not a measure of validity, for evidence of this see: The Bay City Rollers. https://www.youtube.com/watch?v=yUwW108ITzw

 

I wasn't advocating "Root Theory" (even though there is no such thing), I was attempting to express my concerns with what is lacking in Tissue Stress Theory. Build a better mousetrap -----. The devil is in the details. I still don't see how anyone can teach tissue stress theory as a treatment approach when there are no standards and no protocols.

Jeff

 

stand·ard/ˈstandərd/
noun
a level of quality or attainment.
an idea or thing used as a measure, norm, or model in comparative evaluations.
an object that is supported in an upright position, in particular.
a tune or song of established popularity.
adjective
used or accepted as normal or average.
(of a tree or shrub) growing on an erect stem of full height.

pro·to·col/ˈprōdəˌkôl,ˈprōdəˌkäl/
noun
the official procedure or system of rules governing affairs of state or diplomatic occasions.
the original draft of a diplomatic document, especially of the terms of a treaty agreed to in conference and signed by the parties.
a formal or official record of scientific experimental observations.


The question is, are there really no "standards" nor "protocols" in tissue stress? Or is this simply a "straw-man" that Jeff is attempting to construct?

 

Simon,

I own an orthotic lab. What prescription writing protocols can I give to my clients if they want to follow the tissue stress approach to orthotic therapy? Not a straw-man argument at all given that the topic is "Has Tissue Stress Theory Supplanted Root Theory?". The very nature of the question requires us to understand both approaches. Trying to defend my line of questioning using the straw-man tactic fails.

Jeff

 

Name calling, Todd? Tsk, tsk. Ivory Tower type? LOL! Not me. Au contraire. It has been my "job" here at PA to knock down those here that placed themselves in that position...with the assistance of many that keep them there. I'm no Ivory Tower type. Hope that helps.

OA is as you described...a systemic disease. That's why I called medial knee arthrosis DJD, because that's what it is. And yet you bring up RA, septic arthritis, gout, Paget's, blah, blah blah...that's NOT what anyone here, IMO, is referring to. But let me ask you this...what % of prosthetic knee replacement surgeries are performed because the medial tibial plateau is worn out? Have a guess? Perhaps Kevin can bail you out here, since he's worked with so many orthos in his career. In 2010, 720K prosthetic knee surgeries were performed in the US. What % of those do you suppose were necessary due to any of the laundry list of arthritic conditions you listed?

The last interview I did on GP's and RLS was with an prosthetist/orthotist...and he gave a great interview. He had GP's as a kid, and RLS as an adult and I solved his problem as well. His own orthotist didn't have a clue. I gave him the measurements for correction of his skewfoot deformity and he designed his own SMO...really great stuff. I'll include a pic of his design, which is cutting edge, IMO.

 

Thanks for the link...but I think that would be long term loss...if I really was accounting for all the posters here...or even cared.