Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

The lack of peroneal strength does not mean the STJ is more inverted than before. For the STJ to be more inverted than before there would have to be a supination moment from some source to make the STJ more inverted.

Matt, the closed chain forces that you are referring to are the same thing as the moments that I am referring to. The difference is that there is greater understanding of what those forces are when use moments to describe them. You obviously feel that the "closed chain forces" are important.

A good example of why we need to understand moments is your claim that testing for further eversion doesn't require peroneal strength. When you look at patients when they internally rotate their leg, you will see contraction of the peroneal muscles. Can you explain how you can you can internally rotate the leg without using the peroneals. Can you explain that without using moments?

My definition of pronation problems is pathology caused by high pronation moments. High pronation moments cause posterior tibial dysfunction, sinus tarsi syndrome and windlass related pathology: plantar fasciitis, hallux valgus and hallux limitus. Patients with PT dysfunction rarely sprain their ankles. In my experience, patients with the other pathologies would experience ankle sprains about the same proportion as the general population. So, we have feet that have pronation related problems that can also experience a supination related problem. How does neutral position theory explain that?

Matt, what is the difference between a serious force and regular force? Is a serious force one that causes a supination moment and regular force one that causes a pronation moment?

Root et al., used to teach that a forefoot valgus could predispose to ankle sprains. Are you familiar with the Coleman block test to differentiate between forefoot cause of inverted heel and a rearfoot cause of an inverted heel. Do you stand behind your observation almost every single one of them has a partially compensated varus. (You might want to review the terminology on partially compensated and uncompensated varus.)

Patients with a partially compensated varus will tend to have sinus tarsi syndrome. Talliard noted that patients with sinus tarsi syndrome had low peroneal activity. When injected with local anesthetic in the sinus tarsi the average peroneal activity returned. When the sinus tarsi doesn't hurt there is normal. The sinus tarsi hurts because of a pronation moment from the ground. When the peroneal muscles are fired there is increased compression in the sinus tarsi and this would hurt more. So, people with sinus tarsi pain use their peroneal muscles less when it hurts. When you have less peroneal activation, when you do experience an unexpected supination moment, (uneven terrain, serious forces?) you are more likely to suffer an inversion sprain. So, when you give these people an orthotic that inverts the STJ, there will be less pain in the sinus tarsi and more normal peroneal activation. So, the explanation for why this works is more physiologic than mechanical. This treatment does not work for those patients who have a laterally deviated STJ axis or, very loosely, in neutral position terms a forefoot valgus.

Matt, you are dancing around the concept moments when you talk about closed kinetic chain forces. Maybe you will come around some day. There was a time when sailors could navigate to ports when they thought the Earth was flat. There was a time when doctors bled their patients in the belief that it would make them better. If they didn't get better, then they were just too ill to survive even without the best treatment. Successful treatment is not a good argument that you don't need to understand how things work.

Eric

 

Is Dennis having a senior moment?

 

Eric,

yes, my seniority in a science based technology with my knowledge of biomechanics, has definitely given me a "moment"

 

No, he's just using the wrong worms...

http://m.youtube.com/watch?v=aJ0nFQgRApY

 

Another excellent reply from the Land of Oz. First...no one I know back here in the States utilizes TST to write orthotic Rx's...but just to placate the horde from Down Under...I'm leaving for the Western Podiatry Conference tomorrow and I'll do a cursory, informal and random poll...asking the Podiatrists at Disneyland if they utilize TST in their practices, when ordering orthotics, or if they even know about it. I'm sure the results will be immeasurably scrutinized by your very own, whom will claim, ad infinitum, ad nauseum about not having a "control group"...like several did when they stated so eloquently, that I didn't know Research 101 and should've used a "placebo orthotic".

On another note, the force plate data isn't giving you the results you stated it gives...and really doesn't measure "moments". But you just keep thinking that way, and forward that train of thought to others. It will actually make my job easier.

 

On another note, the force plate data isn't giving you the results you stated it gives...and really doesn't measure "moments"


I agree

 

Eric-I loved your condescending lines at the end of your reply...it means I must've seriously struck a nerve. Good. As far as I'm concerned, the TST free-for-all that existed here for who knows how long needs to be challenged.

When I suggested you look at professional basketball players, it wasn't just a "passing thought". Patterns, Eric. And while I can understand that a significant FF valgus can be the cause of inversion type ankle sprains, that's not what I see in my practice. So whom am I to believe...a former biomechanics prof at CSPM, or the biomechanics of those I treat and the successes/failures I have experienced while doing so. Root's work was a "work in progress" and I'm quite sure he would applaud my efforts, but not agree with everything I do.

For instance, I'm the only Podiatrist ordering forefoot varus wedge extensions to the end of the toes currently on the West Coast. 100% success treating GPs and RLS patients. Why would I order this on all of my patients with these symptoms? Because they all present with either FF varus, RF varus or both. They also describe a history of lateral instability, but when I hold them closer to neutral, not only are they better balanced, but they have better propulsion, especially when the orthotic provides better hallux purchase.

The problem with Ivory Tower types, is that the branches up at the top of the tree are very thin that they cling to. When someone like me shakes that very tree at the base, it makes their position quite tenuous.

Patterns, Eric...I discussed this before with you, and you dismissed it summarily. Yet I have solved a serious problem that has plagued mankind for well over 200 years. I have yet to witness TST doing the same.

 

sorry Jeff.. when was the conversation about podiatrists?.. The comment was they are hard to measure.. these days they are not. In the little old backwater of Adelaide South Australia..we have a biomechanics lab.. run and owned by a very smart young podiatrist named Chris Bishop.. and anyone.. any podiatrist can sent their patient there for a full assessment.. just like you would for an X-ray.. amazing what you find..

 

What on earth have I wandered into?

If you're finding a significant portion of your patients have forefoot varus in your practice, you're simply not looking beyond that for anything else. what percentage approximately of your other patients do you post a varus ff extension?

David

 

That's not what I wrote...sorry that you interpreted my post that way. What I wrote was that those patients which present with lateral instability, many had GPs as a child, and may have RLS as an adult. One needs to know what questions to ask in order to dig a little deeper. One of the problems I have with TST adherents, is that they promote treating symptoms...not the underlying biomechanical problem(s). I have referenced this on PA with anecdotal evidence previously, but also have written an article about GPs/RLS which was published last month. Since the time of that article becoming public, I have had quite a few more referrals...all treated similarly, all with positive results. If one takes the time to ask patients the right questions, they represent a treasure trove of information along with their family members.

 

I believe a quick overview of terminology is in order for those who are still following along on this thread.

A "moment" is synonymous with "moment of force" or "torque" in biomechanics. Currently the term "moment" is the preferred term within the international biomechanics scientific literature.

A moment is a rotational force acting across an axis of rotation and is determined by measuring the perpendicular distance from the force vector acting across an axis of rotation, known as the "moment arm" or "lever arm" and then multiplying that moment arm by the magnitude of the force vector.

Moments are measured in Newton-meters, generally abbreviated Nm and rotational acceleration is known as "angular acceleration". The principles of equilibrium apply when moments of equal and opposite direction counterbalance each other across an axis of rotation and that condition is called "rotational equilibrium".

No joint of the body will move without a moment being applied across it. An application of a moment across a joint axis will cause an angular acceleration or deceleration across the joint axis. The clinician who seeks to understand how the body works must understand these concepts completely, or else they will continually be making up things that aren't true and believing things that aren't true.

These concepts are not esoteric but are taught in every undergraduate level kinesiology (i.e. biomechanics) course around the world. I would think that every graduate level podiatrist would want to know these concepts completely.

 

Or any chosen point within a structural system such as the foot or lower-limb.

Amen. However, lessons I've gleaned from the best part of 20 years of podiatric biomechanics focused social media: some are unable to know these concepts; some are unwilling to learn these concepts; some just make their own concepts up because they are incapable of understanding basic physics; some disagree with these concepts because they don't understand the laws of physics; some just talk plain old horse **** because they are selling an insole/ product; some hang on to the older ideas because they don't like to think that what they have been doing previously was wrong; some hang on to older ideas because they are incapable of understanding basic phisics; and so the cycle continues....

 

Kirby


The Archimedes principle is taught in every undergraduate high school science class around the world.
I would think that every graduate level podiatrist would already know these concepts completely.

amen

 

I understand Archimedes. I have a patient with acute peroneus brevis tendonitis; tell me the measurements you require to prescribe one of your fluid filled orthoses for this individual...? Do I need to send you a cast?

 

You would think so but clearly it not the case , as someone reading this thread would see clearly

 

Simon

I understand Archimedes. I have a patient with acute peroneus brevis tendonitis; tell me the measurements you require to prescribe one of your fluid filled orthoses for this individual...? Do I need to send you a cast?

Well, if you want to do it the hard way—use calculus to determine the volume of the arch in grams, with the foot in “neutral”. Or you can take your own cast and I'll determine the volume of her arch chamber with the foot in neutral.

It most likely would require one or two adjustments of fluid volume to get the fit right.

 

I asked:

I have a patient with acute peroneus brevis tendonitis; tell me the measurements you require to prescribe one of your fluid filled orthoses for this individual...? Do I need to send you a cast? [/I]

The last time I went to school volume wasn't measured in grams and the determination of volume didn't require "calculus" :morning: Perhaps you could post up the required calculus so that we might work through it together?

I'm happy to take my own cast, but before I spend my money with you, could you tell me exactly how you determine the volume of fluid required based only upon a cast of a foot? Of course, you can't. Go away and come back when, and only when, you have something worth discussing.

Now that calculus, Dr Kiper...

 

The last time I went to school volume wasn't measured in grams and the determination of volume didn't require "calculus"

Then your not familiar with conversion tables to acquire that answer?--no problem make a cast.

could you tell me exactly how you determine the volume of fluid required

that's proprietary—

a practitioner would be using a calibration system that measures the arch as it pronates to neutral, using displacement as the means for fitting.

 

No Dennis. End of story. Lets take a known volume, say: 1cm cube, let us take 1cm cube of silicone and 1cm cubed of mercury, do they have the same mass in grams- NO. Get over yourself. I'll make a cast...

In other words, you don't know and you are making this up as you go along. If all you need from me is a cast, how can you possibly know how much silicone to put into the insole? Answer: you can't, but you don't care because you are making this up as you go along.

Brilliant. Please post details of your "callibration system method". What if it needs to "supinate to neutral".

I just love people who make **** up as they go along because the more they get involved, the bigger the bull**** becomes.

Now, Dennis, I'm really interested in that calculus. Could you please post the calculus required that you alluded to above? No, you can't because you were bull****ting, end of story.

Moral: "You can fool all the people some of the time, and some of the people all the time, but you cannot fool all the people all the time"- Lincoln

 

Simon

In other words, you don't know and you are making this up as you go along. If all you need from me is a cast, how can you possibly know how much silicone to put into the insole? Answer: you can't, but you don't care because you are making this up as you go along.

Are you an idiot? I've been doing this for 15 years, and you accuse me of making it up? Well, if you thought like an engineer, I make a positive mold from the cast and use it on the calibration system. A technique I've developed, thinking like an engineer would. There's more involved in the displacement of the mold, but I've answered your hostility and you don't need to know the rest.

Brilliant. Please post details of your "callibration system".


The calibration system is brilliant. It was developed by Martin Krinsky, whom I mentioned in my article. It's simple, it's easy to use. It follows exactly the stance phase of the gait cycle. You guide the foot into neutral (not for a pt—you'd have to supinate to neutral)

His patent and a small pic of the calibration system can be seen here:

http://www.google.com/patents/US4993429


What if it needs to "supinate to neutral".

That would be very unusual , I certainly need a lot more information but if necessary, I could probably do it, but not explain it here and now (I'm sure you're going to whine about this one Simon—eh mate?)
If I couldn't do this individual, then I couldn't do it and the pt is out of luck. This then would require the super efforts of the PA 3

I just love people who make **** up as they go along because the more they get involved, the bigger the bull**** becomes.

Do you feed this crap you eat, to your children as well?

You want to know about the calculus? Well, I'm just tuggin' on superman's cape and just said that so you'd say you're going to make a cast. End of story.

 

Simon,

The following was supposed to predede the response above:

You strike me as a really are a vitriolic individual. What business is it of yours, how I do something I do? If you're truly interested in knowing how a volume is determined, lookat the post. I explained how a volume is determined by anyone else.

 

Just the calculus will do for now, Dennis. But we all know that you don't have it in your locker.

To remind you, you said:

I'd like to do it "the hard way"- please define the calculus required. You can't- end of story.

 

Jesus!--it's so easy to give you diahrrea--end of story

 

Yes, but you can't give me the calculus because you don't know what the calculus is. You sir, are nothing more than a charlatan, attempting to flog your product on a site designed for academic discussion. When anyone probes your sales flannel, you are unable to provide a reasoned answer. Now,

I wish to "do it the hard way", please provide me with the calculus that you need me to solve. You can't because you made that statement up in the hope that the word "calculus" would frighten people off; it doesn't frighten me off- provide the calculus your require me to solve...

 

Simon,

you're an a-- h---.

Do you think you got me?--no--I got you.

you think this calculus is something to hang your hat on? Maybe it invalidates everything else I've said. It invalidates the Archimedes Principle?--for something that was said to annoy you.

You're going to prove there's no calculus--wow

Just like you to turn away from your pt, for her benefit--to say look at me! I'm with the PA 3

 

Simon,

I wish to "do it the hard way", please provide me with the calculus that you need me to solve

Get this straight, you asked me what measurements I needed to provide you with a Rx. For fun, I gave you a choice of computing the area of the arch chamber and then figure out how many cc of fluid fits in that area—you would have your answer to give to me.

That said, I don't use the “hard way” to figure the volume out. If you want to do it the hard way, you figure out what you need to get me the volume of fluid or send me a cast.

 

None of the above. Dennis, everyone and anyone reading this knows that you are simply making things up as you go along, Moreover, that you are now making a fool of yourself. For example:

You really are quite callow aren't you? I asked you how you should require me to prescribe one of your insoles for my patient, I didn't say whether that patient was male or female, although you seem to have decided that they are female. What is clear is that you are unable to provide me with anything approaching your prescription protocol for this patient, other than "send me a cast". Which tells me, you are just in it for the money, lovey.

You said:

I wish to do it the hard way, please provide the calculus required... what are you saying, that you don't know the calculus? Then why did you bring this up? Define "the easy way". -send you a cast? let's do it "the easy way" and you decide how much silicone to inject into the insole how?

That said, you don't know the "hard way" because that was something you just made up.

Get this straight, we only tolerate and respond to you for the humour value.

 

Kevin-thanks for the definition of moment, (as if we all didn't know what torque is). You, as well as the other TST adherents have yet to answer one simple question which has been asked by myself, Jeff and Dennis. And that is...how do measure torque in the foot? Does a force plate measure that? Does it alter the Rx for the orthotic when you know what torque "may" be occuring? Do the Rx's for orthotics written by TST adherents differ significantly from those written by "Rootians" for the same pathology? And fwiw.... I will conduct a survey here at the Western on how many Calif Podiatrists use TST when ordering orthotics. That should prove interesting, eh?

 

The question has been answered on this thread. For different approach to Rx see posts 785 and 801. I could go back farther to show that the other questions have been answered.

The technology for how to measure moments acting on joints of the foot, using force plates and motion analysis, was around when I wrote my chapter on computerized gait analysis over 20 years ago.


Eric

 

According to TooMoon, all that is needed is a force plate....and not one of you corrected that poster. As far as motion analysis is concerned, I haven't see the two sets of data coalesced and demonstrate reproducibility. You're being coy again, Eric. No such study exists, (if it had, this would be a known factor...which it's not), and we wouldn't be having this discussion. The fact that Dr. Smith has established a gait lab at CSPM means that the quest continues, in spite of your suggestion otherwise. I have shown you a sliver of the direction we should be going as a profession...and you simply poo-poo'd it, stating to the effect that you were beyond this approach because you saw some fluoroscopy video from Green shot in the '80's which few others have seen, because its not open source. It is this Ivory Tower, dogmatic attitude that several of you adopt that I object to the most. The answers are REALLY much easier than several here at PA want to make them, and I believe I know the reasons why...$$$$$$$$$$$. (Notice that Kevin hasn't answered my full disclosure question). I'm planning on having fun at the Western...much to discuss, right?

 

Simon,

Your statements are ridiculous, I don't know if your “pt” was even real, but I was willing to step into the lion's den. You didn't “ask” me if I would do it. I thought for a moment that maybe you were growing up and really wanted to do it—nah, I just knew you'd find some way to back out, since it wasn't real anyway.

You make a big deal out of nothing and deflect what's important. A serious discussion of a new technology, there is no place for petty crap, at least that's what a civilized scientist would say. You're one of those that holds the future up. And you do it, for your own selfish purposes.

You're worried, no more books, no more travel at somebody else's expense, no more boot camps—after all, who's going to want to pay for an inefficient and archaic technology?

Well, you and PA3 anyway. None of you have challenged my assessment of bio/fluid mechanics. You can't—you wouldn't know where to begin. You know that you can't win any biomechanical discussion with me.

Your friends have been letting you take it on the chin for them. All you can do, is twist what people say. I stand here accusing you of being a liar and saying you and the PA3 don't want a technology that you can't understand, or works for the betterment of mankind.

You just want to sell your crap, regardless of the benefit even to your own colleagues.

I'm here to be a pain in your butt. I intentionally will look for all your errors in orthotic technology and theories of biomechanics, with a few scientific words thrown in.

 

There we go.

 

Matt, you might want to reread post #790. So, it doesn't exist because you don't know about it? You could go to pub med and search inverse dynamics to see the amount of research that has been done with these systems that can be bought off of the shelf.

Matt, let me try and understand your criticism of tissue stress. Are you saying that it is too hard so we should not use it? You do keep saying that it doesn't solve real world problems (ivory tower). I've given several examples of solving real world problems. It is not too hard. I've taught this to podiatry students and have had many tell me that the principles of tissue stress are much easier to understand than neutral position theory.

Your video was nice. There was an anatomical inaccuracy where the lateral process of the talus disappeared into calcaneus. I can see how students can be helped by seeing the bones under the skin with a video like that. However, it is just motion. Understanding the cause of motion is important too. Saying thing like inversion sprains are caused by serious forces shows a lack of knowledge about the forces that cause inversion sprains.

Eric

 

Eric-I read that post...but it still doesn't measure what you think it measures...obviously, because Drew Smith is still pursuing this investigation at his lab. I think I'll visit that lab/school in early November for their biomechanics presentation on the gait lab. The problem I have with TST is you're still promoting treating symptoms, and not the underlying problem. For instance, did you read my post on the Myth of GPs thread on the patient I treated? Its post #15, about a patient who presented with heel pain. Would the TST crowd treat that alone? Or would they dig a little a little deeper to uncover the real problem? I don't see that TST adherents overcomplicate matters of the foot, but they oversimplify symptoms while overly complicate treatments and explanations. Root, IMO, gave us the foundational outline, describing "normal" in terms that I believe to be understandable. It was up to us to "fill in the blanks", and I can't envision that he saw us trying to reinvent biomechanics. In that regard, I think we're failing our patients, if for no other reason then our insistence in describing something that is not that difficult, and making "it" unwieldy, not just for our colleagues, but for other specialists as well. Orthopods refer patients to pedorthists and orthotists, which means we've lost that battle.

 

Your basing your claim that I don't know what I'm talking about on that? There are hundreds of articles published using inverse dynamics. There are textbooks written on how to perform the analysis. Do you ever look up articles on PubMed?

Tissue stress does try to understand the underlying problem. For example, posterior tibial tendonitis, we theorize is caused by a high pronation moment from the ground. What do you think causes PT dysfunction?

I'll believe that neutral position theory is simpler than tissue stress theory when someone can provide a simple explanation for how orthotics work using neutral position theory. There are a lot of blanks to fill in. Those blanks keep getting glossed over. When I tried to fill in those blanks, it led me to tisssue stress. Tissue stress is not that complicated. The majority of podiatry students that I taught it to didn't have any problem understanding the concepts. Perhaps the Orthopods are referring to pedorthists because the pedorthists use the tissue stress approach, and not the neutral positon approach.

Eric

 

I don't see that TST adherents overcomplicate matters of the foot, but they oversimplify symptoms while overly complicate treatments and explanations. Root, IMO, gave us the foundational outline, describing "normal" in terms that I believe to be understandable. It was up to us to "fill in the blanks", and I can't envision that he saw us trying to reinvent biomechanics. In that regard, I think we're failing our patients, if for no other reason then our insistence in describing something that is not that difficult, and making "it" unwieldy, not just for our colleagues, but for other specialists as well. Orthopods refer patients to pedorthists and orthotists, which means we've lost that battle.
__________________
Matthew H. Sciaroni DPM


Matt,

I have to say, that this is due to a less than adequate medical technology. Results are poor comprable to my results, not because I'm better, but simply because of the technology I employ.

No one likes me to say that, but it's so dramatic, I have to say it. And our medical colleagues don't respect our present day technology of functional biomechanics. We will continue to lose that battle until podiatry comes up with a science based orthotic technology that is quantifiable and can be shown to work exactly the way the bio/fluid technology should work.

Most and I do mean most all the biomechanical failures out there, would begin to reverse their biomechanical inflammation and injury that has built up. Hard to believe, but if the problem is a valid “biomechanical” problem—then you will have 100% success in on the road to healing.
Do you think, all the allied medical professions (particularly orthopedic) wouldn't take notice?

Sport shows will be talking about players who finally are recovering from PF.

Yes, all this is possible. The real problem will be meeting the demand.

 

Simon Bartold gives a nice overview of Tissue Stress Theory in his summary of the first day of the Biomechanics Summer School 2015 in Manchester, UK, June 19-20, 2015 in his interview with Ted Jedynak.

 

In a very unscientific poll taken at the Western Podiatry Conference last weekend in Anaheim, I came to the conclusion that: a) TST is not being taught to any significant degree in the US, (at least out here in the west), b) many of those I polled didn't really know the details of TST and c) it has not supplanted Root biomechanics.

Hope this helps.

 

Not really...

 

I too asked several DPM's at the Western Foot and Ankle Conference if they used tissue stress theory in their practices and if so, how. I got the deer in the headlights look. Although I was unable to attend all of the lectures, I did not hear the term TST once. So it appears that TST has not supplanted "Root Theory" (even though we know there is no such thing as Root Theory). That may explain why it can't be supplanted!!!!!

I do support evolution in biomechanics theories, education and practices and I do believe we need to find better systems of examination, evaluation and treatment. The operative word here is systems. TST is not a system. Although I don't like the term TST any more than I like the term "Root Theory", I do believe we need better systems in lower extremity biomechanics and orthotic therapy. I do think it is important for members of this forum to understand the limited impact that TST has had here in the U.S. because it one were to rely on the PA to form their opinion they might think that TST is much more widely accepted in the U.S. than it is.

Jeff