Challenging the foundations of the clinical model of foot function

No Jeff, your point wasn’t missed by me, I just didn’t agree with it; as if I did then we would both be wrong ;-)

You do not need to ‘support’ or ‘brace’ (horrible terminology as already mentioned by Simon) a foot to produce mechanical change (kinematic and/or kinetic). It’s about the application of external force and the subsequent tissue response. Hence my Socratic nudge towards the material science literature.

It’s a bit worrying that the owner of an orthosis laboratory doesn’t seem to have an up to date understanding of how the little bits of material he sells exert their effects, no?

 

So,, we have four individuals based in the USA that have published nothing in peer reviewed journals with regard to how foot orthoses work; and then we have some of their representatives associated with foot orthoses labs in North America and Canada agreeing with the representatives from foot orthoses laboratories agreeing with them. Well how scientific of you; didn't realise you'd gone to that much trouble on a global basis. God bless America, so that the rest of the world can sleep in peace. Hell yeah:

 

How surprising to see another xenophobic remark from Simon, not.

 

How surprising to see a definition of foot orthoses which only considered the USA from Jeff. Egocentric. You've lost again, Jeff. How surprising to see Jeff bailing out with another straw man? USA, USA, USA... the world no longer revolves around the USA when it comes to podiatric biomechanics, Jeff. Unless of course you got a peer reviewed reference published in the last couple of years that actually supports your daddy's position? No? Sleep tight. Just keep selling the "bent pieces of plastic"- still a better definition than yours.

 

We are applying external contact forces with an orthosis. Can an orthosis work without contacting the foot? No. The material properties of an orthosis are extremely important as it governs the ability of the orthotic shell to deflect yet resist some deflection as forces change and the foot changes shape during the gait cycle. If that isn't a property of support, then what would you call it? We compare an orthosis to a spring, correct? What does a spring do? A spring is elastic and it compresses and extends. Why do orthoses sometimes change shape and lose some of their original contour? Because they deflect under repetitive loading which can cause molecular flow. This would not occur if an orthosis wasn't acting to support the foot.

 

Simon, you spoke at one PFOLA conference, correct? Why do you suppose you were never invited back? And for the record, I had no input or influence on the decision by the future PFOLA scientific chairs who did not invite you back.

 

So this is your attempt at a character attack now fireman Jeff? I spoke at two; the first one I smashed; the second one I presented the worst lecture of my life- spent the night before getting pissed until 5 in the morning, I was a kid- you live and learn, but it didn't help that I had Magnum PI next to me on the stage; never mind. I went on to present that same lecture around the world and smashed it on every occasion Built a reputation and keep getting invited back to this day on the strength of that work :learn and move on; got two international dates coming up in the next few months; y'all have never moved on from your bad day though have you, Jeff? Lets also be honest PFOLA fell apart after that meeting and stopped hosting annual conferences because it had become "too scientific" and had ceased to meet the needs of the Orthotic labs (i.e. selling insoles blindly)- science was starting to ask questions. How many international lectures have you been invited to give since that date outside of the USA and Canada? When was the last time you were invited to speak in central Europe Jeff? That'll be a total of none, right? My lecturing reputation aside, your fathers theories are in taters. Wouldn't waste my time trying to teach in the USA anymore, bottom of the list when it comes to countries progressive in podiatric biomechanics. Never mind. So you talked about licenses to practice podiatric medicine in you previous post: where did you get your license to practice podiatric medicine from? I can tell you my publication record on foot orthoses, if you'd like to compare the size of our cocks, Jeff. Dont' worry, I know I win.

 

Speaking of lecture invitations, it is known that there is a real lack of good quality biomechanics conferences in the states since PFOLA stopped its annual conference series. A group of us have been contacted by someone trying to organize a biomechanics conference for students and residents at one of the podiatry conferences. The speakers were asked to pay for their own travel and accommodations and the college will take care of the rest. Although no date has been established yet, I was disappointed to learn the Kevin Kirby declined the invitation. I know that Kevin has expressed his frustration about the lack of good biomechanics conferences in the states and that he feels that the U.S. is slow to adopt new theories and approaches to treatment. This would have been a great opportunity to present these new concepts to a future generation of DPM’s.

 

I'm sure Kevin can speak for himself, but I suspect like me, he feels its an audience which is so far behind current thinking that it is now a waste of his time. Also, if you are expecting internationally recognised lecturers to pay their own board and travel, in addition to giving up several days in clinic, it's probably not surprising that they are declining, Jeff. Did you ever go on a call out for the firebrigade without getting paid?

 

A 30 min presentation when prepared for appropriate could take anywhere between 10-15 hours. Then there’s the lost earnings from not being in clinic. Not being paid an honorarium is one thing, but not being paid travel or accommodation after all of this ‘loss’ for the speaker?? But you’ll “take care of the rest”? What exactly is left to take care of?

 

Reallity is: no-one wants to go speak there because they are so backwards in terms of podiatric biomechanics it's like trying to take Biomech 101, when the billing and coding lecture next door has more interest.

Jeff, if you want to pay for your flights and hotels to here in the UK, I'm sure me and Griff can get a gig for you- we'll pay your breakfast and dinner.

 

Jeff, I thought this would be a private discussion between me and another podiatrist who you obviously know. However, since you have now made it public, let me explain the circumstances of the invitation that was made to me. First of all, the other podiatrist contacted me last week and asked me to lecture for free and pay my own travel room and board at a planned seminar. I told him that I couldn't afford the time to lecture due to my very busy practice, seeing about 30 patients a day on my full days, and already having a full schedule of national and international lectures that I had already committed to lecture at for the next year.

The seminars I had already agreed to lecture at include giving a one and a half day seminar in Auckland, New Zealand in two weeks, lecturing multiple days at a very large podiatric conference in Naples, Italy on April 27-29, giving three lectures and moderating a session at the Western Foot and Ankle Conference on June 21, giving a series of lectures and workshops at a podiatry conference in Helsinki, Finland on October 4-5, and also lecturing at a podiatry conference in Zaragoza, Spain on April 5-6, 2019. This is in addition to the four hours of lectures I give at the California School of Podiatric Medicine every year for the 2nd and 3rd year podiatry students, the numerous articles I still write for Precision Intricast Orthosis Labs, Podiatry Today magazine (I just today finished an article on Longitudinal Arch Biomechanics today that will be published in the June 2018 issue of Podiatry Today), Podiatry Management magazine annually and the papers I review (for free) from the Journal of Biomechanics, the Journal of the American Podiatric Medical Association, the Journal of Foot and Ankle Surgery, and the Journal of Foot and Ankle Research.

What is interesting, Jeff, is like all of the other 43 international seminars that I have lectured at over the past 26+ years, all my expenses are paid by the seminar committees including travel, lodging and meals and offer me some compensation for time lost from my busy private practice where, when I am not there seeing patients, I am, in effect, not making any income but am still paying office rent, employee salaries, etc. In addition, due to my busy schedule, I generally need to turn down about half of the seminar lecture invitations that I receive.

These international seminars are filled with podiatrists, pedorthists, orthotists, physiotherapists and even orthopedic surgeons who are very interested and eager to learn the latest theories of foot and lower extremity biomechanics and foot orthosis function and practical foot orthosis therapeutic and clinical techniques. We discuss modern podiatric biomechanics theories and relevant research. Root biomechanics is not discussed by me in any of these seminars, except as a historical perspective. There are many good questions from the audience and, in general, the level of biomechanics knowledge and biomechanics research awareness is at least as good, if not better, than the level of biomechanics knowledge and research awareness at any of the podiatric seminars I have lectured at here in the States over the past 10 years.

If I weren't so busy, I would be happy to lecture, and even pay my own way, to lecture at a biomechanics seminar for US podiatrists. If I did that, I would probably prefer to just lecture for a day, on my own, without anyone else lecturing, to a group of very interested podiatrists close to my home so I didn't have to travel so far. Currently, however, I am so busy that I now just pick a few seminars every year to lecture at and prefer to lecture when the seminars do not interfere with my family life, my practice, my vacation schedule and, more importantly as I grow older, sleeping in my own bed.

 

Simon, I was in the fire service for 11 years. The first half of that time I was a volunteer firefighter and I regularly took time off of work to respond to emergencies and I paid for equipment and training out of my own pocket. When I became a chief officer I was paid a monthly stipend and I was paid through the state of California when I responded to wildfires in other areas of the state. I still worked full-time at Root Lab but I did take time off when responding to emergencies. I spent the majority of my nights and weekends training firefighters, responding to calls and serving my community for a $500 monthly stipend. So yes, I do know a little about giving back to society by volunteering my services. I left the fire service to devote more time to my young children, my family and the needs of my business. I wouldn't trade those experiences and rewarding times for anything.

 

The other costs include marketing costs, facility fees, CME costs, food and beverages, and on and on.

 

Simon, since you questioned why I brought gender into another discussion, perhaps you should consider your own use of gender specify terminology. In the states the term fireman went out back in the day when the term flight attendant replaced stewardess. They have been referred to as firefighters here in the states for the past 35 to 40 years or more. Referring to someone as a fireman or firewoman is antiquated and considered sexist.

 

Simon, I also waived my honorarium when lecturing for PFOLA so that the funds could be used for research and for other PFOLA objectives. There were a number of us speakers who did this.

 

This is a very sad commentary on the state of the Podiatry Arena. When the internet was much younger and we had very productive discussions and debate about biomechanics and foot orthotic therapy on the JISC mailbase, the moderator would have shut this kind of inappropriate conduct down in a fraction of a second. And you wonder why you weren't invited back to speak at future PFOLA conferences Simon. Perhaps it was your conduct on and off the podium.

 

No, I don't wonder, Jeff; it was you that bought this up. I had no interest in it whatsoever. You on the other hand needed to change the line of discussion away from your use of the term "brace" so went for an attempted personal attack on me as a diversion tactic, not expecting me to be honest and just state that when I spoke for the second time I was rubbish- I was. You give out many personal attacks Jeff- this is just another case in point; we've also had your sly attack on Kevin over the course of the last few days too. I see he's called you out on that as well. Jeff, you might want to get your own house in order before you start with the ad hominem attacks. I don't like you Jeff and you don't like me, that's fine but it won't stop me calling out your non-science in public. Everytime you are loosing an argument Jeff (the one regarding the term "brace" here being a case in point) you go on the personal attack as a deflection strategy. As I've said before, your game is old.

For the record, you seem to have forgotten- I was a moderator (actually we were called list owners) of the JISC mail service.

 

So, the normal costs associated with running a course/conference then. Genuine question: what does that have to do with an invited speaker? “We’re organising a conference and we’d love you to speak at it Dr. Don’t worry about the costs of the conference though, we’ve got that - you just pay to come and speak for us”.

 

I fear this discussion is losing track. There are members on here who I class as friends, and many I have not met so cannot form a personal opinion but are colleagues working with the same patient group.

If I am not mistaken, these threads can be read by anyone. I am not for one instance suggesting comments made should not be challenged, but the written word loses all intonation and things are often written (and more importantly the wording used) that would not be spoken were the debate happening in an open meeting session - it might in a personal discussion but this is more like the open forum.

Many very good points are raised in these discussions, let us not lose that aim and remember that the many readers we will never meet or hear from will forumlate their opinions of each of us and more importantly our professions, on what they read.

I really do not wish to come across as sanctomonious but I have read the thread with increasing discomfort and felt compelled to comment.

 

If we go back to the case of the 80 year old patient with adult acquired flatfoot we would see that her foot, over time has developed a lower arch profile and that during stance her foot or feet collapse. A typical orthotic prescription for this type of foot would be to support the medial arch by using one or more of these; little to no medial arch fill on the positive cast, a medial heel skive, and possibly invert the cast to increase the arch height and invert the plantar plane of the heel. We would expect this patient's medial arch to be supported in a higher attitude with her orthoses in place as compared to her arch profile without her orthoses. So supporting the foot is an essential component of successful treatment here.

This definition is not about the USA, contrary to what Simon believes. Below are some descriptions of foot orthoses from around the world. The common theme is that orthotic devices are used to support the foot. None of these descriptions are similar to Kevin’s definition:

From the Australian Podiatry Associations website:
What are foot orthoses?
Foot orthoses are shoe inserts designed to support, align or improve the function of the foot. They are
commonly referred to as ‘orthotics’ and fit comfortably inside your shoes.
https://www.apodc.com.au/foot-health-resources/prescription-orthoses

From the National Health Service website in the UK:
Podiatrists can also supply orthotics, which are tailor-made insoles, padding and arch supports to relieve arch or heel pain. You put the orthotic device into your shoe to re-align your foot, take pressure off vulnerable areas of your foot, or simply to make your shoes more comfortable
https://www.nhs.uk/livewell/foothealth/pages/foot-problems-podiatrist.aspx

From the Canadian Podiatric Medical Association website:
What are orthotics?
A biomechanical foot orthotic is a highly specialized piece of medical equipment that enables the joints and bones of the foot to be in a more stable position for standing and while in motion. Orthotics control each phase of the walking cycle, from the moment your heel contacts the ground to when your toes push off the surface.
https://www.podiatrycanada.org/faqs/

From the American Podiatric Medical Association
What are Prescription Custom Orthotics?
Custom orthotics are specially-made devices designed to support and comfort your feet. Prescription orthotics are crafted for you and no one else. They match the contours of your feet precisely and are designed for the way you move. Orthotics are only manufactured after a podiatrist has conducted a complete evaluation of your feet, ankles, and legs, so the orthotic can accommodate your unique foot structure and pathology.
https://www.apma.org/Patients/FootHealth.cfm?ItemNumber=988

 

Wow. Just wow. You can take all of these definitions and drive a bus through their fallacy holes. End of story. I do note that none of them use the term "brace" though- which was the moot point (not raised by me, but by several of my colleagues before I even entered the debate). "Brace" is still a woeful term for the reasons described. We can pick apart each of these definitions above too, if you really wish. Lots of different individuals repeating things that are wrong, doesn't make them right, right? And that, unfortunately is what happened with podiatric biomechanics: a fallacy was accepted and spread to the point that everyone thought it might be true; then some people started saying "hang on a minute, that doesn't stand up to scrutiny" then the people who'd gone along with the fallacy said, "hang on a minute, we've invested big bucks and our reputations on this, we can't back away, moreover, this is making me rich", while others said "you're right, lets take a look at the evidence, lets try to be scientific about this". Sides were taken and battle lines drawn, and twenty odd years on here we are... At the end game. Bring it on.

 

This is an issue of semantics. I contended that a foot orthotic can’t influence kinetics and kinematics unless it support the foot in some way. I have yet to have anyone explain how it can influence kinetics and kinematics without supporting the foot or a part of the foot.

 

OK Jeff, lets go on a thought experiment journey: let's make a spike orthosis- an insert which is so painful the subject withdraws their foot to keep it away from the insert: does it change kinematics and/ or kinetics? Yes. Does it do this by "supporting" the foot? No. Viz. i have provided an example in which your contention is wrong. Thus, your argument is falsifiable and fallable. Now you say: "yeah, actually you are right, Dr Spooner", we kick the football about for a while, then retreat to our trenches... Except that bit will never happen.

 

Here’s another: the neuromotor effect. A central nervous system driven change in kinematics at foot level as an output secondary to the novel sensory input it received peripherally. Thus, kinematic (and of course kinetic) changes with “bracing of the foot” having nothing to do with it.

 

Simon, I don't know why you even persist beating your head against the wall. It's a losing proposition.

I have long given up on trying to convince the 5-6 individuals here in my country who continue to publicly promote Merton Root's teachings, even though there is no scientific support for nearly all of Root's ideas. It is simply not worth it anymore.

Thankfully, we have people like you, Ian, Trevor and Chris Nester in your country, the many great podiatric PhD and non-PhD researchers in Australia (thanks Craig Payne!) and Spain, Eric Fuller and Larry Huppin here in the US, and the many other biomechanics researchers in Belgium, Canada and other countries who are seeking the truth about foot function, and who do have their prime goal as keeping Mert Root on a pedestal.

It is really sad what is happening here in the US, basically ignoring biomechanics and focusing on surgery as a profession. In the remaining years of my practice and life, I will continue to educate those who are willing to learn and also hope that you all will continue to inspire and educate the international podiatry profession for the therapeutic benefit of our patients for many years after my time here has past.

Thanks for your support and your intellect.

 

No, because
1. That is not how orthoses work and
2. If they did work that way, then you would be shifting support to another area of the device so the device would still be supporting the foot unless the foot didn't contact the device
Pain avoidance is a mechanism of compensation. Functional orthoses, when properly made, should not cause pain but rather should reduce or eliminate it. Since we are discussing the definition and influence of functional type foot orthoses your example does not apply.

 

With regard to 1) you know that because? Actually if you read the literature many believed this was the mode of action of Whitman and Roberts devices. I've certainly seen it in patients 2) not valid as my orthosis in this thought experiment was a drawing pin inserted into the shoe (by your definition this should be classed as a foot orthosis BTW). And here we go again...... "functional type" you say......? Presumably as oppose to the non-functional type of foot orthoses? Your attempted shift in stance notwithstanding : your argument is falsifiable; end of story. Yet 20+ years experience tell's me that you will never concede any point, even when proven wrong, Jeff.

 

Likewise.

 

Couldn't help but get a chuckle at this given that the word support is central to this discussion!

 

I thought we were talking about functional type orthoses. However, how does an accommodation work? It provides greater support to the area surrounding the area that we are attempting to offload. How can an orthosis have any type of accommodation such as a plantar fascia accommodation, a styloid accommodation, an ulcer accommodation, etc. unless the surrounding area is supporting a part of the foot? It can't! Try to explain that one away.

 

All foot orthoses are "functional", Jeff. Did you read the paper that Griff and I had published in the BJSM? Anything inserted into a shoe, "supports the foot" by your defintion, Jeff. Thus, anything, including a dollar bill, is a foot orthosis, by your definition Jeff. If you read back through this thread, you will see that this is exactly what I said yesterday. Thus, by your definition a drawing pin is a foot orthosis, as such a foot orthosis can influence kinematics and / or kinetics without supporting the foot. Thus, your conjecture is proven falsifiable. yet you will still not concede that you were wrong. Even though... you were wrong.

 

If a car runs over your foot it is changing the foot's kinetics and kinematics so a car is also a foot orthotic. In fact, all physical objects must be foot orthotics. I think we have spent more than enough time on this. I think it is time for us to agree to disagree.

 

Personally, I think it is time for you to concede that you were wrong.

 

No, in this situation the car is pushing down on the foot, so it is the shoe and the road that "braces" the foot in this example, by your definitions. If I'd have placed a dollar bill inside the shoe, then by your definition that would have been a brace to the foot and as such "an in-shoe foot orthosis". It is clear that you are incapable of ever conceding when you are wrong and that moreover, you need to re-think your definition of a foot orthosis... QED. But then, I did say that yesterday. Tick, tick...

 

"Normal Force: The normal force is the support force exerted upon an object that is in contact with another stable object. For example, if a book is resting upon a surface, then the surface is exerting an upward force upon the book in order to support the weight of the book".

"Applied force: An applied force is a force that is applied to an object by a person or another object. If a person is pushing a desk across the room, then there is an applied force acting upon the object. The applied force is the force exerted on the desk by the person".

If you look at a typical description of a normal force like the above you will see that support is involved. Until you can prove to me that an in shoe, foot orthotic device does not involve a normal force and an applied force that act to support the foot due to the physical characteristics and shape of the device, then I will not, nor should I have any reason to concede that I was wrong. If you can prove to me that there is an absence of a normal force and an applied force acting between the orthosis and the foot then I will gladly to concede that I was wrong. Until then, I will continue to disagree with you Simon.

 

Your terminology is again weak, the "normal force" in physics is the force which acts perpendicular to the supporting surface. We discussed this in our 2010 paper: https://www.ncbi.nlm.nih.gov/pubmed/21084541

Jeff , we have already been around this stump, to recap: a) anything we place inside a shoe acts as a "brace" by your definition, viz. anything placed inside a shoe is by your defnition "an in-shoe foot orthosis", so a dollar bill is an in-shoe foot orthosis since it braces the foot. Thus, your definition is weak; b) we can have a situation in which the foot orthosis does not act as a brace by your definition yet still brings about changes in the kinetics and kinematics, for example via a nocioceptive effect. Thus your definition falsifiable. Put it together and what have we got? Your definition is weak and falsifiable.

 

Simon, using your logic then Kevin's definition is just as weak because you could custom fit a dollar bill in shoe:
"Definition of a Foot Orthosis
A foot orthosis is a custom fitted, in-shoe medical device which is designed to alter the magnitudes and temporal patterns of the reaction forces acting on the plantar aspect of the foot in order to allow more normal foot and lower extremity function and to decrease pathologic loading forces on the structural components of the foot and lower extremity during weightbearing activities.
Kevin A. Kirby, 1/7/98"

 

Probably, so does that mean you concede?

 

it's sad when the parlimentarians of our two noble countries get more accomplished than most of the talk here.

1. As I tell my patients when we talk about "soft" and "hard" orthotics -- if you weigh 14 stone, it doesn't matter if I put something made of feathers or something made of concrete, both have to put 14 stone of total force upward on the foot (I realize there's some averaging here).

2. Even a $2 bill in the shoe is going to change the force somewhere on the foot. Any change in force, even if it is the difference between going barefoot and wearing crocs is going to change the function of the foot.

So most of the arguments above are summed up in the following well known verse:
"And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right
And all were in the wrong!"

It seems like some people here are more interested in "winning" an argument than in promoting education, good will and better communication. Unfortunately there is more education, communication and good will being sown on the West Bank of the Jordan River than here.