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Forefoot Supinatus definition 2018

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Mar 20, 2018.


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    1st I have started a new thread from a question Jeff Root asked in the Challenging the foundations of the clinical model of foot Posture thread- https://podiatryarena.com/index.php...f-the-clinical-model-of-foot-function.108197/

    here is a definition that I found

    Jeff rather than give you referenced definitions I will give you might thoughts, which might be called BS but there you go

    Forefoot supinatus.

    Evans EL1, Catanzariti AR2.
    Author information

    Abstract


    The supination of the forefoot that develops with adult acquired flatfoot is defined as forefoot supinatus. This deformity is an acquired soft tissue adaptation in which the forefoot is inverted on the rearfoot. Forefoot supinatus is a reducible deformity. Forefoot supinatus can mimic, and often be mistaken for, a forefoot varus. A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation. This article discusses the acquired form of forefoot supinatus.

    https://www.ncbi.nlm.nih.gov/pubmed/24980930

    Not once it there mention of what position the Reafoot needs to be in or a measurement so I could just leave this here and Jeff et al would ask what position is the rearfoot in it must be in STJ neutral and we would go round and round again.

    So apart from having a busy life with work and running and having a birthday I have been thinking, why does it matter what we do, measure define etc and what would we get out of a discussion apart from people getting cranky.

    So during my runs last week I have been thinking which like I have written before this is dangerous.

    Point 1 - do we even need to know if it is a FF Supinatus or Varus - sure we do,

    Point 2 do we need to know how many degrees it is - Nope

    Point 3 does this link a non-weightbearing assessment "measurement" to a weight-bearing, (which I believe is the key to any assessment - ie assessing motion at MTP1 non-weight bearing to weight bearing ) and I believe it does if we look at the Maximum Eversion Height Test . Eric talks about here - https://www.podiatrytoday.com/guide-orthotic-prescription-writing-tissue-stress-theory-approach.

    If we look at the gait cycle when does a forefoot "deformity" become something that will be important for us to consider. So if we look at the relationship in "general" forefoot loading will occur as the Tibia reaches perpendicular to the ground. so this is the point that is interesting for us when thinking about the forefoot.

    So if we place the ankle at 90 degrees and use the idea that the ground represents the frontal plane, look at the forefoot relationship to the frontal plane - Inverted, Everted or Parallel

    Then we need to look at stiffness if the Forefoot is inverted how much force does it take to get parallel to the frontal plane without any rearfoot motion occurring. This guessturement of Force is important not the degrees, lets face it a true FF Varus deformity is extremely rare so what we really need to know is the amount of force required to get a change at the forefoot if that is what we want to do. This then combined with the Maximum Eversion Height Test will give us the angular posting we might want and the stiffness will add us in the material choice.

    So how would I assess this

    Pt lies prone on the assessment coach, ankle joint is placed at approx 90 degrees, look down the heel using an imaginary line to represent the frontal plane, look at the forefoot, see the relationship to the frontal plane if inverted, hold the ankle joint and calcaneous in one hand, evert the forefoot until parallel to the imaginary line representing the frontal plane and take note of the force required.

    I would then use the Maximum Eversion Height Test but take that measurement with the ankle at about 90 degrees .

    I am sure there are wholes in the idea and it might be a bit of a word salad, but I don´t think we need to have the STJ in any "position" if the ankle is at 90 degrees, we don´t need to measure the forefoot from the rearfoot but in the frontal plane alone, we don´t need a measurement in degrees, but need to look at stiffness, and the Maximum Eversion Height Test gives us a way to communicate with labs or ourselves on the height we want in posting and the stiffness at the forefoot helps us in the material/process of cast modifications
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
  3. One of the problems with the term "forefoot supinatus", is that it presupposes that only an "inverted forefoot deformity" can have a soft tissue contracture due to "overloading" of the medial column by ground reaction force causing this "inverted forefoot deformity". My clinical observations, and my knowledge of the viscoelastic nature of the restraining ligaments of the midtarsal and midfoot joints, seems to indicate to me that even "everted forefoot deformities" may also have some degree of "forefoot supinatus". In other words, we should not assume that only inverted forefoot deformities (i.e. "forefoot varus", "forefoot supinatus") can have soft-tissue contractures that reduce the "everted forefoot deformity" or increase the "inverted forefoot deformity".

    Rather, I believe that the frontal plane relationship of the forefoot to the rearfoot is a dynamic structural parameter that can, and does, change over time depending on the prevailing subtalar joint (STJ) pronation and supination moments which occur during the individual's weightbearing activities over time. More STJ pronation moments over time tends to reduce "forefoot valgus" and increase "forefoot varus". More STJ supination moments over time tends to increase "forefoot valgus" and reduce "forefoot varus". That is true only if we can assume that calcaneal bisections and measuring STJ neutral are reliable, which we can't. Certainly however, the basic mechanical concepts still will apply, as long as we aren't too concerned about the absolute values of "rearfoot varus", "STJ neutral" and "forefoot to rearfoot relationship" of the individual.

    Due to these problems, the term "forefoot supinatus" should eventually be phased out of our podiatric lexicon, or redefined. Until we can accurately measure forefoot to rearfoot relationship, we are only talking about broad biomechanical concepts and can't reliably and confidently talk about the absolute degrees of "forefoot supinatus" or "forefoot varus" or "forefoot valgus" or "inverted forefoot deformity" or even "everted forefoot deformity".

    By the way, I haven't used the term "forefoot supinatus" in any of my Precision Intricast Newsletters for the past 17+ years, for these reasons.
     
  4. Important point I missed in the opening post that a FF Supinatus deformity can occur when the FF is everted just less so than before
     
  5. Jeff Root

    Jeff Root Well-Known Member

    It should also be noted that there is a condition called an acquired plantarflexed 1st ray. This is typically seen in cavus feet with an everted ff to rf relationship. The acquired portion of the 1st ray plantarflexion increases the everted ff to rf relationship and contributes to increased rf inversion. What is interesting is that these individuals typically have an increased and acquired element of ff adduction and plantarflexion in addition to the acquired sagittal plane plantarflexion of the 1st ray. This makes mechanical sense since increased STJ supination would result in increased abduction of the STJ axis, which would reduce vertical GRF plantar to the 1st met head thereby allowing it to plantarflex relative to the lesser mets. The increased STJ supination also enables the adduction and plantraflexion of the ff because talar and STJ axis abduction also occurs with a simultaneous increase the sagittal plane orientation of the STJ axis.
     
  6. Jeff,

    I agree. In this case, the acquired plantarflexed first ray would be considered to be due to increase STJ supination moments. However, in this specific case, the "deformity" of the "acquired plantarflexed first ray" (i.e. more everted FF to RF) is in the opposite direction to that seen in "forefoot supinatus" (i.e. more inverted FF to RF).

    Like I said, "FF to RF deformity", "FF supinatus" and "acquired plantarflexed first ray deformity" should all be regarded as being at least partially due to the viscoelastic nature of the restraining ligaments that comprise the joints of the foot and the prevailing forces acting (and not acting on them) during weightbearing activities. It is well known that viscoelastic structures, such as ligaments and tendons, will deform over time given sufficient loading forces. If less tension load is placed on these tension load-bearing structures, they will shorten. If more tension load is placed on these tension load-bearing structures, they will lengthen.

    As such, these "deformities" regardless of whether we consider them "congenital" or "acquired", can change with time with changes in STJ supination and pronation moments. In other words, the "FF to RF relationship" of the foot is a fluid relationship, which is dependent on the prevailing internal and external forces acting on the foot over time.
     
  7. Jeff Root

    Jeff Root Well-Known Member

    The acquired plantarflexed 1st ray increase the degree of ff eversion but, if we look at the other planes of compensation and see a simultaneous increase in ff adduction and plantarflexion then this is what has been traditionally called supination about the oblique axis of the MTJ. So this is a form of forefoot supinatus as well, just as an increase in ff inversion is a form of forefoot supinatus.
     
  8. Petcu Daniel

    Petcu Daniel Active Member

    As Precision Intricast Newsletters are one of my most important "fishing rods" I can make just an accountant type of comment: "forefoot supinatus" is mentioned 5 times in the first 2 volumes (including one newsletter in vol 2).Of course, I don't believe an accountant can teach how to catch fish !
    Daniel
     
  9. Petcu Daniel

    Petcu Daniel Active Member

    Yes, but Kevin is right as the newsletter from vol. 2 was from 2000 which means more than 17 years! Sorry for these 2 useless posts!
    Daniel
     
  10. efuller

    efuller MVP

    I'll bet there are some accountants who are very good fisherperson/people. And some of those could also be good teachers.
     
  11. Petcu Daniel

    Petcu Daniel Active Member

    For sure! I'm trying to imagine how an accountant will assign numbers to a forefoot varus or a stress in a tissue and how will succeed to explain the 'equilibrium' between active and pasive 'accounts'...;)
    Daniel
     

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