Help with patient with arch pain

Righto. Not sure whether to be affronted or commend you on your carbon footprint awareness.

Last world cup final I was in a restaurant with approx 30 Sith Ifrikaans, watching the game on a big screen, eating biltong and boerewors.....lekker.

 

Dennis, you got a fair review. Some of us read all that there is available to read about your ideas. We had some questions. We asked those questions of the inventor and he was unable to answer them. No further review is possible. Dennis, please stop whining and stop calling us closed minded.

Eric

 

My presence would indicate an openmindedness that's for sure.

You know something ?
First off just sitting down with a beer I must say, it has been a busy week. Both at work and during my after hours thinking. It I will admit excites me. I am thinking about my mods in my feet and how I have been using my shape to influence the movement of the mass over the center of pressure over the foot over time.. For me and I know you will correct me if needed here but I have been thinking about it in terms of how the "structure" accepts the "load" and when and where. Thanks...:bang:

Your discussion you all had on CNS control of stiffness was very interesting. I am nowhere near finished reading it yet but so far it makes total sense to me. I have always known that there was this connection and it was "almost" instantaneous....

But I always just referred to this effect as "proprioception" and lumped all this info under that label regarding balance of load over a stable base with maintenance of COM in a given area. I say given area because I do deal with some who have a very dynamic COM pattern and utilize a great deal more contractile units over time. But positive trendelenburg will most always lead to over time very telling postural habits.

I also have realized an important factor while getting to know myself educationally here. I have all this while had a very good shall we say "intuition" regarding what I see and the motion that can be controlled. And I also see it as a weakness... I say intuition not because of some silly mental bull but more along the lines of "if I see it I can generally figure out what will get them moving without pain with greater mobility and comfortably". To me if it is not worn it is worse than if you do not work with them over time. In other words regular follow up gets them where once every month or four can not. Incremental changes over time have thier place as long as they know what you are trying to do. And you do not take on too many...Or what you are dealing with.

Reading so far on the midfoot balance thread in my free time (I also have two boys 18 and 13) I noticed I was thinking along those lines as well. That one to me is where the point about which I exert a force on a foot came to that started this part of the discussion in the first place . I have been using that bolstered effect to "rotate" if you will the COM around it (equal but opposite to) to try and bring around that flexible forefoot and try to tighten it up using that I guess is just triplanar rotation about the subtalar and will be at a position of medial deviation at the start or it will want to early in stance...and I want to provide an obliquely directed force that promotes a shall we say more efficient movement of the load onto the midfoot that allows acceptance in a position that does not promote degenerative effect(tissue stress?). So I want to provide force couple at the heel area below the sustentaculum tali that flows into the arch area ...I only meant that I "see" that valgus heel (which now I know means really nothing as it is quite subjective. And that is quite true though isn't it).....or as I now see it "everted" all makes sense?...I am looking to have if you will a "wire rope" connecting the Weight to the "hopefully" correct shape beneath (ORF) to balace out the malfunction. When I said "flexible valgus with a un unlocked midfoot" I meant that under load the midfoot will not close pack and ligamentously and muscularly hold the load and move that mass over the foot and off the big toe without reversal of the windlass. Does it always work? No. That's why I see this as a great opportunity. I have used what you refer to as a cluffy wedge but just referrred to it as a 1st met ramp. (I had no idea that stuff was patentable...seems costlyparticularly internationally.....) Anyway I'm not hurting anyone or ripping anyone off if that comes up. (You never know what goes through a person's mind)...I take our canons very seriously. I have always custom made most of what I do. I was a technician in my start and was so for a quite while early in my career.

We guarantee for three months any orthosis we do. 100% They are not an item to abuse and there is far too much of that out there. We feel like if that happens we need to make sure we do what we can. (and yes I have modified someone else's work that the patient has not seen in ten years and does not want to go back and is broke and on AISH. I will do it for free as I do also believe that life is a very simple place. You get what you give. I believe it.

Thankyou

 

Oh, and an S.T. bolster is only one way for goodness sakes. "One" not only. Not everyone needs it or should have it..... many feet equal many options... many ways to do similar things....

 

Curses!! My secret has finally been discovered! Alas....I now must confess...my real name is Darth Kirby. I admit it...for the last few years I have used the Dark Side of the Force to control the minds of all the contributors and lurkers here on Podiatry Arena for one purpose....to steer them toward my Evil Empire where the Death Star lurks in the shadows so that I, and I alone, can finally rule the Universe of Podiatric Biomechanics.

 

You are back to stating that we all use many methods and change our casting and prescrtibing techniques at our level which is a given for any student of biomechanics.

I believe foot typing (mine or anyone elses tries to profile all feet into subgroups that can then adhere to some basic rules that are then further modified, case to case, patient to patient.
Is that such a profane idea?

The
post to casters, 3 degree varus wedgers in America and I assume Canada as well are not evident on The Arena.

Do you believe that I am one of those?

How would you compare your infrequent use of frontal plane rearfoot correction with the fact that almost every patient presented for possible care on this site that has a medially deviated subtalar joint axis gets a medial heel skive, blake casting or varus posting correcting a frontal plane that I believe often needs no correction.

Correct me if I am wrong, in these cases, you would attempt your S.T Bolster instead correcting on the sagital and transverse plane as you describe using ORF's and changes in COM?

No one is using medial skives or ST Bolsters on feet with laterally deviated STJ Axis, I assume. Not even I.

No one is using one thing for all cases, period except the biomechanically impotent.

Can't we agree on that, Orthocan?

Dennis

 

Of course it is. It simply has to be.

That would entirely depend on who you talk to.

I would ask only why you would assume I do not use frontal plane corrections. I have not made such a statement. I see a lot of adolecents with femoral anteversion and "Arch" or "bolster" only promotes and worsens this patient's rotary pathway.

Nor I. The effect of such things is so obviously wrong when the person walks. Spraining peoples ankles is not good for my business.

Of course we can agree that we cannot use one way to treat all. I try to look at all ways that people say and make up my own mind based on one thing. Does it work for me in the clinic for real world application.
Comfort and control and the willingness for the patient to want to use it makes my day go easier. Doing things that do not work and are uncomfortable make my life at work difficult. . The way I do Afo's K.O.'s and KAFO's, upper extremity, has evolved from this thinking. I see far too many people to complicate my days with things that do not work well. I have a very good success rate with the way I do things.
I am good with feet but I want to be very good. That means I need to read and comprehend as much as I can from as many sources as I can and then put those ideas into practice and see what comes out as I go along. What I have in the "tool box" for feet is not enough to satisfy me any more. I want to do better than what I am for them...my patients.

I am quite flexible in my acceptance of ideas. As long as it works for the problem that presents at that time I'm all for it.. I dropped my ego at the door a long long time ago. No place for such things in the clinic room for the mom and her son whom you know will eventually die. Compassion is my main modus operandi. I have a very solid following because of that, my honesty with them in that I am the first to admit a mistake and will re do what I have done wrong, and that they all know I will not give up on trying to provide the best solution to thier thier problem. None of us are perfect. The difference comes when one is willing to admit that.

Hence, here I am.

So .... To all I say , I am clay...mold me...Feel free to correct me, throw an idea at me etc. I will not do anything but read, digest, and ask for more...

After years in the trenches I am up for air as it were...I am a dry sponge looking for water. What you all have here is quenching and I am soaking it up.


Thankyou

 

LOL! hahaha...that pic is pretty funny.....perhaps...too funny...hmmm you evil one you... but perhaps your name is not Darth Kirby...you sneaky sneak...perhaps a better monicher would be

"Darth Insidious" master of all that comes in sneakily and without us knowing or feeling you are there...Second in command you are to "Darth Podius"...master of all things tautalogical and illogical but still omnipotent....

:drinks

 

Todd:

I like your attitude. I think you will be a very welcome addition here to Podiatry Arena.

As you will probably discover here, there are many different opinions from experienced clinicians as to how one should treat certain pathologies with custom foot orthoses. Let me give you a brief synopsis of my experiences.

When I was in my Biomechanics Fellowship back in 1984-85, I taught Root biomechanics to the students at the California College of Podiatric Biomechanics. During that time, I soon discovered that the concepts taught by Dr. Root and his coworkers could not adequately explain many of the pathologies that I was seeing at the time.

This is when I first began to explore the STJ axis location and its variation from one foot to another. From that information, I then began to understand how the STJ axis spatial location may have a profound mechanical effect on the biomechanics of the foot and lower extremity but also on the mechanical effects of foot orthoses. This "kinetic" approach to the foot that I proposed was quite different than the "deformity-based" biomechanics of Root et al and was initially met with lukewarm enthusiasm, even though I strongly felt that it was a very significant factor in foot and lower extremity function, in the productin of foot and lower extremity mechanically-based pathologies and in how best to treat these pathologies with foot orthoses.

If you are interested in reading about these concepts, I would suggest you read the following papers, in chronological order, to try to appreciate the theoretical significance of these concepts.

Kirby KA: Methods for determination of positional variations in the subtalar joint axis. JAPMA, 77: 228-234, 1987.

Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989.

Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992.

Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992.

Kirby KA: Podiatric biomechanics: An integral part of evaluating and treating the athlete. Med. Exerc.Nutr. Health, 2(4):196-202, 1993.

Kirby KA.: Biomechanics and the treatment of flexible flatfoot deformity in children. PBG Focus, J. Podiatric Biomechanics Group, 7:10-11, 1999.

Kirby KA: Biomechanics of the normal and abnormal foot. JAPMA, 90:30-34, 2000.

Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000.

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001.

Kirby KA: Foot orthoses: therapeutic efficacy, theory and research evidence for their biomechanical effect. Foot Ankle Quarterly, 18(2):49-57, 2006.

Kirby KA: "Evolution of Foot Orthoses in Sports", in Werd MB and Knight EL (eds), Athletic Footwear and Orthoses in Sports Medicine. Springer, New York, 2010.

You can download these papers from my website:

http://www.box.net/shared/z9vvdj6lt8

You will need to contact me via e-mail to get the password to my website:

kevinakirby@comcast.net

Good luck in your educational adventure.:drinks

 

So, Dennis, when are you going to write up those rules so that we can examine them fairly? We won't know if it's a profane idea until you do. At least Root et al, published how they would treat different foot types differently.

Eric

 

One of the problems that I had when I first started learning biomechanics was the loose usage of terminology. For example, can you describe what you mean by promotes a more efficient load onto the forefoot.

The term force couple has a very specific meaning. There are two forces that create a moment. When devising a treatment it is very helpful to be able to identify both of those forces. For example, you could create a adduction moment on the rearfoot with a force couple from a force from medial to lateral at the talar head and another force from lateral to medial at the inferior posterior lateral part of the calcaneus. Body weight and ground reaction force can create a force couple.

Another area that can help you is to understand what close packed means in terms of the anatomy of the joints. If the close packed position is maximally dorsiflexed, then activation of the windlass will move those joints away from the close packed position. It is more helpful to think in terms of which anatomical structures are creating stiffness. For example compression of the joint surface and tension in the plantar ligaments of the first met cunieform joint will create a force couple that will attempt to prevent further dorsiflexion.

 

Thankyou Eric . I know that I have to get terminologically up to speed and will make sure my next posts make far more sense descriptively. And yes I have over these years run fast and loose with terminology. My bad.

Thankyou.

 

Thankyou Kevin for the invite to read your information. An e mail will be coming your way shortly.