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Maximum eversion height test

Discussion in 'Biomechanics, Sports and Foot orthoses' started by efuller, Sep 16, 2011.

  1. efuller

    efuller MVP


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    Re: Correcting for genu varum without risking inversion sprain

    {ADMIN NOTE: I have copied a couple of posts on this test from the thread on Correcting for genu varum}

    The idea of measuring maximum eversion height is that you don't have to guess, or that you have some idea, of what amount of valgus wedge would be too much. In someone with Sinus tarsi pain (the uncompensated varus foot) any wedge might be too much.
     
  2. efuller

    efuller MVP

    Re: Correcting for genu varum without risking inversion sprain

    Are you talking about here or an article. Or both?

    Here

    The maximum eversion height test is one I devised after trying to understand what John Weed was teaching at CCPM. He was trying to relate how tibial varum, calcaneal range of motion and forefoot rearfoot relationship relates to the ground. He also was teaching that you should not evert the calcaneus further than it its range of motion allowed. There are many problems inherent in the approach that he used, but it is a very important concept.

    Background:
    There is a limit to eversion range of motion of the forefoot. One of the limits is the end of range of motion of the STJ when there is bone to bone contact of the lateral process of the talus when it hits the floor of the sinus tarsi. Another limit is when the lateral metatarsals become maximally dorsiflexed and their plantar ligaments become taugth (and there stiffness increases) The position of the forefoot, relative to the ground, varies from individual to individual.

    The test:
    Patient standing in angle and base of gait. Ask them to attempt to evert their foot without shifting their weigth to their other foot. Asking the patient to do both feet at the same time helps prevent the patient from cheating too much. Patients will also try to bring their knees closer together as this will tend to allow them to get the lateral forefoot higher off of the ground. When they are maximally everted, not the height of the lateral forefoot off of the ground. Some people will not be able to lift their lateral forefoot off of the ground and others can lift it more than an inch with many possibilities in between. Do not make a forefoot valgus wedge higher than this height as it will attempt to evert the forefoot farther than the range of motion allows. A wedge that is too large will create a discomfort of either high pressure under the lateral forefoot or pain in the sinus tarsi. It is conceivable that knee pain could develop as well.

    Eric
     
  3. davidh

    davidh Podiatry Arena Veteran

    Re: Correcting for genu varum without risking inversion sprain

    I understand that, which is why I was careful to suggest raising the lateral FF in very small increments of 2 degrees, or use some easily deformable felt to effect a raise.

    Without denigrating your test I would also point out the obvious - you cannot precisely visualise a 2 degree tilt, nor can you measure maximum eversion height accurately. I would also point out that the initial answer I gave was deliberately vague in recognition of an equally vague clinical query.
     
  4. efuller

    efuller MVP

    Re: Correcting for genu varum without risking inversion sprain

    I agree the error in the test may be a few millimeters, but it gives you a starting point for your adding or removing a a couple of mm from the height of the wedge. If you see someone who cannot lift their lateral forefoot off of the ground, then you know you cannot add much wedge.

    Eric
     
  5. davidh

    davidh Podiatry Arena Veteran

    Re: Correcting for genu varum without risking inversion sprain

    Eric,

    I have no disagreement with that at all.

    David
     
  6. Orthican

    Orthican Active Member

    Eric, May I aks your opinion on something?

    I use a variation of the coleman block for assessment of this. I have several pieces of
    mdf that I use for assessing LLD's that are everything from 2mm and up to 24mm. I use the thinnest to assess movement in the hindfoot and forefoot to see if there is any flexibility in eversion and it provides me a starting point without too much in the way of guesswork.

    Sound reasonable?
     
  7. efuller

    efuller MVP

    The difficulty with using sheets of a particular thickness is that you don't know the force applied. You would have to ask the subject if it was a tolerable amount of force.

    At one point I embedded a large hinge into a platform. The subject would stand with their first met head at the hinge and the arm of the hinge would extend beyond the fifth met head. I then had a rope with a pulley attached to the arm of the hinge. I could hang various weights from the rope and then observe the eversion height at the fifth met head. Well, different weights produced different heights. When I stood on the platform some weights were clearly uncomfortable as it felt like there was a valgus stress on the knee and there was a tendency to shift weight to the other foot. It was hard enough to get a measurement with no other problems, but when people would shift their weight to the other foot the measurement would change. People of different weights felt the discomfort at different weights hanging from the rope.

    So, one of the difficulties I see with sheets of various thicknesses is that it is hard to watch for body lean. When you ask the person to evert, without moving their body, or knee, you have a pretty good idea that they start with even weight on both feet and that if you control body lean they will have even amount of body weight on both feet.

    Feel free to experiment with it.

    Eric
     
  8. what about adding a medial wedge to the foot being tested ?

    Yes then the questions become How much wedge?

    But just an idea
     
  9. efuller

    efuller MVP

    Why?

    Eric
     
  10. so have a greater understanding of what the forefoot post will have when the patient is wearing their device.

    Say you decide medial skive and FF valgus post , in foot flat the medial skive will be affecting the outcomes of the FF post.

    ie the maximum eversion height maybe different until the heel has become non-weightbearing.

    or it might not ?
     
  11. efuller

    efuller MVP

    To get prediction of effect your rearfoot varus wedge would have to create the exact same change as the medial heel skive device. There are some feet that a varus rearfoot wedge will actually cause the STJ to supinate. This will not effect the maximum eversion height as that range of motion is still available. (I'm not sure that you should be putting a varus heel wedge under feet that will actually supinate with the wedge. A lot of feet will not change STJ position when standing on a varus wedge.)

    I'm not looking at this test as a what will happen if I add a wedge. I already know what's going to happen when I add a wedge that's too large. I just want to make sure that the wedge that I add is not too large.

    Eric
     
  12. Orthican

    Orthican Active Member

    Thankyou for responding Eric. And yes I do intend to do just that.

    I should be more clear though as to what I do with them. I'm as has been noted by others only looking at whether or not there will be motion and if if I need body load to demonstrate it at the STJ I will sometimes do this. I am looking for postural cues as you have noted as well. :deadhorse: I'm kind of chuckling to myself right now because I get this funny feeling that I'm talking to those who have been where I am ...
    I as well have noted the sinus tarsi swelling, position of the external landmarks and assumed a bone to bone issue from faulty mechanics was at the heart of it.

    You have sound advice here Eric.

    Thanks

    Todd
     
  13. drsha

    drsha Banned

    Re: Correcting for genu varum without risking inversion sprain

    This test sounds very interesting but for me, it only has applicability when using TS Theory.

    If I am rarely using skives and RF varus wedges to evoke tissue stress relief, why would I have to do this test, especially if it is unproven?

    I would like to review this test more completely.

    Do you have any peer reviewed articles on this test you devised?

    Any information in textbooks or lectures that have been delivered further defining your test?

    Do you have any studies that show applicability, accuracy, reproducibility among practitioners or clinical results that it works?

    As there has already been discussion on this very thread claiming inaccuracy and possible flaws of this test why should we consider making it part of our exams?

    As you have personally stated about the test "I agree the error in the test may be a few millimeters, but it gives you a starting point", I'm wondering what makes you so upset when I claim that Functional Foot Typing is a new starting platform for biomechanical diagnosis?

    All you have proven to me about FFTing is that, like MEHT when applied to Foot Centering, it has no applicability for you in TS Theory.

    Dennis
     
  14. efuller

    efuller MVP

    Re: Correcting for genu varum without risking inversion sprain

    I don't see why you couldn't use it when you were using neutral position theory.

    Tissue stress also used forefoot wedges. For example, a patient with peroneal tendonitis will often have a laterally positioned STJ axis and you will want to increase pronation moment from the ground to decrease the need for peroneal muscle activation. This is better done with a forefoot valgus wedge rather than a rearfoot valgus wedge because there is usually a longer lever arm at the forefoot. I have made forefoot valgus wedges too high and seen the pain that they cause. This test will give me an idea of how big the wedge should be. Thus this measurement can prevent too much stress on another structure when successfully treating peroneal tendonitis.


    No. But I do have a logical explanation for its use. This is the problem that I have with functional foot typing. There is no logic given for why foot typing measurements would be useful. At least with the neutral position measurements there was the "support the deformity" rationale. Functional foot typing gets away from even that rationale and there is no reasoning to replace it.


    No, just what is here on the arena.

    Just personal experience.


    Because if part of your treatment regimen is to add valgus wedging you need to know how much wedge will be too much. Dennis, this is why you should add this test to functional foot typing. You have described using the Root protocol for cast balancing. If you use this protocol and you send a cast to a lab, and the lab determines that the cast has a forefoot valgus, they should, if they follow the protocol put an intrinsic forefoot valgus post in the orthotic. (Of course if the lab just takes the cast and doesn't even look at forefoot to rearfoot relationship and never adds forefoot valgus wedges then you would never have to worry about this.) So, Dennis, what instructions do you give to your lab techs?

    My starting point is for something specific. When you have decided that you are going to add a forefoot valgus wedge then you have a starting point for how big that wedge should be. If the patient returns after getting their orthotics with either sinus tarsi pain or too much pressure on their lateral column, then you will know that your wedge was too big. You will also know what correction to make to your orthotic.

    Your functional foot typing platform does not give any specific guidance on how to alter the orthotic or change treatment.

    Dennis, you should re-read your posts to make sure they make sense before you hit the submit button.

    Eric
     
  15. Bruce Williams

    Bruce Williams Well-Known Member

    Re: Correcting for genu varum without risking inversion sprain

    Dennis;
    please spell out your abbreviations as they are confusing to those who are not familiar with your posts. I make this mistake often and try to not abbreviate as much except on widely accepted things.

    as to peer reviewed articles, there is the Kogler article on the use of FF valgus posting to decrease tension in the medial band of the plantar fascia. It has been cited repeatedly and while not specific to Eric's primary usage, does represent some aspect of peer reviewed discussion.

    You might read some of Jim Clough articles on digital wedging as the concepts are similar though used in a different format.

    I have been utilizing Eric's test since he first described it here or on the podiatry Jisc serve. It works well and serves a very useful purpose. I use mostly soft full length devices and often patients will deform the devices in such a say so that either the device must be varus posted, or posted lateral at the FF to balance the RF to FF relationship. In many instances, simply adding the FF valgus post will alleviate symptamatology equal or better to any additional varus posting.

    It is a valid theory and I think extremely valid in clinical usage and I use it repeatedly and multiple times daily.

    Cheers,
    Bruce
     
  16. drsha

    drsha Banned

    Re: Correcting for genu varum without risking inversion sprain

    Bruce:
    I haven't seen you posting here in a while. Hope u and your family are well.

    Thank you for your civil and easy to reply posting. What a breath of fresh air.

    Many of my abreviations and terms, like Kevins and Erics are becoming more commonplace in biomechanics venues.
    We are all trying to make the terminology more universal and understandable so that it can be taught and appreciated by others less schooled in our beloved science.

    Fully compensated rearfoot varus, partially compensated forefoot varus or flexible rearfoot, flexible forefoot.

    SERM-PERM are two tests that can be done to any joint that has a range of motion that educate the examiner when an ORF (Orthotic Reactive Force) or a MERF (Muscle Engine Reactive Force) will stop moving the joint and start developing a moment that will leverage tissue or store energy into that joint for future use.
    This gives us insight as to how we want to control that joint or its musculotendenous leveraging of tissues that are deficient or compensated, foot type-specific.

    I am not a big believer in forefoot valgus (like tibia varum) as I feel it is a man made concept and not one that serves me well clinically.
    The posterior tubercle of the calcaneus sits in varus to the body of the calcaneus providing an inversion force to load the lateral column primarily in stance and gait.
    Likewise, the Tendo Achilles is slightly medially inserted in order to provide a supinatory moment to the lateral column as it begins to weight.

    The thought that I want to lift the lateral column from the ground with a valgus posting instead of letting it make ground contact naturally seems counter productive.

    Roots forefoot test drives the forefoot valgus diagnosis but gives little information as to the pathology present and doesn't give insight as to forefoot function in closed chain.
    Forefoot SERM testing incorporates a practitioners moment downward and finds the 1st ray either plantar or dorsiflexed. This gives insight as to the position of the first ray in early midstance as it starts to bear weight.
    Forefoot PERM provides an examiners moment to the 1st ray upward and is read as plantarflexed, online or dorsiflexed to the fifth ray. This gives insight as to the compensatory position of the first ray as the forefoot continues to bear weight from midstance on.
    If the FF SERM is plantarflexed and the FF PERM is dorsiflexed, I know that the first ray will contact the ground below the level of the fifth ray and that it will lack stiffness in countering grf. It will dorsiflex producing FHL and even before symptomatology exists, I need to compensate that biomechanical bomb waiting to go off. Forefoot valgus only created confusion for me (as I think it does many others trying to practice biomechanics).

    Another thing I have done in my system (which proves to me that none of my antagonists have ever visited it) is utilize the architecture of the foot to define pronation/supination.
    To me, pronation is bad, supination good. Yet when defined by motion rearfoot pronation is bad and forefoot pronation is good.
    Architecturally, the rearfoot strengthens when dorsiflexed, the forefoot strengthens when plantarflexed so I have reversed my definition for forefoot ROM and made plantarflexion supination. My S (Supinatory)ERM Test plantarflexes (pronates) the 1st ray.
    This makes peroneus longus a rearfoot pronator and a forefoot supinator and makes teaching it so much more universal.
    No one has yet to call me on that in 3 years here on The Arena until one of you (You know who) tried to correct me the other day privately. This means that none of you has actually "visited and tested my work".

    As far as weakening the plantar fascia with a valgus wedge that to me makes no biomechanical sense. An EPF relieves plantar fascial pain and gifts the patient to a weaker lifestyle from then on in.

    The Cluffy Wedge elevates the great toe necessitating a larger toe boxed shoe and allowing for greater repetitive microtrauma to the distal hallux nailplate causing micrografmentation and secondary fungal invasion. That's why most "Fungal" Toenails are of the hallux. Why would I want to do that.

    The place to treat FHL is the first metatarsal. Vaulting it so that its declination is greater is my primary treatment paradigm. This allows for Wolfs and Davis's Laws to strengthen and leverage the system, not stretch or weaken it.

    Stopping pain with care that produces ???? as an pathological compensation and then treating the consequences with another caring but negative treatment makes no sense. A pill that stops arthritis and produces hypertension leads to an antihypertensive. A joint that is mobilized, stabilized and strengthened cures the pain as well and leaves the system stronger not destined to fail.

    I am not trying to say that Eric's is not useful clinically and utilized by many practitioners like yourself. I am merely trying to present an opposing school of thought that I think more reflects the biomechanical history that I inherited.

    Maybe more importantly, as a strong believer in the principles laid down by Merton Root, D.P.M. I think that I have maintained his principles of examination, the importance of the muscle-tendon units in the biomechanical cascade and the need to find a better optimal functional position (one that can lend itself to being proven) than STJ Neutral. I think I have made his language more universally understandable and teachable and most importantly, I have maintained his positionalist attitude with my Foot Centering Theory of Structure and Function.

    Dennis
     
  17. Bruce Williams

    Bruce Williams Well-Known Member

    Re: Correcting for genu varum without risking inversion sprain

    Dennis;
    I and my family are well thank you, and I hope and wish the same for you and yours.

    I am busy with several other projects right now, writing a book chapter, working with some new technology for sports med applications, etc, so I have been primarily lurking.

    You wrote: "As far as weakening the plantar fascia with a valgus wedge that to me makes no biomechanical sense. An EPF relieves plantar fascial pain and gifts the patient to a weaker lifestyle from then on in."

    The FF valgus wedge does not weaken the Plantar fascia, but reduces the force of tension within the medial band. Read Eric's paper on the plantar fascia and it will make much more sense to you. My interpretation of the paper is that there is bad tension, which I feel is when the foot is elongated from FF and RF pronation with the hallux plantar flexed, and good tension, which I think is when the hallux will dorsiflex in a timely manner and the RF is in a more rectus to supinated position and the FF is in a pronated position as I think you would describe it.

    If I am understanding your ideas above, when the FF is pronating in late mid stance, especially if there is a functional hallux limitus, then it would be best to aid the pronation of the lateral column to drive the foot towards a plantar flexed 1st ray position. This may be an artificially created plantar flexed 1st ray due to the valgus posting of the lateral column, but often is necessary.

    My general thought about a foot that has minimal lateral dorsal excursion, as Eric states, is a foot that will usually have a very rigid stable lateral column with very little chance of a having a tailor's bunion. Similar to a PF'd 1st ray, but lateral if you understand my meaning.

    Those feet that will often need posting of the lateral column usually will also have lateral excursion. I think this is often related to a medial axis stj position and ankle joint equines as well. These feet will generality have minimal DFion stiffness of the 1st ray, or hyper mobility for those who hold to that definition.

    These are issues that need to be addressed and I feel there are few ways as beneficial to assist that than with a FF valgus posting, in many instances. It's part of an ala carte deal on a patient by patient basis.

    Dennis wrote:"The Cluffy Wedge elevates the great toe necessitating a larger toe boxed shoe and allowing for greater repetitive microtrauma to the distal hallux nailplate causing micrografmentation and secondary fungal invasion. That's why most "Fungal" Toenails are of the hallux. Why would I want to do that."

    I can't disagree more. It is the downward force of the hallux due to the elongated tension of the plantar fascia allowing a DF'd 1st ray and a PF'd hallux that often contributes to the nail issues you cite. Pre-loading the hallux with digital wedging or a cluffy wedge will alleviate this negative elongated tension in the Plantar Fascia by "winding the windlass", DFing the hallux, and PFing the 1st ray. This is seen regularly with in-shoe pressure. You need to re-think your process here.

    Dennis wrote:"The place to treat FHL is the first metatarsal. Vaulting it so that its declination is greater is my primary treatment paradigm. This allows for Wolfs and Davis's Laws to strengthen and leverage the system, not stretch or weaken it."

    I disagree here as well. I am a firm believer in 1st ray cutouts, but they have limited usefulness when used alone. It would be nice if we could ratchet down the 1st ray and keep it in the position that would benefit the foot and fit into a cutout to create the vaulting you talk about. Unfortunately, it only works to a point and very little in many feet. This is why utilizing a digital / cluffy wedge with a cutout works much better. Get an F-scan, you will see what I am talking about immediately!

    I have no issue with many of your ideas, there is overlap in my our processes, just as there is with Eric's, Simon's, Kevin's and others. It is the blending of all of these ideas that will hopefully make us all better practitioners and teachers in some aspect so that we can pass on what we do and don't do well to others and that they may learn from our mistakes, and successes.

    cheers
    Bruce
     
  18. efuller

    efuller MVP

    Re: Correcting for genu varum without risking inversion sprain

    Tension is tension. The plantar fascia can't tell the difference between good tension and bad tension. However, tension in the plantar fascia will tend to cause several motions, STJ supination, MTJ plantar flexion, first ray plantar fexion and hallux plantar flexion. So, if there is increased resistance to these motions then there will be higher tension in the fascia. In just looking at STJ motion, Tension in the fascia will tend to cause supination of the STJ. If there is a high pronation moment from the ground or muscle then there will be higher tension in the plantar fascia before the tension will cause a supination motion.


    Eric
     
  19. drsha

    drsha Banned

    Re: Correcting for genu varum without risking inversion sprain

    I disagree.

    Since the 1st met head and the hallux are firmly on the ground at the end of plantarflectory motion, I think that the PF will produce a plantarflectory moment on the first ray and the hallux in your description as no plantarflectory motion is available.

    Dennis
     
  20. drsha

    drsha Banned

    Re: Correcting for genu varum without risking inversion sprain

    How can you reduce the tension on the plantar fascia without weakening it. The PF exerts its force on the motion and moments of tissues with tightening power, not by stretching. An elongated or stretched ligament applies less force (that"s why the pain goes away.

    Eric thinks you're opinion about bad tension and good patient is wrong, so I'll pass on the article.

    If there is a FHL then in your terminology the forefoot would be supinating, not pronating at that time?

    So if you have a "plantarflexed 5th ray, why would you want to add a supinatory moment to it

    If you are working with a STJ Neutral shell and are willing to allow the foot to suffer future consequences of your valgus wedge in the foot and posture, which I am not.

    Dennis wrote:"The Cluffy Wedge elevates the great toe necessitating a larger toe boxed shoe and allowing for greater repetitive microtrauma to the distal hallux nailplate causing micrografmentation and secondary fungal invasion. That's why most "Fungal" Toenails are of the hallux. Why would I want to do that."

     
  21. efuller

    efuller MVP

    Re: Correcting for genu varum without risking inversion sprain

    Dennis, when the foot is on the ground, the Met cuneiform joint will be at its end of range of motion in the direction of dorsiflexion not plantar flexion. In some feet, usually those with low pronation moment from the ground, when an examiner dorsiflexes the hallux in stance, you will see plantar flexion of the metatarsal. Plantarflexory motion is available.

    When I say tend to cause motion, I am saying that it will create a moment in the direction of that motion. If there is an equal moment from some other source then that motion will not occur. For example, in static stance ground reaction force acting on the first met head will create a dorsiflexion moment of the first metatarsal. Tension in the plantar fascia is one source of moment that will create a plantar flexion moment on the metatarsal. If the metatarsal is not moving then the net moment acting on it must be zero. We know the ground is pushing it up, so something is holding down.

    Eric
     
    Last edited: Mar 22, 2012
  22. Bruce Williams

    Bruce Williams Well-Known Member

    Re: Correcting for genu varum without risking inversion sprain

    Dennis,


    You reduce the elongated tension positionally by DFing the hallux and PFing the 1st metatarsal. This creates Tension that will supinate the FF on the rear foot.


    Eric is correct in a purely definitional way. Regarding the situation that the tension is affecting, there is good positional tensions that affect joints in a way we feel works best for foot function, and bad positional tension that can lead to "bad" tissue stress. Semantics.


    Yes, my bad I think. I always feel that when the lateral column is elevate above the 1st ray that the foot is technically pronated. My positional dyslexia kicks in now and then.


    You would not. A "plantar flexed 5th ray" will likely not evert significantly given Eric's test. But, if it does, and you can add valgus wedging then you may still want to to aid the PFory function of the 1st ray that is effected by FnHL ( functional hallux limitus).

    Harder shell devices often will need less wedging under the metatarsal itself. But, tip posting the 4-5th metatarsal heads often will make it more effective.

    Because it is the plantar pressure of the hallux from a FnHL that is causing this trauma to the nail as you describe it. Elevating the hallux with a wedge will not necessarily decrease the PSI under the hallux, but will usually increase the pressure under the 1st metatarsal and the timing of the pressure sub hallux will shorten substantially. I have treated many IPJ hallux calluses and ulcers this way and so long as there is no structural limits of the 1st mpj they all decrease significantly. Why should pressure at the nail be any different so long as the toe box has adequate height?


     
  23. drsha

    drsha Banned

    Re: Correcting for genu varum without risking inversion sprain

    Bruce: I remain so pleased that you are posting again.

    So, as to the importance of our discussion biomechanically.

    1. It is a forefoot biomechanics discussion. The rest of the foot and posture has been amputated.
    2. Neither of us thinks that as part of care, in these cases, we need to measure SALRE or discuss the STJ.
    3. Neither of us is suggesting the use of STJ Skives, posts or casting variables as part of our treatment
    4. Our discussion includes physics, engineering and Newtonian science but it also includes architecture

    If the 1st MP Joint is the attack point for care then architecturally, I agree that the two changes in structure that we can make are DFing the Hallux and PFing the 1st met.

    All of us, including Eric knew exactly what you were trying to say but he must keep asking for better definitions and explanations in order to deflect and divert the power of your arguments.

    I think the problem here is that when you pronate the STJ it is bad and when you pronate the 1st ray, it is good. That's why in Foot Centering, I have reversed the definition of 1st ray SERM and PERM so that SERM is always good and PERM is always bad. This is a great teaching advantage.

    [/Quote]You would not. A "plantar flexed 5th ray" will likely not evert significantly given Eric's test. But, if it does, and you can add valgus wedging then you may still want to to aid the PFory function of the 1st ray that is effected by FnHL ( functional hallux limitus).[/Quote]
    I understand what you are saying but in Foot Centering, we use 5th ray cutouts and MERF's to solve that situation biomechanically.

    Foot Centering uses harder shell devices and 5th ray cutouts and MERF's because tip posting 5 will have a supinatory momentous effect at the 5th met which will be detrimental in all cases of F5thRayL as you have alluded to.

    Agreed once again.
    As any experienced closed chain professional knows, most of our patient, especially women wear shoes with a toe box that does not have the "adequate height" you are talking about so IMHO, making your statement so matter of factly forces you to either marry your patients to therapeutic toe boxes, minimalistic shoes or failure IMHO.

    I have looked at pressure studies (My practice was a beta site for the EDG before you were in High School) and I continue to disagree.

    .

    1. I agree that I have not read Dr. Dananberg's papers nor studied with him over the years at your level and I will use your comment to review his papers and be educated by your suggestions.
    But OMG Bruce have you, other than the brief time we worked together when you utilized my lab (and enlightened me so much about Howard's work during that time) have you spent any time with me or reading my chapters and publications in forming your opinion about FFTing and Foot Centering?

    2. We agree that a cutout alone will not accomplish what I am suggesting. Where we differ is the attack point and architectural engineering methodology we use to evoke positive clinical results.

    3. Foot Centering, instead of architecturally changing the position and structure of the hallux for care corrects the proximal architecture by Vaulting, foot type and patient specific and by training the muscle engines (P. Longus, FHL and Abductor Hallucis in FHL) primarily involved utilizing Compensatory Threshold Training (Boot Camp or Yoga Training if you will).

    4. What you are suggesting with "digital skiving" is a non operative 1st MPJ fusion by restricting the total motion of the Hallux, reducing heel height variation and exposing your patient to all the complications of that wedging procedure unnecessarily IMHO.

    5. What I am suggesting with Vaulting into an Optimal Functional Position is a non operative Lapidus which, along with a plantarflectory CBWO and Keller Buns was always my biomechanical surgical treatment of choice.
    I never was a big fan of the 1st MP fusion and used it as salvage in practice.

    My point here Bruce is aimed at The Arena faithful and not you personally, sorry.

    You are I are not profit motivated primarily. We believe that we are offering an opportunity to our profession to expand and grow their diagnostic and clinical accumen and we both realize that in doing so, the profit if the end user and their patients will benefit as well ).
    Summarily, I have a Huge Profit Motive and yours is smaller but the profit motive is collateral damage to our dreams.

    DITTO, DITTO, DITTO
    The difference between you (and I believe your method is less personally traumatic in the long run) and I is that I grew up in Brooklyn and I P#$$ BACK.

    "I am reminded of a colleague who reiterated "all my homosexual patients are quite sick" - to which I finally replied "so are all my heterosexual patients".
    Ernest van den Haag

    Live, Love, Laugh and Be Happy
    Dennis
     
  24. Petcu Daniel

    Petcu Daniel Active Member

    Sometimes the 5th metatarsal is high, let say at 5 mm above the ground while the 4th is almost in contact with the ground. How the wedge's height should be chosen in such cases?
    Thanks,
    Daniel
     
  25. efuller

    efuller MVP


    It depends on the intended goal or the loads you want to change. Also, the measurement is a starting point. If you do not see the results you want you change the device. There are several competing considerations. Too much wedge and you can get sinus tarsi pain or lateral column overload. With too little wedge you might not shift enough load from medial to lateral. Also, at some point the wedge can become large enough that it takes up too much volume in the shoe.

    Yes, the MEH measurement gives you a number. But, with any clinical measurement there can be error, and you have to adjust for that.

    Eric
     
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