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Type of insole used to treat the PreClinical Clubfoot or Primus Metatarsus Supinatus deformity

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brian A. Rothbart, Jul 30, 2021.

  1. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Members do not see these Ads. Sign Up.
    Are the insoles used to treat the Primus Metatarsus Supinatus or PreClinical Clubfoot genetic deformities, supportive or proprioceptive?

    The answer lies in how you view the action of the insoles.

    • Supportive Orthotics: Traditionally, podiatrist see the action of their orthotics as supportive in nature. They envision that by supporting the foot, the functional position of many (if not all) of the weight bearing joints are improved. (This follows the Engineering Axiom: Support the foundation, stabilize the structure above)
    • Proprioceptive Insoles: Posturologists use thin flexible insoles which place focal points of stimulation/irritation underneath the feet. These points of contact generate tactile (proprioceptive) afferents which are transmitted to the brain as proprioceptive signals. Acting on these proprioceptive signals, global adjustments (via the cerebellum) are automatically made in the posture.
    • The insoles I use are thin and flexible with a support system (wedges) underneath the medial column of the foot. The placement and dimension of these wedges is determined by the type and severity of the genetic foot structure you are treating. So, in essence, they are an hybrid insole: they use a supportive wedge to adjust the proprioceptive signal sent to the cerebellum.
    Succinctly: The wedges, in themselves, are not proprioceptive in nature. Rather, the wedges decrease abnormal closed kinetic chain pronation which, in turn, normalizes the generated proprioceptive signals. (See Chapter 5 in the Foot to Brain Connection, which describes how proprioceptive signals are generated in a closed kinetic chain)
  2. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Why Not Orthotics? As a practicing Podiatric Physician and researcher for over 45 years, I have had a passion for understanding the link between foot mechanics and overall body health. I can still remember my professor in biomechanics saying ‘the patient’s manner of walking not only affects the overall health of the feet, but also the overall health of the body’. At that time I did not fully appreciate how prophetic his statement was.

    How the foot functions, referred to as biomechanics, is a major determinant in the overall wellness of the patient. From an engineering point of view, this is easy to understand. An unstable foundation can produce problems in the entire building. Likewise, an unstable (pronated) foot can produce problems in the entire body.

    For years I attempted to stabilize foot mechanics by using a supportive type insoles (orthoses). These orthoses typically incorporated an arch support with forefoot posting (wedging). They were very effective for controlling foot, knee and low back pain, but at a very high price. Over the years, it became apparent to me that by supporting the foot I was weakening it (e.g., inner arch collapsed more and more). As long as my patients wore their orthoses, their body pain was less. However, their pain quickly returned when the orthoses were not worn. It appeared I was addicting my patients to their orthoses!

    The link between foot function and musculoskeletal health can not be overstated. However, I discovered (1988) another important link between the foot and the body: Posture. My research indicates that a weak and unstable foot can and often results in postural distortions (poor posture). And these postural distortions occur in young children. It also became clear that postural distortions are a harbinger in the development of chronic body pain. The child with poor posture is the adult with chronic body pain.

    In my pursuit to reverse and correct these postural distortions, I continued to use orthotics. The long term results were less then desirable: These orthotics definitely improved posture. However, when the orthoses were not worn, the postural gains were quickly lost. And alarmingly, in many cases, the posture appeared even worse when compared to pre-therapy photos. This suggested a disturbing link between supporting the foot and weakening the posture.

    Obviously, a different approach in therapy was needed!

    Proprioceptive Insoles

    In 1995 I invented a non-supportive type foot insole which incorporates a form of acupressure therapy. These insoles, now referred to as Rothbart Proprioceptive Insoles, apply a tactile stimulation to the bottom of the foot. In theory, this tactile stimulation transmits a signal to the cerebellum (the balance center of the brain). Acting on this signal, the cerebellum initiates a postural correction affecting the entire body. The posture shifts from a forward, inward position to a straighter more upright position. Postural photos visualize the immediate and far reaching impact proprioceptive insoles have on the body.

    Published studies confirm the link between improving posture and reducing or eliminating chronic musculoskeletal problems. While both proprioceptive insoles and orthoses improve posture, unlike orthoses, proprioceptive insoles do not weaken the foot. In fact, many of our patients find that they are able to use their proprioceptive insoles less and less and still maintain their level of wellness (a process referred to as engramming).

    Pre vs Post Orthotics.gif

    • Rothbart BA, Esterbrook L, 1988. Excessive Pronation: A Major Biomechanical Determinant in the Development of Chondromalacia and Pelvic Lists. Journal Manipulative Physiologic Therapeutics 11(5): 373-379.
  3. scotfoot

    scotfoot Well-Known Member

    When you encounter patients with weakened feet, do you prescribed any strengthening exercises ? I have asked you this question a number of times now , Dr Rothbart, but you have yet to give me any answer .
  4. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Below is an example of a "proprioceptive"insole used "iatrogenically". Note the increased anterior body sway (a negative postural response) when the insoles are placed underneath the feet.

    "Proprioceptive" insoles are basically a "twin edged sword". As much good that can be derived from their judicious use, the results can become quite draconian when used without discretion and discrimination.

    Forward Postural Distortion.gif
  5. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    There is an insole, that I designed nearly 20 years, being sold by a company in the state of Washington. I designed that insole ONLY to treat the Primus Metatarsus Supinatus foot structure (aka Rothbarts foot).

    Over the past two decades I have had people contact me who have purchased that insole, only to have their symptoms exacerbate. (above individual is one such example)

    I have treated some of those people. Everyone of them had the PreClinical Clubfoot Deformity.

    This is one of many examples of why one must first determine the foot structure the patient has before dispensing any type of insole.
  6. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Below is an animation demonstrating the supinatus of the calcaneus and talus (and with it, the entire medial column of the foot) seen in the PreClinical Clubfoot Deformity:

    The blue arrow depicts the supinatus of the calcaneus
    The red arrow depicts the supinatus of the talar head (and with it, the entire medial column of the foot)

    PG vs PCFD.gif
  7. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    PreClinical Clubfoot Deformity - Differential Diagnosis

    Twenty years I was using microwedges to determine which congenital foot structure I was dealing with. Since then, in lieu of microwedges, I know advocate using the Knee Bend Test and Computerized Postural Analyses to arrive at the differential diagnosis.
  8. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Current research has demonstrated that any insole underneath the feet impact the entire weight bearing joints, and most likely visceral function (Rothbart 1995, 2006,2008, 2013, 2014).

    I believe all insoles should require medical supervision. For example, I believe the insoles I engineered should be dispensed only by physicians, and not sold to laypeople over the internet.


  9. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Are you promoting the Jomarg Innovation for strengthening the foot muscles? If so, I believe the Podiatry forum should not be used for that purpose.
  10. scotfoot

    scotfoot Well-Known Member

    I genuinely burst out laughing when I read your latest post ,#9 above .

    It would appear that the average habitually shod person may have toe flexor strength of only about half of the natural unshod level .
    Do your over the phone consultations pay any attention to foot strength levels, and, if so, how would you advise a client to address toe flexor deficits ?
    Actually , in partial answer to my own question, it is probably safe to assume that 90% + of hab shod people have very weak feet so my question would simply become ,what strengthening exercises do you advise your patients to use .

    You have published a lot of material over the years so perhaps you could quote from one of your publications . Except of course if you have never talked about foot strengthening exercises ever .

    I await your response with some interest . I expect nothing concrete, only word salad, but you never know .
  11. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I am not ignoring your comments, nor do I wish to sound deprecative, but you have not answered my question:
    • On this forum, Are you promoting the Jomarg Innovation for strengthening foot muscles?
    If so, laugh or not, I suggest this is a conflict of interest. And I believe when you joined this forum you agreed not to engage in this type of promotional activity.
  12. scotfoot

    scotfoot Well-Known Member

    In answer to your question, if you have to ask if I am promoting my company's foot strengthening device then I am not doing much promoting ,am I ?

    "You have published a lot of material over the years so perhaps you could quote from one of your publications . Except of course if you have never talked about foot strengthening exercises ever ." So go on then , enlighten us .

    With regard to what should or should not be posted on this forum, it is owned and run by Craig Payne and, from what I have seen, your opinions are unlikely to carry much weight with him .
  13. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Above you wrote, "I am not doing much promoting, am I?" So, You are answering my question, with a question. To me, that is evading my question.

    I believe you are promoting your company on this forum and I do not wish to be involved in your promotional activities.

    However, If I am wrong, I would be pleased to answer your question about strengthening exercises for foot pathology.
  14. scotfoot

    scotfoot Well-Known Member

    So nothing on strengthening then ? Thought not .
    On another note and on another thread I was glad to be able to help you with the meaning of the word "proprioceptive " .

  15. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I got it, you will not answer my question. No more to be said on this subject - it is not my attention "to beat a dog to death", so to speak.

    Good luck on promoting your company. However, Follow the agreement you made before entering this forum and promote where appropriate - not here.
  16. scotfoot

    scotfoot Well-Known Member

    Here ,from just a few weeks ago, is lot of words about Rothbart's insoles . You will find nothing so blatant from me .
    I did wonder at the time why the moderators allowed it to stand but its not my call .

    "What is the process of Rothbart Proprioceptive Therapy?

    Following is the process of Rothbart Proprioceptive Therapy - the only treatment that brings about a permanent great reduction or total elimination of chronic muscle and joint pain caused by two common, inherited abnormal foot structures - the Rothbarts Foot and the PreClinical Clubfoot Deformity.

    1) Intake and Assessment

    Questionnaires will be emailed to you to fill out. Your answers will give Professor/Dr. Rothbart initial information about your chronic pain problem(s).

    An Initial Phone Consultation is then scheduled. During your phone consultation, the doctor will answer your initial questions about your chronic pain problem(s) and whether he feels that you might have one of the two abnormal foot structures that he treats.

    To know for sure that you do have either a Rothbarts Foot or PreClinical Clubfoot Deformity, you will then take specific postural photos of your body and email them to the doctor.

    2) Proprietary Computer Postural Analyses

    Professor/Dr. Rothbart will run extensive proprietary computer analyses of the postural photos you have sent him. A telephone appointment is then scheduled to discuss the results.

    The analyses of your photos give Professor/Dr. Rothbart the wealth of information that he needs in order to determine that you are a candidate for Rothbart Proprioceptive Therapy. This information includes:
    • Your specific foot structure and its' severity
    • The possible additional presence of a mixed pattern (cranial, visual, TMJ problems, etc.)
    • The type and strength of proprioceptive insole needed to start the process of normalizing the distorted signals generated by your abnormal foot structure and initiate the healing of your body
    • The approximate duration and cost of your therapy
    3) Prescriptive Rothbart Proprioceptive Insoles:

    Based on the results of his computer analyses, Professor/Dr. Rothbart custom designs and fabricates proprioceptive insoles made to fit and function in simple, flat-bottom, non-orthopedic shoes.

    Your healing begins once your start to stand on and walk in your prescriptive proprioceptive insoles. With each step, corrected signals are sent from your feet to your brain (cerebellum). Acting on these signals the brain corrects your posture, which eliminates the stress on your joints and muscles. They then begin to heal.

    4) Continual Patient Monitoring (required for complex cases):

    As your body heals, it will go through changes and these changes are carefully monitored during your entire therapy. A close and continual connection is maintained by weekly email updates that you will send to Professor/Dr. Rothbart. He uses these updates to determine when there are issues that need his immediate attention.

    For any questions you may have during your therapy (or when Professor/Dr. Rothbart needs to speak with you), office or telephone appointments are promptly scheduled.

    5) Ongoing Treatment (required for complex cases)

    Computer analyses are run periodically to determine when the strength of the stimulation within your insoles needs to be adjusted, in order to continue your postural corrections and the healing process. Based on these analyses, a new set of Rothbart Proprioceptive Insoles will be designed and dispensed.

    Rothbart Proprioceptive Therapy can take only a few weeks or, in complex cases, up to six to eighteen months to complete. When the results of the computer analyses tell Professor/Dr. Rothbart that your posture is now both anatomically correct and stable (thus allowing your body to heal itself) and when you are satisfied with the results you have obtained, your therapy is then complete. At the completion of your therapy you will have a permanent great reduction or total elimination of your chronic pain.

    Following your therapy as instructed by Professor/Dr. Rothbart, is crucial to its' success. For more information, please read the Patient's Commitment.

    It is important to note that there are some distributors selling pre-fabricated insoles (which Professor/Dr. Rothbart invented years ago) directly to the public. The wearing of these insoles is not Rothbart Proprioceptive Therapy."
  17. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Exactly, you made my point.

    If I tried to sell, on this Podiatry forum, the insoles I designed and patented, it would be inappropriate.

    And, in my opinion, it is inappropriate that you advertise my work (Rothbart Proprioceptive Therapy) by placing that page from my website on this forum.
  18. scotfoot

    scotfoot Well-Known Member

  19. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    That was a discussion that another member started entitled "Rothbart Therapy Cost"

    You can read the many comments. There was a great deal of confusion as to exactly what my therapy entailed. That was the reason that page was placed in that thread. Simply to clarify what my therapy encompassed.

    If I had started a discussion to advertise my therapy and entered that page into the discussion, for that purpose, that would have been inappropriate. But that was not the case.

    This discussion is on the type of insoles one can use to treat the two abnormal, inherited foot structures. This discussion is not about the device you are marketing. So, if you have anything to contribute on subject, let's hear it.
  20. scotfoot

    scotfoot Well-Known Member

    You've given yourself a real pasting in this thread .
  21. efuller

    efuller MVP

    I have to agree with Gerald. You complaining about self promotion is quite hilarious. You have posted the same information before, and it was discussed. I don't recall anyone agreeing with your ideas. Yet, you post it here again and continue to bring up other old threads where you did not answer criticisms of your ideas.

    The reason that no one has added comments to your posts on this thread is that you have said it all before. As someone who has argued many a point beyond a reasonable amount of time, even I have given up responding to your posts. The only reason, that I can see, for you posting the same thing over and over again, is self promotion.

  22. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Researchgate would disagree. My Research stats as of 08/13/2021

    Research Interest: 149.1
    Citations: 194
    Recommendations: 35
    Reads: 13,430
    Research Rating: 15.58 (a score higher than 62.5% of all ResearchGate members scores)

    Just food for thought.
  23. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Interesting. On this Podiatry forum I have garnished a great deal of criticisms.

    As Zig Ziglar said: Don't be distracted by criticism. Remember — the only taste of success some people get is to take a bite out of you."
  24. scotfoot

    scotfoot Well-Known Member

    You have taken a bite out of yourself .
  25. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    What do you mean?
  26. scotfoot

    scotfoot Well-Known Member

    Re postural stability and the intrinsic foot muscles, you might be interested in the linked to paper .

    Seems that a history of lower leg pain is linked to intrinsic foot muscle atrophy and increased reliance on visual cues for balance .
    Clear connections between the vestibular apparatus and the intrinsic foot muscles are demonstrated in other papers.

    Controlling posture /balance is linked to the intrinsic musculature and weak intrinsics are likely to cause problems .

    This is why I ask you about your strategies for strengthening them .

    Abstract from paper
    Our objective was to quantify the functional and morphological characteristics of the plantar intrinsic muscles in those with and without a history of exercise-related lower leg pain (ERLLP). Thirty-two active runners—24 with a history of ERLLP—volunteered. Strength of the flexor hallucis brevis and flexor digitorum brevis, postural control, and navicular drop were recorded. Morphology of the abductor hallucis, flexor digitorum brevis, and flexor hallucis brevis muscles were captured using ultrasonography. Those with ERLLP had smaller flexor hallucis brevis morphology measures (p ≤ .015) and a greater reliance on visual information while balancing (p = .05). ERLLP appears to alter intrinsic muscle function and morphology.
  27. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    My research and clinical practice was limited to patients diagnosed with either the PreClinical Clubfoot Deformity or the Primus Metatarsus Supinatus. Rarely was it necessary to strengthen any specific muscle chain.

    The global postural shift is initiated by the corrected proprioceptive signal sent to the Cerebellum. In most cases, the muscular rebalancing occurs automatically (e.g., no specific exercises were required to strengthen the intrinsic muscles of the feet).
  28. scotfoot

    scotfoot Well-Known Member

    "My research and clinical practice was limited to patients diagnosed with either the PreClinical Clubfoot Deformity or the Primus Metatarsus Supinatus."

    Much is know about different types of foot pathologies and the effects of these pathologies on the muscles of the foot . Can you direct me to any research on the 2 foot conditions you have mentioned and foot muscles ?

    Are you saying your practice does not involve injuries caused by overuse ?
  29. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Overuse Injuries are a symptom, not a primary pathology. If the overuse injury is secondary to either of the above two genetic foot abnormalities, I would treat that individual.

    I have written a great deal about these two foot structures. You can download my publication on Researchgate.
  30. scotfoot

    scotfoot Well-Known Member

    Research from Brian H Dalton

    "Our results indicate that a complete model of the sensorimotor control of quiet standing should include foot muscles. Future research should focus on examining whether decrements within foot muscles lead to impairments in standing, and whether rehabilitative strategies involving these muscles can improve postural control in those with standing balance problems."

    I wondered if this research had been moved on at all .
  31. scotfoot

    scotfoot Well-Known Member

    Vestibular-Evoked Responses Indicate a Functional Role for Intrinsic Foot Muscles During Standing Balance

    Author links open overlay panelJonathan W.WallaceaBrandon G.RasmanbBrian H.Daltonac
    Show more
    Add to Mendeley

    Vestibular control of standing balance is represented in toe abductor activity.

    Vestibulomyogenic responses can be characterized over 0–20 Hz in the intrinsic foot.

    Toe abductors respond to a vestibular error directed anterior-posteriorly.

    Removal of vision increased the vestibular-evoked response at lower frequencies.

    Intrinsic foot muscles provide an active postural role to standing balance control.
  32. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    All very interesting. But not my area of research.
  33. scotfoot

    scotfoot Well-Known Member

    Our sense of touch is not proprioception .
    The stretch receptors in muscles are involved in proprioception .
    One could argue that putting a small wedge under the big toe could alter the stretch in the muscles attached to the toe and alter proprioceptive signals from the muscle . I am not saying it does or even that it is a good idea , I am just saying it might .
  34. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I have written a paper on this subject, the Biomechanical Model vs the Neurophysiological Model. If you would like to discuss this in more detail, take a read. Your comments would be most welcomed,
  35. scotfoot

    scotfoot Well-Known Member

    Thanks ,I had a look but the paper is not really about what I was focusing on in the last few posts .

    I am simply saying that if your insoles have a proprioceptive mechanism rather than mechanical, then it is probably caused by altering the response of muscle spindles in the intrinsic foot muscles producing an earlier burst of contractile activity than would otherwise be the cases, and thus affecting pronation .

    Farris et al shows activity in the intrinsics when the foot is held in the jig shown and the shank loaded . Dorsiflexing the toes, even a little, produces an immediate burst in intrinsic activity .

    During gait ,a small wedge under the great toe might give earlier stretch of the muscle spindles, in the intrinsics inserted into the great toe .
  36. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Interesting. Below I have presented my thoughts on this.

    Understand, that at this point in time, all information regarding the action of insoles (referred to proprioceptive insoles), is opinion (theoretical) only. To date, there have been no double blind studies to establish or confirm the exact modus operandi of these insoles. However, the one thing I am absolutely sure of is that they readjust (improve) the global posture quickly and very efficiently.

    There are many different “proprioceptive insoles” sold. Some use focal points geometry for stimulation, others use diversity of materials to achieve their effect. I have had no clinical experience with these insoles nor have I done any research on them. All the discussion below is on my research and clinical studies and is an attempt to describe how the insoles I use alter posture. This is a brief outline, if you would like a more thorough discussion, I will link you to a chapter in my book (Chapter 5 - The Foot to Brain Connection) which presents this in more detail.

    Proprioceptive signals are generated from the plantar surface of the foot and transmitted to the cerebellum. Acting on these proprioceptive signals (which change from moment to moment), the cerebellum adjusts the posture globally.

    How these proprioceptive signals are generated and how they are transmitted to the cerebellum is still theory. Below I have outlined my thoughts:

    In a closed kinetic chain, an abnormally (gravity drive) pronating foot generates aberrated proprioceptive signals. (The chapter in my book goes into this in great detail)

    This aberrated proprioceptive signal, acted upon by the cerebellum, results in an aberrated posture. (How and where exactly in the Cerebellum this happens is still theory).

    In time, the weight bearing joints, functioning around this aberrated position become inflamed and arthritic (e.g, chronic musculoskeletal pain). (I am seen this over and over again in my clinical practice spanning nearly 50 years now).

    I use insoles that incorporate geometric wedges to attenuate the gravity drive pronation (I have documented and published on this, using postural photo analysis and pressure plate studies). From our discussion, I realized the insoles I use function both mechanically and proprioceptively.
    • Mechanically in that the geometric wedges change the functional position the foot.
    • Proprioceptively in that this altered functional position changes the generated proprioceptive signals to the cerebellum.
    The cerebellum acts on these “normalized” proprioceptive signals and adjusts the posture accordingly (clinically observed and recorded using computerized postural analysis).

    The weight bearing joints, functioning around this improved posture, heal (the pain symptoms attenuate)

    That is a brief discussion. Read chapter 5, the Foot to Brain Connection, in my book. Happy to discuss any questions or comments you might have.

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