Treatment direction tests (TDT's) for foot orthoses

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I first came acorss the term 'Treatment Direction Tests' in a paper by Bill Vicenzino. While many of us were probably using TDTs, but we never explicitly referred to them as such with that term.

TDTs are clinical tests that direct the treatment and for our purposes here, its a test to determine the likelihood of a foot orthoses working or not or even if they are indicated.

The obvious TDT is the use of low dye strapping. If the strapping works clinically, then there is probably a high chance foot orthotics should work (even though they probably have different mechanisms of action).

Another one, that I think Craig Tannner first described to me, is the use of the lunge test for achilles tendonitis. You do the lunge test and see if its painful; if it is, then repeat the lunge test with a medial heel wedge - if there is an improvement in symptoms, then use foot orthotics.

A couple of recent studies have shown what predicts foot orthotic success in patellofemoral pain syndrome.

The usefulness of a TDT was highlighted in the thread on the use of foot orthoses in Osgood-Schlatters disease. As DocBurke pointed out, there is no evidence for this and there is also no rationale for its use. I made the suggestion to

and CraigT suggested:

What TDTs do you use in addition to the above?

 

I've been doing this for a while, but as you say never explicitly referred to them as treatment direction tests (although do so within my notes now, since reading the Vicenzino paper).

I use the edging of a gym mat:



This can be used as a medial or lateral wedge, (or a heel raise) during a small single knee bend or lunge. It's fascinating that the pattern of pain for some individuals improves almost immediately whereas for others it stays the same (or sometimes worsens). I always use a TDT in this way now if I am considering lateral wedging for a medial compartment knee OA.

Another real positive from the Vicenzino paper is that a lot of the Physio's are doing TDT's and making some really good referrals for Podiatry/orthoses.

 

Craig

I can see the value of your enquiry but:

TDT - isn't this the basis of tissue stress theory? So the test is really to give a clue as to which tissues is pathologically affected by a certain stress i.e. eliciting or reproducing symptoms at the site of pathology by applying a certain force in a certain direction that causes enough stress to cause pain. And of course the reverse applies i.e. reducing force reduces stress which reduces pain.

For me (and I believe you admit this point too) this is a logical fallacy since there is no link, in terms of logical argument, between the conclusion and the premise. The test would better be called a tissue stress test (TST) since there is a link between the premise and the conclusion as explained in the first paragraph.

It might be possible to make the argument that - if the forces applied in the test would be applied in a similar way by the orthoses then we can conclude that an orthosis designed to apply forces in the same way might be effective in reducing symptoms of interest. However we cannot make the conclusion that because the test didn't work then the orthoses are unlikely or less likely to work.

I believe this is an important point to establish i.e. 'TST is a better term that TDT' because otherwise this has a danger of becoming an algorithmic process tool.

Regards Dave

 

Has anyone a copy of the paper they could please let me have?

Thanks

 

There you go Sir

and anyone else

Foot orthotics in the treatment of lower limbconditions:
a musculoskeletal physiotherapy perspective Bill Vicenzino

 

Thanks Mike.

 

I was thinking a little bit about what Dave wrote - maybe why Ive go a little less skin on a finger and my grinder has grown some tissue.

Anyways - I don´t mind the term TDT and see its role as a step between Tissue stress and Treatment Prescription Values ( TPV)

The other day we were discussing similar ideas I guess.

I wrote

Which Rebecca added

If we change 4. Decide on prescription variables to Decide on Treatment Variables which would included the prescription variables of a device the TDT would fit in this area here.

or even have a new subheading Treatment direction tests.

So ....


1. what tissue is stressed ?
- history
-direct palpation

2. why is it stressed ?
ie mechanically why is the tissue stressed - ie Peroneus Longus strain and the relation to the STJ axis as an example

3. Tests which will change prescription variables ?
ie Supination resistance.

4. Treatment direction tests.
ie lunge test with or without medial wedge for Achilles tendinopathy

5. Decide on Treatment Variables

All seems a nice way of treating a patient .

 

Dave:

I'm with you. Do we really need a new term to describe the way medicine has been practiced for the past 50+ years? Why do we do any test in medicine? We do every test in medicine to establish a diagnosis and/or gain more knowledge about the pathological condition so that we can better treat the patient.

50 years ago, when someone sprained an ankle and the doctor performed inversion-eversion and anterior drawer tests, we called these "ankle stress tests", not "treatment direction tests". 50 years ago, when someone had heel pain and the doctor pushed around on the heel to find the point of maximum tenderness, we may have called this "finding the point of maximum tenderness test", not "treatment direction tests".

Please tell me this, which test that is done currently in podiatric medicine is not a "treatment direction test"?

 

Craig

I think TDT's are the way forward to help practitioners make the link between diagnosis and orthotic intervention.
I know some really intelligent Pods and orthotists who struggle to make this link - partly due to time constraints and partly down to experience.
TDT's will add to our clinical tools and hopefully de-mystify orthotic prescribing.

One of own TDT's is to get the patient to close then eyes and describe the load they can feel in the foot - is it on the heel, inside or outside etc.
This info is then to 'balance' the patient prior to the foot RX - I use this when patients have a history of idiopathic lower back pain. weird but it works.

Phil

 

Since we will now are going to change the commonly-accepted term of "clinical tests" to "treatment direction tests", I suppose I will now start calling my foot orthoses "treatment direction orthoses", my x-rays "treatment direction x-rays", my MRI scans "treatment direction MRIs", and my wound cultures "treatment direction wound cultures". Why not add a few more words to acceptable and useful medical terms just to make it seem like we are doing something new and unusual so everyone can be more confused?! Maybe these terminology changes will make it look like we are actually doing something new and exciting?!:bang::bash::craig:

 

Although the name may be an issue to some, I can't help feeling that this approach is relevant.
Orthoses don't need to be mysterious and if a name change is needed, then I would consider it evolution in the same way others have described existing concepts, re-packaged them and made them more acceptable to the profession.
Just because it is different, it doesn't make it wrong.:drinks

Phil

Ps it is not worth arguing about, some will accept new ideas, some won't. Pay your money and take your choice.

 

Phil:

The approach is relevant, I have been lecturing on clinical tests for foot orthoses for the past 20 years. In fact, I have a whole handout on the various clinical tests that I have invented over the years to be used by the clinician when prescribing foot orthoses. My argument, is why do we need to call them "treatment direction tests" when the term "clinical tests" seems to a very nice term, is shorter and more to the point.

By the way, Phil, which clinical test that we use is not a "treatment direction test"? Why do you feel we need a new term? Is a "treatment direction test" defined any differently than a "clinical test", or does it mean the same thing?

 

On the one hand I think Kevin has a mute point. The longer you are around the more you can see some people take something, repackage and rebrand it and sell it as something new and pioneering etc. It happens in all walks of life (education I'm informed in one of them) and those who have been around a while will be rightly cynical.

Equally, the way something has been packaged previously is not always accessible to all. This needs to be acknowledged and recognised that sometimes that packaging, rightly or wrongly, gets in the way of understanding for some.

I would argue that, for example, this could be the case in the new biomechanics where engineering and more complex physics terms and concepts are aired and discussed.

Absolutely nothing wrong in that, as they may be more accurate, but again it may come with a packaging that will obscure knowledge and understanding for some (myself included). Personally I have to read it a zillion times and reduce it to The Sun level and then start to grasp it, then go back to the original and slowly make sense of the stuff.

So at one level I think Kevin is right but then I think we need to step back and decide if it is a repackage that for some leads to clarity then okay I can live with that. If it is a repackage so someone can have their 15 minutes fame, then be cynical and ignore it.

It is perhaps true though that sometimes in the repacking we can lose something of value that was in the original though.

Anyway enough of my rabbiting on......

 

I trying to make a big distinction between clinical tests to derive foot orthotic prescription variables vs clinical tests to indicate foot orthotics are needed and if they will work.

This a good point:

 

What did Bruce call foot orthoses the other day? It was a gem, and I want to use it...

 

Kevin

Good questions that I don't necessarily have the right answers to but have the the following opinion.
I feel that orthoses prescription and TDTs need to be separated from clinical tests as I see to many people prescribing orthoses without linking this with the patients complaint and lifestyle needs.
By focusing more on diagnosis and not worrying about the intricacies of orthoses design, the Orthotic TDTs will give people more confidence as the evidence does show that orthoses work and in my experience most orthoses are returned for adjustment due to lifestyle issues e.g. fitting footwear and not that they aren't effective. This seems fairly consistent no matter how simple or complex the prescription..

Cheers

Phil

 

Never liked the concept of "test devices to see if an orthotic will work"- low-dye is not an orthotic; simple wedging on an insole is not the same as a prefab or custom orthotic. I'm going to test to see if an aspirin will work by giving you a paracetamol.... that's basically what y'all are saying :bash:

 

High tech guidance systems.:drinks

 

Clinical tests: Treatment direction tests

Racing flats: Minimalist shoes

I guess you youngsters need a new name for something that already has a well-established term so you can feel that you are doing something truly new and unique in order to separate yourselves from what us old guys were doing and saying a quarter century ago.:boxing::drinks

 

I'm with Kevin and Dave; please no more needless terminology simply for the sake of change. But I can guess where this one is heading.....

 

BTW:

Supination resistance test, maximum pronation test, forefoot plantarflexion test, barefoot standing orthosis test, orthosis deformation test, midfoot compression test, subtalar joint palpation test, and heel pain gait test are all clinical tests (i.e. medical tests done to better direct treatment). I don't think I will need to call these tests, which I have described in my publications and lectures and have been using over the years, "treatment direction tests".

 

as i said above

I refer back to what I said in the first post:

and also the use of low dye strapping:

NONE, of those eg's are what we generally use clinically to derive an orthotic prescription (...low dye strapping is not even a clinical test!)

 

I'm reminded of a spoonerism (the original).

 

I use most of the above tests also. They will help direct me to certain prescription variables which may be appropriate. I think the delineation with TDT's here is in a set of tests which potentially inform as to whether foot orthoses may be of therapeutic benefit, which the above tests do not do. (I say inform, but it would be naive to ignore Simon's point).

TDT's would ideally be used concurrently with the above clinical tests. So with someone performing a single knee bend on a varus wedge (and it positively changing their pattern of pain) it may suggest that orthoses would be of clinical benefit, and the supination resistance test would then suggest what sort of post may be appropriate. [Enter Spooner's kinetic quantification of wedging??].

Whether or not they are called them "TDT's" or not is irrelevant in my opinion, I think they have a positive role to play clinically. Both in referrals from other health professionals (as previously mentioned), and in patient confidence in proposed management plans.

 

Kevin

Nice to be called a youngster - many thanks.
Does that make you a crumblie?
What's in a name? I am with Ian, I use 'em and don't really mind what we call them but I think they need differentiating from each other.

Ta

Phil

 

Ian:

So if you had someone perform a single knee bend on a varus wedge and this didn't improve their pain, you then would not attempt a custom orthosis for them to help them relieve their pain during walking, running and other weightbearing activities? Please help me understand how these "treatment direction tests" would be used in clinical practice or change my clinical practice.

 

Yeah, Simon...my new "treatment direction test" will be to see if my patients will respond favorably to a plantar fasciitis night splint by having them stretch their calf muscles in my office to see if this relieves their plantar heel pain. Makes about as much sense as the other "TDTs".:bang::butcher:

 

Here are the clinical tests I have developed for those who may be interested.

 

Hey Kevin,

I have no idea how these tests would change the clinical practice of someone with 25+ years of experience, as I do not have this. My guess: well maybe they wouldn't change that your practice at all. But I do see worth in these tests for those without this many years under their belt. The tests take seconds, are not used in isolation to make clinical decisions, and in my opinion just add to the arsenal of other brief tests we can perfrom when faced with a patient and trying to get a better understanding of the clinical picture. It is of course important to be aware of their limitations.

What I have noticed is that there is significant variability from patient to patient when perfoming a small single knee bend on wedging. Not just in symptom changes, but in alignment/knee kinematics. I'm not saying this predicts orthoses outcomes, nor that I fully understand the mechanism behind this seemingly 'subject-specific' response, but the fact it differs from patient to patient makes it worthy of further thought for me.

Here are the two main ways this test has changed my working days:

1/ Marked increase in referrals from Physiotherapists
2/ Directed they way I counsel patients prior to recommending foot orthoses for their knee pain. In the private sector in the UK patients have to pay for orthoses, and before they part with their hard earned they want to know the chances of success/failure. Whilst these tests do not accurately predict this, I find they set the tone for this conversation.

Hope this better explains how I use these tests in my practice. As I mentioned earlier, I had been using them for some time before reading Bill's paper (I was shown them by a good friend/mentor back in 2006). Never called them "TDTs".

 

As this thread has been bumped by another thread , it reminded me that I meant to post on it before.

I think the point about payment for foot orthoses is a salient one. I haven't n opinion on renaming the concept of testing. For the inexperienced practitioner qnd other health professionals these tests will almost certainly improve prescription variable choice and inevitably their clinical outcomes.

With pfps, I use a test athol Thomson described which was a single leg knee squat whilst mwnually applying a medially directed force on the patella. In cases where the symptom description and clinical history points to pfps but I cannot illicit the same symptoms on examination, I use this test and it gives the patient a very good demonstration of why the explanation I have given of pfps can be applied physically.

The instant change in pain level very quickly and with no equipment allow the patient to see that there is a high likelihood of success with intervention and a reason to part with hard earned cash

Apologies for typos. Done on my phone