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Challenging the foundations of the clinical model of foot function

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Jan 31, 2017.

  1. Jeff Root

    Jeff Root Well-Known Member

    As I have stated over and over, time and time again on the Podiatry Arena, I never said Root created these terms. These terms were in common use prior to Root but they lacked a clear definition. Root proposed that clinicians place the STJ in the neutral position and fully pronate the MTJ when assessing the forefoot to rearfoot relationship for purposes of identifying the presence of forefoot varus/ff supinatus, forefoot valgus or a rectus forefoot. He also proposed clinicians use this position to assess the position of the 1st ray when evaluating for a plantarflexed 1st ray or a metatarsus primus elevatus. He also proposed that by defining the neutral position of the STJ and having a bisection reference on the heel, clinicians would be better able to determine if and when the heel was inverted, perpendicular or everted to the plane of the floor.

    In his book Biomechanical Examination of the Foot Root defined the normal foot. He wrote: "The term normal represents a set of circumstances whereby the foot will function in a manner which will not create adverse physical or emotion response in the individual. This definition applies when the lower extremity is used in an average manner and in an average environment as dictated by the needs of society at the moment".

    With respect to Root's biophysical criteria for normalcy, Root wrote: "The following criteria represent the ideal physical relationship of the osseous segments of the foot and leg for the production of maximum efficiency during static stance or locomotion. Such ideal relationships are seldom seen clinically, and merely represent the basis for evaluation of the degree of deformity present. Minor variations from these established criteria may be observed without associated symptomology. Only the clinician can determine when the variance is sufficiently great to produce pathology".

    Root tried to improve communication between practitioners by providing a more concise definition of forefoot and rearfoot varus and valgus. Root did not invent these terms! Root also theorized criteria for normalcy but stated that variances in the structure of the foot were not necessarily pathological and that is was up to the clinician to determine if and when variances in the structure or function of the foot were associated with or produced pathology.

    As an example of Root's thinking, he developed a technique to assess the range of dorsiflexion of the ankle with the STJ in the neutral position and also proposed that a minimum range of ten degrees of ankle joint dorsiflexion was necessary for normal locomotion. Root did not say that anyone with less than ten degrees of ankle joint dorsiflexion would develop pathology. He did propose that if there was insufficient ankle joint dorsiflexion available the subject may compensate by abducting and pronating their foot. But he said Only the clinician can determine when the variance is sufficiently great to produce pathology. Root's system of evaluation and his definition of normal (ideal) were never intended to be an absolute but rather more of a guide for clinicians. It did not preclude the clinician from thinking. And Root was very open to change and believed that with time these concepts would change. I advocate for change but I also advocate for truth. And the truth is we have techniques (casting, examination, orthotic fabrication, etc.) and terminology that originated from Root's work and that clinicians depend on today. So to say that tissue stress theory has replaced Root theory in a logical fallacy.
     
  2. Jeff Root

    Jeff Root Well-Known Member

    In the 1982 March-April edition of the California College of Podiatric Medicine’s Newsletter Pacesetter, Merton L. Root, DPM wrote the following:

    "When an orthosis is selected as a method of treatment, knowledge of biomechanics enables the practitioner to select the best casting position to resist the abnormal forces acting on the foot. The knowledge he has gained during examination also determines what he prescribes to have an orthosis made that will most effectively resist abnormal forces. Biomechanical knowledge also enables the practitioner to immediately evaluate the effectiveness of an orthosis just dispensed.

    What Orthoses Do and Don't Do
    An orthosis that is prescribed to resist specific abnormal forces identified by examination and is designed to promote improved function of the foot is called a functional orthosis
    . A functional orthosis does not support the arch of the foot. A functional orthosis does not "balance" a foot. A functional orthosis does not hold a foot in any position. A functional orthosis does not accommodate lesions or painful areas of the foot. A functional orthosis only resists abnormal forces and promotes improved foot function.

    Functional orthoses were conceived on the basis of the following premise. Biomechanics indicates that a foot only moves abnormally when that foot is subjected to abnormal forces. Those forces that cause foot malfunction can be either compression or tension. There are no other forces acting upon a foot. Compression or tension forces can become abnormal when they vary from normal in either their direction or their strength within the foot.

    Abnormal strength of forces can only be resisted slightly by orthoses of any kind. True bracing of the foot is the only mechanical method that can resist forces that vary from normal in strength. However, the most frequent abnormal variant of forces is a variance in the direction of forces acting upon or within the foot. Functional orthoses are primarily designed to resist the abnormal direction of forces and to redirect those forces into a more normal direction within the foot.

    Fortunately, with the exception of some neuromuscular diseases, pathological symptoms most commonly treated by the podiatrist are caused by abnormal direction of forces and thus are amenable to treatment by functional orthoses. Abnormal direction of forces causes the large majority of corns, calluses, bunions and other symptoms such as neuromas and heel pain, as well as many postural problems such as instability, knee, leg, hip and back problems. Therefore, the knowledgeable use of functional orthoses can alleviate the large percentage of these symptoms. Furthermore, recognition of the cause and effect relationship between such symptoms and abnormal mechanics allows the podiatrist to prevent the development of these symptoms by timely treatment with functional orthoses".

    Rather than debate about what people think Merton Root may have said, why not read and discuss what he actually did say?! Root said the practitioner should select the best casting position to resist the abnormal forces acting on the foot. He did not say that that position was always the neutral position and he did advocate casting the foot in other positions for certain conditions in order to address the pathological forces acting on the foot. Root did not say that the orthosis needs to hold the foot in any position nor did he say that it balances the foot. He said that "A functional orthosis only resists abnormal forces and promotes improved foot function". There are many ways to attempt to achieve this objective. Root taught about the ways he found were the most successful for him at the time.
     
  3. OK Jeff: With regard to foot orthoses your dad said:
    “The primary objective of treatment is to control position and motion of the foot”. This statement by your father, as you know is fundamentally flawed, as exemplified by the 2003 Williams et al. study. There was no statistical differences in the position and motion of the rearfoot between test conditions. Yet the patients didn't get better with the Root devices, their symptoms improved with the Blake inverted devices because the Root devices didn't signicantly alter the kinetics, yet the Blake devices did. Viz. it's not about "controlling the position and motion", rather: it's about altering the kinetics, Jeff. So, here we have a statement made by your father which is incorrect. You will now argue that black is white and what your father really meant to say was.... Whatever. Since what he did say was: “The primary objective of treatment is to control position and motion of the foot”. Move along, move along, nothing to see here...
     

    Attached Files:

    Last edited: Feb 7, 2018
  4. Jeff Root

    Jeff Root Well-Known Member

    Simon, he also said "The knowledge he has gained during examination also determines what he prescribes to have an orthosis made that will most effectively resist abnormal forces". Control (ie. orthotic influence) of position and motion of the foot are the result of altering forces. It is possible to alter forces without the clinician being able to visually appreciate any alteration in those forces. Just because the clinician can't visually appreciate a change in position or motion doesn't mean that it doesn't necessarily take place. However, in many patients with foot pathology the clinician can visually identify abnormal or pathological forces in their physical examination, gait analysis and due to the nature of the pathology present. Functional Orthoses are used to alter pathological forces and can alter the position of the foot or of segments within the foot and the motion of the foot, legs back, head and arms. Patients who present with symptoms to a podiatrist's office do not represent the general population but do represent a pathological population. Many podiatrist attempt to alter foot position and motion with their orthoses and do expect to see improved function during their gait examination, in part, because they are dealing with a pathological population who have visually appreciable structural and gait conditions.
     
  5. You are of course right, Jeff: black is indeed white. Did he say: “The primary objective of treatment is to control position and motion of the foot”. Yes or no? Let's save some time, does the Williams et al. study provide evidence to suggest that your father's statement above was incorrect? Yes, that's right, it does. So, back we go to the PhD work of Hannah Jarvis which was the reason for this thread: Did the now Dr Jarvis take certain statements that your father had made and using the best, up-to-date methods of scientific enquiry in the field of podiatric biomechanics test the accuracy of many of your Dad's statements and beliefs? "Yes she did" is the answer you are looking for. We all know that she didn't find a great deal of scientific evidence to support your Dad's writings nor beliefs. We do know now that she successfully defended her thesis and was awarded a PhD on the stength of that thesis and its defence. At what point do you let go of the beLIEfs, Jeff? No doubt it is hard for you Jeff as he was your dad, yet I know I'm not alone in finding it weird that you don't refer to him as such.

    And by the way, "normal force" is the component of force that is perpendicular to a given surface, so presumably an "abnormal force" is one that is not perpendicular to the surface. I have no other understanding of an "abnormal force". The statement "to resist abnormal forces" is an odd one since by the very nature of the curvi-linear surface that foot orthoses provide at the foot-orthosis interface, the magnitude of the "abnormal" (i.e., non-perpendicular) components of the net ground reaction force vector should likely be increased, not reduced. Maybe your dad had a different idea of what an "abnormal force" was, but I try to stay in line with the laws of physics and the accepted terminology of physics, since biomechanics is simply a branch of the afore mentioned core science.
     
    Last edited: Feb 7, 2018
  6. Jeff Root

    Jeff Root Well-Known Member

    Yes, that is what he said. The fact that that was a primary objective to him doesn't negate that fact that one can successfully treat some patients by altering forces that do not produce a visually appreciable change in motion or position. Anyone who treats patients knows that some times you can see radical changes in position or motion. And in reality the primary objective is to alleviate the patient's symptoms, is it not?
     
  7. In your opinion, your dad was wrong in his assertion then?
     
  8. Jeff Root

    Jeff Root Well-Known Member

    Not a the time. However, we have come to appreciate that, with the condition that we fully acknowledge the limits of current measurement technology, it appears that altering forces doesn't always result in a measurable kinematic change or that the kinematic changes that occur may be too small for us to detect with current technology. We don't necessarily know how to determine and measure the exact amount and direction of force required to produce an optimal clinical outcome, be it a kinetic or kinematic quantity.
     
  9. Dude, you've just said that: "And in reality the primary objective is to alleviate the patient's symptoms, is it not?" so either you are wrong or your dad was wrong when he said that: “The primary objective of treatment is to control position and motion of the foot” . Just admit that your dad, just like my dad and every one elses dads was and or is fallible.
     
  10. Jeff Root

    Jeff Root Well-Known Member

    Simon, you're taking the statement out of context and being absurd in the process. As a physician, my father's primary objective was to reduce pain and suffering and to improve the quality of life for his patients. You are suggesting that his primary objective for treating patients was to control the position and motion of the foot, not to reduce pain and suffering and to improve the quality of life for his patients. That is just an absurd position for you to take. If my fathers real primary objective was to "control the position and motion of the foot" then he should have fused every joint following your logic, since he would then have total control of the position and motion of the foot. In reality what he did was try to produce kinematic changes that would improve the function of the foot and lower extremity in order, in most by but not in all cases, to reduce pain and suffering in an effort to improve the quality of life for his patients. He also, in some cases, treated asymptomatic patients so pain reduction was not always his treatment objective. In those cases he was treating an asymptomatic patient who, in his expert opinion, needed treatment to improve function and/or had a condition that was likely to induce further pathology or symptoms in the future.
     
  11. drhunt1

    drhunt1 Well-Known Member

    Dude? Did Simon Spooner just write that? How professional! Dude is a term used by those "not in the know", or by guys dancing with Kevin Kirby in two-toned, highly polished brogues. Merton was right about many things...and Simon places ALL credence at the feet of Jarvis. Typical of those that take their job MUCH too seriously, though, they make this entire topic too difficult...too complex. It is not. Kudos to Dr. Root for publishing what is THE compendium on Normal and Abnormal...still to this day. And kudos to Dr. Phillips for writing in his response to Kirby's article in Podiatry Today, a private conversation he had with Merton and the contents of that conversation.
     
  12. rdp1210

    rdp1210 Active Member

     
  13. rdp1210

    rdp1210 Active Member

    Simon,
    Your diatribes and arguments are so unprofessional. I would think you'd be embarrassed at the disrespect you show others. Maybe if you had 30-40 diabetic ulcers to deal with every week, with a dozen cases of osteomyelitis, you wouldn't have so much time to put up so many pointless postings. I would recommend that you spend more time writing real research papers and try to contribute more to the actual literature.
    There are a couple of points I will make, and then you can continue on in your meaningless methodologies.
    1. You never knew Mert Root. I was fortunate to make his acquaintance when I was a student, and I kept in contact with him until his death in 2002. Your whole argument with Jeff Root seems to be to find some point to say, "Root was wrong." In fact it has become a real obsession with you. And you take the stance that if you can find one thing Root was wrong about, then everything Root said must be wrong. Mert Root was a person I have the greatest respect for. Why? Because he never stated that he knew it all. He was the first person to admit that he didn't know it all. He maintained that he was constantly learning and that he had to change his mind many times through his life. He expressed several times to me as well as publically how he really never wanted to write any books because he knew that if he did, he would be pinned down by the future practitioners as taking a stand and they would never allow him to change his mind. It wasn't until Bill Orien pushed him (whose passing we recently mourned) that he decided that he needed to write a book. At the first John Weed Seminar in 1994, he expressed his surprised that a better book on biomechanics hadn't already replaced his as the primary textbook for podiatrists to study biomechanics. There have been some good books published. Kevin has tried to contribute, Valmassey, Shearer and most recently Albert have contributed. However the impact of any other book on a worldwide podiatric profession hasn't been matched yet as much as Root's book. Maybe it's time for you to start writing the book to replace Root. Make sure that the book has a good description of normal foot and lower extremity kinematics and kinetics as well as normal muscle function, and that it also proposes mechanisms for many of the common deformities seen by the podiatrist. When you do this, then I will begin to take you seriously. Also, please in the future, when you quote Root, make sure you quote the source of the quote. It may be that you are quoting some of his earlier thoughts, not his latest opinions.
    2. You seem to place a high value on Hannah Jarvis' work. You have some sort of false belief that if a panel of PhDs at a university declare a thesis to be acceptable and grant a degree, then that carries with it all the authority needed and makes the thesis unquestionable. I have her thesis and her article published. It looks impressive to say the least, however when one starts to dig into the article with some critical thinking, one finds many problems. I wish I had been there at the defense of her thesis and pointed out some of the following:
    a. It is assumed that the author is looking for the normal functioning foot. By eliminating so many foot types from the study, i.e. anyone who had hallux valgus or who had worn orthotics in the past or had had any foot pain in the last 6 months, a great many foot types were eliminated. By eliminating so many feet, can one say that the Root proposals carry no validity? In podiatry offices we are not being asked to look at normal asymptomatic feet, instead we are treating patients with pain and deformity.
    b. When looking at the variables that were measured, one is struck with the few number of variables that were evaluated and also the poor techniques used. Relaxed calcaneal stance position was evaluated with a simple digital level that can be bought from Amazon.com for $US35. (Don't know how Langer cxplains the cost of selling it with their name on it). The number of variables were fewer than that proposed by Root. For example, transverse abnormalities were ignored, something which Root proposed was of great importance. Also no explanation of the techniques of drawing bisection lines on the heel and lower leg are given. Was the technique of LaPoint et al used to draw the calcaneal bisection? This technique was shown to be reliable, but instead pre-LaPoint references are used claiming unreliability. Certainly a flaw in the showing the bias of the author. The plane of bisection of the leg was also not given except in generalities (i.e. the frontal plane). Jarvis would find that in my article on STJ axis 1992 that I was very precise in describing the plane of lower leg bisection. Jarvis also failed to mention an important article by Freeman in which very good intertester reliability with a special instrument. One is also struck with the acceptance of a visual nonquantitative method and dichotomous classification of forefoot to rearfoot. In fact the only acceptable instrumentation for doing any measurements was the flexible goniometer for ankle joint dorsiflexion and the finger goniometer for first MTPJ motion.
    c. The mean rearfoot varus angle was 9.2 degrees with a standard deviation of only 1 degree? This should have raised some serious questions in the minds of the thesis reviewers. It also means that almost no one in the study could show the calcaneus everting from perpendicular, unless there is some very strange skewedness in the distribution. One of the criteria of a good paper is that the reader should be able to read only the intro, methodologies and results and come up with the same conclusions. After doing so, I come up with the following conclusions: 1)That people with high degrees of rearfoot varus may be able to function for the first 40 years of their life symptom free. 2) That rearfoot varus feet tend to function very similarly in the face of other forefoot deformities. 3) That the current methodologies of identifying the Root deformities may not be accurate due to either inaccurate instrumentation or due to poorly defined methodologies. Certainly I have stated number 3 for many years. Root’s Volume I is not an exact technique book but is more of a book of general concepts and proposals. I have made many refinements to his descriptions of techniques to try to improve reliability. However from the data, Jarvis makes a Giant Leap of Faith and declares that the entire Root evaluation methods are not valid. And I’m surprised that the Committee let her get away with it.
    Finally Simon I reject your basic premise that we are so much smarter than any of our fathers. Certainly, we have much more technology, however the more I study about history, the more impressed I am with those who have come before us. I think it’s time for you to come down to earth about your own fallibility and the greatness of those who have gone before us. I can say that Root did so much more with so fewer resources than you have done with much greater resources. I am not saying that Root said everything correctly – he didn’t have an engineering degree. And not everything he said was correct, however I’m finding out more and more how correct in so many things. His midtarsal joint postulate I believe is absolutely correct. Last fall I gave a presentation in NYC, in which I argued that the 8 criteria of Root for normalcy really are couched in good solid basic mechanics. Some are very strong, others do have some weaknesses, but are not totally incorrect. It’s time for you to quit throwing rocks every time you can at Root. We all want things to be better than Root left them, and it’s time for you to start doing some serious contributions. I practice all the points of Root that I find correct, however I have added many things as well and also made some modifications to Root techniques.
    I will look forward to detailing much more with you at i-FAB 2018.
    Daryl
     
  14. Thanks for those kind words Daryl, I'll keep it short as I have patients to see. Over the past twenty years of debating Root with you and Jeff, a couple of things have become apparent during that time 1) you seem to hold him in god like awe and believe the man could do no wrong, yet other people who also knew him paint a very different picture of him. 2) Even when presented with evidence which shows something Root said was wrong, neither you nor Jeff will admit that good ol' Mert could have ever been wrong, ever. He was.
     
  15. Jeff Root

    Jeff Root Well-Known Member

    Simon,
    Let’s assume your assertions are correct and that “Root Theory” needs replacing. Rather than tell us what is wrong with Root’s work, perhaps you can point us in a better direction by answering the following questions.
    1. What morphological classification system can you recommend to replace Root’s neutral position based system that can be used for both non-surgical and surgical evaluation and treatment of the foot?
    2. If we don’t need a system to describe the morphology of the foot please explain why.
    3. What system of evaluating and casting, and what orthotic fabrication protocol can you point me to that replaces Root’s system. Where can I find specific treatment protocols for such a system and what educational resources are used to educate students and practitioners about this system?
    4. Who has described their orthotic fabrication protocol as clearly as Root and where can I find these specifications?
    5. Who has given the profession a more comprehensive model of foot structure and function to replace Root’s system if Root’s system is so flawed and where can I find such a practical system?
    6. Who has written a book to describe gait, muscle function and the motion of the osseous segments of the foot and lower extremity that provides a clearer and more accurate description than that provided in Normal and Abnormal Function of the Foot?
    7. Who has written a textbook or what series of books can be used for teaching today’s podiatry students about biomechanics in a logical and progressive manner so that it can become the foundation for making treatment decisions and replaced the flawed Root system?
    8. Who has introduced better terminology to describe the function of the foot if Root’s method of defining structure and position based on the neutral position is so flawed and where can I find this information?
     
  16. Logical fallacy no.1: there needs to be/ can be a morphological classification system to employ successful treatment of patients attending our clinics- there does not need to be. Especially since each individual is an individual with a unique set of circumstances that has brought them into our clinic. So foot function is unique to the individual thus foot function can be denoted as p= a function of G + E + (Gx E) where P= any quantitative aspect of foot function you care to choose; G + genotype; E= environment (all non-genetic factors), that sums everything up quite nicely I think.
    See your logical fallacy no.1 above.
    Logical fallacy no.2 Foot orthoses dont need to be made from a cast to be efficacious, they just need to modify the kinetics at the foot to orthoses interface in such a way as to modify the tissue stress on the injured tissue to allow it to heal- controlled trial evidence available if you wish. If you want a system, then you could always talk to all the people getting great reasults using weightbearing casting boxes, which as we know are more repeatable than non-weightbearing casting techniques.

    BTW, big logical fallacy no.3 that a flawed theory is better than no replacement. You and Daryl have played this a lot over the years, but it's nonsense. If we know a system is wrong and has been proven to be invalid, we don't have to have a replacement before we can throw the invalid system in the bin- get rid of the rubbish regardless. This tablet lowers blood pressure, but it also causes cancer... Next...

    I'm not sure why you Jeff should require a specific treatment protocol, for any patient, since as a fireman you have no license to practice medicine in any State of the USA, however, if you'd have been keeping up, you'd realise that any management strategy should be tailored to the individual based on their unique set of circumstances. I beieve Tom McPoil intimated that.
    Actually, the one area that I think Root was particularly weak on was his description of how to make foot orthoses. There are several books which describe this better than your dad did, but if we look to individual papers you've got the likes of Henderson and Campbell, G.K. Rose, K .A. Kirby etc.
    See logical fallacy no.3. Personally I think any intelligent practitioner can realise that is about synthasizing the best current evidence and taking this on board to provide an evidence based approach- where do we find the evidence to support you Dad's books, Jeff? i can't recall a paper published in the last 20 years that added support to your dad's contentions- I can list many that detract.
    See logical fallacy no.3. Also I prefer to gather my information from primary sources, rather than text books these days- to look to a textbook, is to look to something that was at best written 5 years ago. In your dads case best part of 50 years ago. So, lets go to the primary sources; as most Universities now expect from their undergraduate students when writing an assignment. While you are in- how many high quality research studies have validated any of your dad's contentions in the last 20 years? None, right? ... Next? Anyway, if you wish there have been several textbooks on gait, for example Chris Kirtley's which provide a nice read. I still like Winter's books on gait though.
    In case you don't know, Universities prefer primary sources (research articles) over secondary (textbook) sources these days. Most undergraduate lecturers will build their syllabus around primary sources of information- drawing from a variety of sources. You point seems to be: my dad put it in one or two books, therefore that is better? Really, this isn't the 1970's. If you really wanted to push me on books though, you could do worse than read Kirby's books.
    I don't believe your dad actually introduced any new terminology, since everything you have suggested he introduced can be found in the literature prior to he. Thishas been demonstrate many times Jeff. See William Sayle-Creer would be a good start in your education, i.e. "Subtaloid joint in it's neutral position". Kirby, Nester, any one of the authors that have published in peer-reviewed journals over the last 40 years since your dad wrote his books might be a good start to get yourself up to speed with modern parlance, failing that try Newton. I think the key is though to keep ourselves up to date, as practitioners here in the UK we have to show evidence of this; I'm not sure about the requirements in the USA.

    I've answered your questions- stop insulting my intelligence, get your "guard-dogs" to wind their necks in and lose the ad-hominens and admit when you are wrong, Jeff. Now, my turn: regarding foot orthoses: “The primary objective of treatment is to control position and motion of the foot” True or false?
     
    Last edited: Feb 8, 2018
  17. Jeff Root

    Jeff Root Well-Known Member

    Simon, before we move on please define the following terms for me:
    1. Forefoot varus
    2. Forefoot valgus
    3. Rearfoot varus
    4. Rearfoot vagus
    5. A supinated foot
    6. A pronated foot
     
  18. Read any paper prior to your dads work that employed these terms, Jeff. Stop treating me like a fool. I'd recommend W. Sayle Creer as a starting point. If memory serves he said something like when the subtaloid joint is in its neutral position and the first metatarsal is off the ground, this is a metatarsus primus elevatus/ forefoot supinatus: 1944, Jeff, 1944. Anyway, I went to the trouble to answer your questions already, but the slippery eel that is Jeff Root avoided the elephant in the room again: I asked: regarding foot orthoses: “The primary objective of treatment is to control position and motion of the foot” True or false? My turn, surely? Y'all right though- "rearfoot vagus".
     
  19. Jeff Root

    Jeff Root Well-Known Member

    No, you did not answer my questions satisfactorily and you're dodging my question by trying to get me to be the one answering questions. I would like you to put in writing the definition of the above terms and provide me the reference for the (your) definition of these terms. These are some of the most commonly used terms for discussing the biomechanics of the foot. You can't do it because you have no point of reference and you refuse to accept Root's method for defining these conditions. You want to revert back to the pre-Root period where these terms very ambiguous because there was no reference given that would enable one to distinguish a forefoot varus from forefoot valgus or rearfoot varus from a rearfoot valgus. If you can't provide a satisfactory definition of these basic terms then why should we not accept Root's more accurate definition. Kirby uses these terms throughout his books so I'm sure you have definition that supports his use of these terms Simon.
     
  20. That's funny: satisfactorally for whom, a fireman? My answers to your questions to your 8 qyuestions above are my answers, like I care if you, Jeff Root, the son of someone who was influential once, loved by some, hated by others, someone who has no influence in my life is "satisfied" with my answers? Y'all didnt even attempt an answer one single true or false question... never mind. You've got too used to being the boss at your works me thinks, fella. You are not in charge of me, chap. Get right over yourself there for a minute Jeff- you are a fireman, born into this nonesense, not someone with any real experience of actually treating patients as you have no license to do so. Now, I took the time to answer your multiple questions above, you have not responded to my replies, rather, you chose to spew out a whole host of "next questions"; at the same time ignoring one single yes or no question from me. Then I deemed to stoop to answer your ridiculous next questions and even offered you suggesteed reading. To repeat myself: As I said none of these terms were invented by your father, all of them existed before your dad was even a podiatrist, I've given suggested reading. So, stop being lazy and look the references up, Jeff. Moreover, cut with the hollier than thou, nonesense, since in my world, you really are a no-one, Jeff. If you could lower yourself to answer my simple question: regarding foot orthoses: “The primary objective of treatment is to control position and motion of the foot” True or false? Then we might be able to move on; but unless you can provide either a yes or no then I feel that actually... you are a wasting of my time. I still prefer Sayle-Creer 1944 and Knowles 1952 to your Dad's ideas. Lets be honest, I think Feiss ,from virtuallly a hundred years before your dad, was more accurate and scientific in his assessment of foot function and the "normal foot".
     
    Last edited: Feb 8, 2018
  21. Jeff Root

    Jeff Root Well-Known Member

    For anyone following this discussion,Tissue Stress Theory advocate Simon Spooner can’t even provide us with a definition for the most common and basic terms used throughout the world in lower extremity biomechanics and podiatry. Simon’s frustration with his inability to provide us with definitions of forefoot varus, forefoot valgus, rearfoot varus and rearfoot valgus that are acceptable to him stems from the fact that he has publically rejected Root’s neutral positon classification system and has painted himself into a corner, since he cannot provide a better and more accurate definition nor does he have a reference for one. So Simon rejects Root’s work, offers nothing better and his only alternative is to stage a personal attack towards me because he is frustrated.

    Merton Root recognized that progress in podiatry and biomechanics was hampered due to a lack clear, concise and commonly accepted terminology. Dr. Root attempted to resolve that problem by providing the practitioner with more concise definitions and terminology. How do others who advocate for TST suggest we discuss structure, position and motion if we can’t agree on the definition of the basic terms that underpin our conversation?
     
  22. Funny., read the thread y'all. The fireman son of Merton Root is incapable of answering a true or false question. Slippery Jeff. For the record, Jeff posed me 8 questions which I answered. After answering those 8 questions, I put one question back, a question that I had asked but recieved no answer to at least two days ago, yet again he didn't answer it; nor did he respond to the answers I'd given to his first 8 questions- nothing, not a word. Rather he put a further 6 question back my way, I answered by saying that his father didn't invent any of those terms, which anyone who takes the time to search the literature will find to be a true statement- all of those terms have definitions defined by those who first described them in the literature- none of which were Merton Root. Incapable of answering one question, which would result in him admitting that his father was wrong, Jeff goes on the personal attack. Nice work fella. As for the title "tissue stress advocate", I prefer the title "science advocate". Eric Fuller and Ian Griffith both called you on claiming the terminology to be your fathers two pages back. Let me try and spell this out for you, in 1944 William Sayle-Creer used the term subtaloid joint neutral, and talked about a vertical heel position from which to assess the forefoot to rearfoot alignment. Your dad, didn't invent these terms, get over it. my question if you would? True or false?
     
    Last edited: Feb 8, 2018
  23. Jeff Root

    Jeff Root Well-Known Member

    The primary objective of treatment is to control the position and motion of the foot in some cases but not in others. For example, if a patient has a high degree of rearfoot varus and forefoot valgus (using Root's system for identifying these conditions) and the talus is subluxing in the ankle mortise, then the goal of orthotic therapy or surgery would be to attempt to reduce the degree of talar inversion in the ankle. It is not a true or false question Simon.
     
  24. Jeff Root

    Jeff Root Well-Known Member

    I have now answered your question Simon. So please tell me the definition of:
    1. Forefoot varus
    2. Forefoot valgus
    3. Rearfoot varus
    4. Rearfoot valgus
    5. A supinated foot
    6. A pronated foot
     
  25. See the definitions of those who first used these terms, Jeffery. Hint, that wasn't your dad, so who did he think he was changing their definitions////?
     
  26. Nope, good try though. Your dad didn't say "in some cases" he said “The primary objective of treatment is to control position and motion of the foot” . No caveat there about "some people and not others" nor, "sometimes and not other"; it was pretty black or white- once again you're on the "I think what he meant to say" BS road trip that you always go down. Moreover, I asked a specific question which required a binary response: true or false. Once again, you're trying to BS your way out of that. it's a simple binary response that is required from you Jeff Root: regarding foot orthoses: “The primary objective of treatment is to control position and motion of the foot” True or false?
     
  27. Jeff Root

    Jeff Root Well-Known Member

    Where are you getting your quote from?
     
  28. Your dad. True or false- still not an answer you can provide then, Jeff? Don't you have your own opinion on this?
     
  29. Jeff Root

    Jeff Root Well-Known Member

    I know your much brighter than that Simon.
    Where exactly? I want to see the statement in full context.
     
  30. Jeff Root

    Jeff Root Well-Known Member

    Simon, you obviously didn't read my post #241 so I have copied it for you.
     
  31. Jeff Root

    Jeff Root Well-Known Member

    "The terms, as defined by the authors in this manual, are in common orthopedic usage, but each term has been provided a strict scientific definition".
    Biomechanical Examination of the Foot
    Root, Orien, Weed and Hughes
    Copyright 1971
     
  32. Nope it was: “The primary objective of treatment is to control position and motion of the foot” True or false? Bless you, 2 days and you still haven't found where your dad said that, but even funnier that you are incapable of forming your own opinion of that single sentence statement.
     
  33. Jeff Root

    Jeff Root Well-Known Member

    So you don't have a reference for your quote? In the interest of your time, my time and anybody who is bored enough to follow this ridiculous circular conversation, can you tell me where you are getting this quote?
     
  34. efuller

    efuller MVP

    I like your concept of plantigrade. From what you wrote it seems that plantigrade would be more important than heel bisection. Or, in thinking in terms of tissue stress, plantigrade would be a position where the pressure distribution across the forefoot would be close to equal.



    As a developer of the tissue stress paradigm, I believe there is a difference between tissue stress and Root theory. Yes, a Root theorist can say that their treatment reduces stress. But there is a difference between saying an orthotic will reduce stress by putting the foot in neutral position, or by pushing the foot toward neutral position, or by supporting the forefoot deformity or making the foot more stable, etc.... and saying that pain in the posterior tibial tendon is caused by a high pronation moment from the ground and an orthotic will reduce stress on the posterior tibial tendon by decreasing the pronation moment from the ground. In tissue stress we design the orthotic to reduce stress on the injured structure by using mechanical analysis of the injured structure.

    Eric
     
  35. Jeff Root

    Jeff Root Well-Known Member

    What is the purpose of this discussion? Contrary to what Dr. Kirby said in his ageist and insulting comment, no one is promoting Root theory here or anywhere else for that matter. On the contrary, there is significant promotion of Tissue Stress Theory as an alternative to “Root Theory” and that is what others are responding to. It is my contention that tissue stress theory incorporates many elements of Root theory and as a result isn’t truly an alternative to Root theory.

    Simon argues that I defend Root theory simply because Merton Root is my father. Although he was my father, the reason I defend elements of Root theory is because, as the owner of a custom foot orthotic laboratory, I depend on elements of Root theory to communicate with my clients and others within the professions that I deal with, and because I employ many of Root's techniques in our orthotic manufacturing process. While Simon suggests that he doesn’t need a system for differentiating functional and structural variations of the foot, that is certainly not the case here in the U.S. when working with doctors of podiatric medicine and other foot and ankle specialists. The terminology used to communicate in an intra and inter professional medical environment necessitates a clear and concise definition and understanding of the terms used in that communication. I have asked Simon to define some of those everyday terms without using Root’s more exact and scientific definitions of those terms. Simon has dodged the question and is being intentionally evasive because he can’t provide a better and more scientific definition. Abandoning Root’s more precise definitions would be a major step backwards. However Simon isn’t willing to acknowledge this because he would have to admit that Root’s imperfect system, which is largely based on the concept of the neutral position of the STJ, is better than the alternative, which is a much more poorly organized and defined system for describing position and structure of the foot and lower extremity.

    Since no one else has suggested an alternative to Root’s definition of the terms that I requested, I think we can assume that others accept Root’s definitions and therefore, they do rely on Root theory to some degree. As I have said before, I am a proponent of change but not just for the sake of change. There are clearly flaws and limitations with Root theory (I’m reluctant to use that terms since it is so poorly defined) but I will continue to challenge those who promote change to provide justification for their proposed changes and I will question the validity and practicality of their proposal until they have convinced me of its benefit. I personally believe this is a healthy process since it forces those with like minds to reflect upon their position and attempt to support it in the face of question or opposition.

    I think some of those promoting tissue stress theory are creating unnecessary opposition by taking such a hard line on their anti-Root stance and should acknowledge the strengths and weaknesses and the benefits and limitations of “Root Theory”. When one uses elements of Root theory and refuse to acknowledge it, or refuses to acknowledge that the profession of podiatry relies heavily on elements of Root theory, it brings their credibility into question and makes their case for change weaker as I have demonstrated with my simple request for the definition of some of the most basic of terms.
     
  36. Don't assume silence means anything. I will answer one question though. The point of this discussion probably got lost 15 years ago.
     
  37. This came through for Jeffery. Sleep tight y'all.
     

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  38. rdp1210

    rdp1210 Active Member

    So the questions are:
    1. Do we need to cast a foot which has bunions with the subtalar joint in neutral position. If so, why? If not why? If sometimes yes and sometimes no, what text can I refer to make my decision?
    2. What do I do if the patient has a calcaneus that is inverted to the ground but the subtalar joint is maximally pronated? Can I make an orthotic for that person. How should I take the mold of the foot. Should I ask that the mold be modified in any way?
    3. If the patient is standing up with the calcaneus inverted from perpendicular, how do I know if the person is standing with the subtalar joint pronated or subtalar joint supinated? How do I know if when standing, a person has used their full reserve of pronation?
    4. Is there ever a reason to put a forefoot post on an orthotic? Where can you refer me for guidance on the need?
    5. How can you say that a foot is in a pronated or supinated position if you don't have a subtalar joint neutral position? You can talk all you want about velocities of motion, however joint position has a great influence active and passive muscle strength and tension. And most people spend more time standing in a static position than in actual walking. So why don't we need static measurements. You will also note from a 1992 paper on STJ axis that joint position also has a great influence on the position of the STJ in both of its spherical coordinates.

    Yes, I'm over 60, however I have almost 40 years of practice experience. And I believe I am as well read as you, Kevin and can calculate joint moments from force plate and kinematic data better than you can. Problem is that I also scrutinize the new literature for problems with methodology and also logic as well as the old literature. And I have no family ties to the Root family. I do believe that the person with the most tools in the tool belt gets the job done best.
    Daryl
     
  39. efuller

    efuller MVP

    Jeff, I agree that Tissue Stress incorporates many things from Root Theory. I use the concept of partially compensated varus. I use intrinsic forefoot valgus posts in my orthotics. I press casts on positive casts that have balance platforms. I take suspension casts, not necessarily in neutral position. Those are all things that I got from Root theory.

    On the other hand is what I do Root theory if I never use neutral position. Is what I do Root theory if I never use a heel bisection in my prescription writing protocol. (I do use changes in the shape of a heel cup that a lot of people will understand using heel bisection terminology, but a heel bisection is not necessary to communicate the heel cup shape that I want. (Symetrical heel cup. Heel cup with the medial third higher off of the ground than the lateral third etc). I could ask a lab for a 3mm forefoot valgus intrinsic post.


    Jeff, I understand your point about these terms are what are being currently used. However, resisting change because the current members of the profession were taught something is getting in the way of progress. The forefoot to rearfoot measurement cannot be done accurately as currently defined. There are very few predictive studies that can be done with the Root measurements because of the inherent inaccuracies in the measurements. Actually the paradigm makes few predictions. (What does a forefoot valgus do in gait? What "deformity" causes a bunion?) Yes, a lab owner is going to have to "speak and understand" two different paradigms as the transition occurs. The lab that is able to do that is the lab that will survive. Hopefully, the transition won't occur over too many generations.
     
  40. I think that once again you hit the nail on the head here, Eric. Certain individuals have attempted to hold back the development of our profession to their own selfish gains for fear that progress may see their financial empires crumble. Moreover, that they themselves may need to learn something new. I think it was Burch although Maslow is often credited with the competence cycle which flows around from unconcious incompetent, through to conscious incompetent, onto conscious competence, up to unconscious competence. Worth remembering that unconcious competence flows back into unconcious incompetence and those with many years of experience are probably most at risk of becoming unconsciously incompetent once again as the knowledge base and evidence moves on without them; stuck as they are; in the knowledge they gained some years previously.
     
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