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Anatomical basis for STJ NP.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ray Anthony, Jan 21, 2013.

  1. Ray Anthony

    Ray Anthony Active Member

  2. Petcu Daniel

    Petcu Daniel Active Member

    DS Bailey, JT Perillo, and M Forman, Subtalar joint neutral. A study using tomography J. Am. Podiatr. Med. Assoc. 1984 74:59-64 ?

  3. Brian A. Rothbart

    Brian A. Rothbart Active Member

    I define STJ aNP as joint congruity. When STJ motion is driven by the transverse plane oscillations of the hip (e.g., Hip Drive), the STJ almost invariably functions around its anatomical neutral position (aNP). When STJ motion is driven by structural aberrations (e.g., Gravity Drive), the SJT almost invariably functions around an altered position (e.g, not the aNP).

    Prof B
  4. Rob Kidd

    Rob Kidd Well-Known Member

    I have no problems with the congruity definition - though am unsure how one would identify its exact position. However any definition based upon "neither pronated nor supinated" or anything similar, is tautological.
  5. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Determining the STJ nP (joint congruity) standing is doable.

    Fortunately the STJ along with the TMJ are two of the easiest joint to locate/feel the articular margins. In the case of the STJ, placing one's index finger slightly below and forward of the medial malleolus, one can easily feel the STJ articular margins.

    You can feel the STJ slipping in and out of its nP (joint congruity) as you pronate and supinate the STJ.

    Determining (e.g., quantifying) whether or not the STJ is dynamically functioning around its nP, is not as easy. I was taught (by Sglatto et al) that if you observe no motion in the STJ (e.g., medial buldging) as the patient walks, then the STJ is functioning around its nP (not very scientific).

    Hence, the best insight I can offer (to date) is the generalization that I made above: Hip Drive - STJ functions around its joint congruity, Gravity Drive - STJ functions around a position other than its joint congruity.

  6. Here is a newsletter I wrote about 22 years ago on the subject of subtalar joint neutral position. My thoughts are now almost identical to these from over two decades ago. The area of my article below that I have bolded agrees with Rob Kidd's concern with the tautological nature of Root's definition of subtalar joint neutral position. (Kirby KA.: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, AZ, 1997, pp. 21-22.)

  7. efuller

    efuller MVP

    The definition of congruity that I learned as a student was the position of maximum joint surface contact. If you look at the posterior facet of the STJ, the position of maximum joint contact is the maximally pronated position. The position of maximum jiont contact cannot really be palpated in an intact foot. I'm not really sure what people are palpating when they are palpating "neutral position." But what they are palpating is something other than maiximum joint contact.

  8. Brian A. Rothbart

    Brian A. Rothbart Active Member

    I have been using STJ congruity (via palpation) to determine the vertical deficits of the Primus Metatarsus Supinatus and PreClinical Clubfoot Deformities. I have found using this protocol to be easy to use and teach with very reproducible results.

    Maximum joint contact is fairly easy to palpate - just underneath the susentaculum tali. One can feel the regularity of the joint surface when the STJ is congruous.

    Prof B
  9. Rob Kidd

    Rob Kidd Well-Known Member

    To the two above posts. Yes, if you say so, but how do you measure it?
  10. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Hi Rob,

    A study, funded by the College of Health Sciences at Georgia State University, was done to determine a protocol for measuring vertical deficits seen in the two embryological foot structures (Primus Metatarsus Supinatus and PreClinical Clubfoot Deformity) that I have published on. The study was conducted by George Cummings and Elizabeth Higbie at Georgia State University, School of Health Sciences (1996) to determine the accuracy and reliability of measuring the standing foot using palpation to determine the nP of the STJ (defined as joint congruity). They used a protocol that I developed (referred to as the BioVector Measurement Test). They found this protocol to be very reliable, both inter and intrarater.

    Below is the abstract of that paper (and citation):

    Discussion: Orthosis prescription for forefoot posting is commonly based upon measures of the forefoot performed on a non-weight bearing foot. However, the relationship of measures of the unloaded foot to determine orthosis prescription for compensatory forefoot function during gait is still in question. Another approach [originally introduced by Dr Brian A Rothbart] to determine orthosis prescription is to, [using microwedges], measure the height of forefoot posting necessary to prevent excessive pronation of the subtalar joint during weight bearing.

    Purpose: The purpose of this study was to determine the intrarater, interrater and day-to-day reliability of forefoot measures during an active, weight bearing movement. Methodology:

    Study: Thirty-two volunteers, 18 females (mean age 38.9 ± 15.3 yr) and 18 males (mean age 44.8 ± 20.6 yr) participated in the study. Four examiners performed repeated forefoot measures on both feet using the weight bearing technique during two test sessions separated by a week. Intrarater and interrater reliability (ICC (3,1)) ranged from 0.90 to 0.95 and 0.87 to 0.94, respectively. Day-to-day reliability (ICC (1,1)) ranged from 0.84 to 0.88 for all measures.

    Conclusion: The weight bearing method used in this study to determine forefoot posting is reliable. The acceptable reliability of this method justifies the need for future investigations of the validity and the clinical efficacy of this technique for orthosis prescription.

    Hope this helps Rob.

    Cummings GS, Higbie, EJ 1997 A weight bearing method for determining forefoot posting for orthotic fabrication. Physiotherapy Research International, Vol 2(1):42-50. [This study was funded by a grant from the College of Health Sciences at Georgia State University]

  11. efuller

    efuller MVP

    Do you mean just above the sustentaculum tali? Actually, at that location you are only palpating the medial side of the joint. You don't know whether or not the lateral side of the joint is in contact. With pronation of the STJ, the sustentaculum tali will slide more laterally under the talar head. As with the posterior facet, you can make the case there is greater congruity in the maximally pronated position.

    The bigger question is why is joint congruity important. Why can't the joints function just fine without them being congruous. There is certainly yet been no explanation of why this palpated position is important for anything. Why should this position be used as a reference point?

  12. Brian A. Rothbart

    Brian A. Rothbart Active Member

    It has been my observations and my opinion, both as a clinician and researcher, that the postural framework functions best around joint congruity (e.g., anatomical nP). The basic tenant in my research is: function follows form. That is not to say, that the postural joints can function somewhat outside their nP without symptoms. But there is a point where the body can no longer compensate and chronic pain issues start manifesting (foot to jaw).

    Obviously more research needs to be done in this area. No definitive statements can be made until that research is completed.

    Prof B
  13. efuller

    efuller MVP

    You don't even know if what you are palpating is joint congruity. As I discussed above you are only palpating the medial side of one of the three facets of the STJ. Why is the middle facet more important than the much larger posterior facet that is more congruous at maximal pronation?

    Obviously, you are not talking about the STJ when you have observed that the postural framework (= skeleton???) functions best around neutral position, because what you have said you palpate (sustentaculum tali) is not sufficient to determine if the joint is congruous. What observations have you made at other joints lead you to believe that things function better around neutral position? Do you have a theory as to why things would function better at maximum congruity?

  14. Greg Quinn

    Greg Quinn Active Member

    Surely maximal congruity of any joint is simply a broad indication of the joints capacity to work around that position.

    This need not be at any predetermined position of the bones involved. Any synovial joint will adapt according to what function is demanded of it but this is also constrained by the individuals capacity to respond to mechanical signals... which diminishes as we age.

    The upshot is that some people's joints fail to respond to mechanical signals and consequentially their joints operate at a position far from fully congruent... This doesn't mean they automatically develop symptoms... But common sense suggests that working any joint around a position that is close to one end ROM carries risks.

    Best wishes


    PS. Why the STJn debate again? Historical reference presumably.
  15. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Hi Greg,

    Basically I agree with you. In my experience, joints that function around or near their anatomical nP is preferrable (from a logical/common sense point of view) than joints that function around a position close to their end of ROM (e.g., an abnormally pronated STJ).

    I believe that joints that function near their end ROM are more prone to develop degenerative changes then joints that function around/near their anatomical nP. My research, over the years, on chronic musculoskeletal pain revolves around this paradigm. Namely, form follows function: (an extension of Wolf's Law). If the joints functions around a position near their end ROM, global postural distortions develop. Over the years I have been linking these global postural distortions to the development of chronic musculoskeletal pain, foot to jaw.

    Thanks for your comments. Appreciated.

    Professor Brian
  16. efuller

    efuller MVP

    Why is this a sure thing? If a joint does not get damaged when it functions at its end of range of motion then what's the problem.

    Brian bases his foot type on it. And there is no reason to.

  17. efuller

    efuller MVP

    The knee, for example, does just fine functioning near its end of range of motion. Why can't the STJ do just fine functioning near its end of range of motion? Why do you think neutral position is common sense? Why is one joint position preferred over another?

    It's the forces acting on the joints that cause problems, its not the position that they are in.

    What global postural distortion develops because the knee functions near its end of range of motion? There must be some cause and effect. The blanket statement about functioning around neutral position is indefensible. You can repeat it as many times as you like, but it wont be true unless you can explain why functioning near the end of range of motion causes problems.

    Form follows function is another meaningless platitude. Anyway, function follows form. The shape of a joints surface and the ligaments (the form) determine the envelope of motion (the function) of a joint.

    You can link chronic musculoskeletal pain to the alignment of the planets. That doesn't mean that there is a causal link.
  18. Greg Quinn

    Greg Quinn Active Member


    Originally Posted by Greg Quinn
    Surely maximal congruity of any joint is simply a broad indication of the joints capacity to work around that position.

    When I suggest a broad indication I mean that the joint has the capability to move into different orientations from that position safely or securely... This is admittedly a somewhat old fashioned use of the word SURELY but it need not have any other implications here... Sorry for any confusion. Just a clumsy phrasing of the point.

    Certainly... and as I pointed out... what position two bones are in when a joint is maximally congruent is not predetermined and in fact likely to alter during development.

    Maximal congruency is not necessarily a sign of anything... Especially as to predicting whether symptoms will necessarily follow if a joint works from a different position from that of maximal congruity.

    As I have tried to show in JAPMA last year... STJn as a concept of normality is Essentialist, fundamentally flawed, biological nonsense.

    As far as the form/function complex goes... It's a 2 way street...
    I recommend reading 'Adaptation and the form-function complex' Bock & Von Wahlert JSTOR, 1965

    Kind Regards

  19. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Hi Greg,

    My research in chronic musculoskeletal pain over the past 30 years or so has led me to this concept of joint congruity as being a major player in understanding the development of chronic pain symptoms. I have found a very consistent correlation between joints functioning around a noncongruent position and resulting inflammatory/arthritic changes within that joint. This is why I have spent so much time running clinical trials on postural distortional patterns initiated by abnormal foot motion (e.g., ascending postural distortional patterns).

    I believe the answer to reversing so much of the chronic musculoskeletal pain, that has become endemic in our population, is by reposturing the weight bearing joints to function around a more anatomical nP (e.g., joint congruity).

    That is why this discussion on the Anatomical basis for STJ nP is so important. Once we have reached an agreement as to exactly what is the STJ nP (which I believe does exist), we will be able to take the next step towards eliminating chronic muscle and joint pain (e.g., plantar fasciitis).

    From my recent publications it is obvious that I do consider STJ np as joint congruity. In fact, I would extend that definition to almost every weight bearing joint in the body. Whether, in time, I am proven correct or not on this, we will see.

    Again Eric, I found your comments very insightful.

    Professor Rothbart
  20. Greg:

    Brian's "research" has led him to also self-proclaim himself the Father of Chronic Pain Elimination, to name a foot with forefoot varus after himself, Rothbarts Foot, to name a type of "treatment' after himself, Rothbart Proprioceptive Therapy and to even name a week of the year after his foot, Rothbarts Foot Awareness Week.

    Please consider these things any time you respond to Brian Rothbart, the self-anointed "Father of Chronic Pain Elimination".
  21. efuller

    efuller MVP

    There is just so much wrong here. You've said, in this thread, that joint congruity of the STJ is easily palpated at the sustentaculum tali. (You actually said that you can tell that by palpating just below the sustentaculum tali, when the bone that articulates with sustentaculum tali is above it. You haven't corrected yourself on that one yet.)

    Palpating for congruency in this location is just looking at one side of one one part of the subtalar joint. This is just the medial side of the middle facet. You cannot determine congruency of the STJ by doing this.

    You say that you believe that congruency is important because you have found over the years that there is a correlation with lack of congruency with pathology. Brian, you can't even determine if the joint is congruous, so all your correlations are made with a measurement that you physically cannot do. Brian, it's time to find a new paradigm.

  22. Brian A. Rothbart

    Brian A. Rothbart Active Member


    In all due respect, I disagree with you. Locating the articular margins of the STJ is very straight forward and like the TMJ, fairly easy to do.

    I am totally baffled by your comments on the medial and lateral margins of the SJT. Quite simply, I am assessing the position of the medial superior margins of the calcaneus relative to the medial inferior articular margins of the talus. If they are congruous medially, it is outside my experience to say they might not be congruous laterally. Perhaps you can point me to an evidence based, double blinded study that substantiates your position.

    Lastly, you need to be a little more tolerant with typing errors. We all make them. Obviously the medial articular margin of the STJ is approximately one finger width below and proximal to the medial malleolus.

    I have stated my position on the nP STJ. You may not agree with it (so be it). But when you say there is 'so much wrong here', how can I take you seriously. Perhaps it is more accurate to say that what I am suggesting is outside your sphere of experience.

    Professor Rothbart
  23. efuller

    efuller MVP

    I'm not saying that you cannot palpate the margins of the joint at the sustentaculum tali. I believe you can do that. What I am asking is why this articular margin is important. It appears that you have said that you do this because you are determining joint congruity. (more on this point later) I am asking why joint congruity is important and you answer has been essentially that this is obvious and I am disagreeing with you here. It is not obvious that joint congruity is important.

    You are assessing the margins at the middle facet. The STJ has 2-3 facets and you are looking at only one part of it. As you move the STJ from a maximally pronated position to a more supinated position, you may get more contact at the middle facet, but you will be getting less contact at the posterior facet. And you don't know if you are getting less contact on the lateral side of the joint because that is not palpable. So, you can't know that you have reached maximum joint contact by palpating what you say you are palpating.

    Brian, you are the one making claims that you can do something. I'm saying you can't. You need to produce the study that says you are correct.

    I'm quite tolerant of typing errors. My problem is with the failure to correct them when asked. You have done so now.

    "Professor", just answer the question: How can you know if joint congruency of the STJ is related to pathology if you can't even know if the STJ is congruent. What you are suggesting is outside the sphere of reality.

  24. ... And infertility, breathing problems, menstural pain, having an odd shaped head, Gastrointesterinal problems, droopy eyelids, peripheral ischaema and autism!

    Amazing what forefoot varus can cause.
  25. Petcu Daniel

    Petcu Daniel Active Member

    Biomechanical Analysis of the Calcaneocuboid Joint Pressure After Sequential Lengthening of the Lateral Column

    Jiang Xia, PhD1, Peng Zhang, MD2, Yun-Feng Yang, PhD2, Jia-Qian Zhou, MD2 ,Qian-Ming Li, MD2, Guang-Rong Yu, MD2

    1Yijishan Hospital, Wannan Medical College, Wuhu, Anhui, China
    2Tongji Hospital, Tongji University, Shanghai, China
    Guang-Rong Yu, Tongji Hospital, Tongji University, 389 Xincun Road, Shanghai, 200065, China Email: yuguangrong2002@163.com


    Background: Lengthening of the lateral column by means of the Evans osteotomy is commonly used for reconstruction of adult and pediatric flatfoot. However, some reports have shown that the Evans osteotomy is linked with increased calcaneocuboid joint pressures and an increased risk of arthritis in the joint. The purpose of this study was to measure the pressure across the calcaneocuboid joint and demonstrate the changing trends of the pressure within the calcaneocuboid joint after sequential lengthening of the lateral column.
    Methods: Six cadaver specimens were physiologically loaded and the peak pressure of the calcaneocuboid joint was measured under the following conditions: (1) normal foot, (2) flatfoot, and (3) sequential lengthening of the lateral column by means of the Evans procedure (from 4 mm to 12 mm, in 2 mm increments).
    Results: Peak pressures across the joint increased significantly from baseline in the flatfoot (P < .05). In the corrected foot, with the increment of the graft, the peak pressure decreased initially and then increased. The pressure reached its minimum value (11.04 ± 1.15 kg/cm2) with 8 mm lengthening of the lateral column. The differences were significant compared to the flatfoot (P < .05) and corrected foot with the other sizes of grafts (P < .05), but differences were not significant compared to the intact foot (P = .143).
    Conclusions: Lateral column lengthening within a certain extent will decrease the pressure in calcaneocuboid joint with a flatfoot deformity.

    Clinical Relevance: Performing the procedure with an 8 mm lengthening may reduce the risk of the secondary calcaneocuboid osteoarthritis.


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