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Anatomical Origin of Forefoot Varus Malalignment

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Sep 22, 2012.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Anatomical Origin of Forefoot Varus Malalignment
    Rebecca S. Lufler, T. M. Hoagland, Jingbo Niu, and K. Douglas Gross
    J Am Podiatr Med Assoc 2012;102 390-395
  2. Admin2

    Admin2 Administrator Staff Member

  3. Craig Payne

    Craig Payne Moderator

    :craig: :eek: :bang: :hammer:

    How did that slip past the reviewers?
    Which is called forefoot supinatus!!! It was not even forefoot varus that they were looking at, and yes, of course it has implications for treatment!!!!!!!

    McPoil et al made the same conclusion and the same mistake as well:
  4. David Wedemeyer

    David Wedemeyer Well-Known Member

    As I read this I was thinking the same thing and since supinatus is more common than true forefoot varus I hope the authors catch this and correct it.
  5. The problem would seem to be this sentence.
  6. David Wedemeyer

    David Wedemeyer Well-Known Member

  7. Or, what this and McPoil's paper tells us is that talar head torsion is not correlated to forefoot frontal plane alignment. I think that's useful information. I wonder what Rothbart thinks?
  8. Craig Payne

    Craig Payne Moderator

    It really is bizarre! They set out to do a study on forefoot varus, but set their inclusion criteria to be that of an inverted forefoot (~>90% probably being forefoot supinatus*) and then conclude that forefoot varus is due to soft tissue deformity (the very definition of forefoot supinatus!).

    The authors totally fail to get that there is a definitional difference between forefoot varus and forefoot supinatus; what is worse it got past the journal reviewers as well.

    *I assuming that the cadavers were older people, so supinatus prevalence would have been close to 100%
  9. Rob Kidd

    Rob Kidd Well-Known Member

    Can anyone see a brick wall; I need to bang my head. So much has been written about talar heaad torsion in1) thaat it has NOTHING to do with forefoot-reafoot aligment, and 2) what it is really about (peramorphic heterochrony), but which is largely ignored by the podiatric world. I think the best plan is that I get back in my box........................ Rob (excuse typo's - I am writing from a MacDonald's carpark - the only internet available)
  10. Craig Payne

    Craig Payne Moderator

    ...at 7.00AM on a Sunday! :santa:
  11. Craig Payne

    Craig Payne Moderator

    Here: :bang: :bang: :bang:
    I going to sort of disagree. "Forefoot varus" is a theoretical construct that is theoretically due to a failure of the full derotation of the head and neck of the talus, theoretically created a forefoot that is theoretically inverted relative to the rearfoot. I have no problems with the definition and the theoretical existence of this foot type. Clinically, it probably exists in 1-3% of the population

    As for the research that has tried to link the theoretical orientation of the head and neck to the forefoot frontal plane angle (ie McPoil et al and the one that started this thread), have failed to find one as there are soft tissues contractures (ie forefoot supinatus) that are more likely to influence the forefoot to rearfoot relationship in the frontal plane (clinically, >90% of the inverted forefoots are a supinatus). This research does not show that the theoretical 'forefoot varus' due to the talar head angle does not exist, it just shows that soft tissue contractures are more influential in the forefoot to rearfoot frontal plane angle.
    I had to look this up!! I will post a wikipedia page below. I not sure I agree on this one - what the authors in the study above and what forefoot supinatus is, by definition, an acquired soft tissue contracture that was traditionally described as occurring when the calcaneus everts past vertical (though we got data saying that a dysfunctional windlass mechanism could explain the same thing) ... I not sure how the development of a forefoot that is inverted to the rearfoot and held in that position by a soft tissue contracture could be explained by "peramorphic heterochrony"

    BTW, this: :bang: always feels good when you stop; so does this: :bash:

    Is this what you referring to:


    Neoteny (/niˈɒtəni/),[1][2][3][4] also called juvenilization,[5] is the delaying or slowing of the physiological (or somatic) development of an organism, typically an animal. Neoteny is found in modern humans.[6] In progenesis (also called paedogenesis), sexual development is accelerated.[7]

    Both neoteny and progenesis result in paedomorphism (or paedomorphosis), a type of heterochrony.[8] It is the retention in adults of traits previously seen only in the young. Such retention is important in evolutionary biology, domestication and evolutionary developmental biology.

    Some authors define paedomorphism as the retention of larval traits, as seen in salamanders.[9][10][11]

    1. ^ "neoteny". Dictionary.com Unabridged. Random House. Retrieved April 21, 2019.
    2. ^ "neoteny". The American Heritage Dictionary of the English Language (5th ed.). Boston: Houghton Mifflin Harcourt. Retrieved April 21, 2019.
    3. ^ "neoteny". Oxford Dictionaries US Dictionary. Oxford University Press. Retrieved April 21, 2019.
    4. ^ "neoteny". Merriam-Webster Dictionary. Retrieved April 21, 2019.
    5. ^ Montagu, A. (1989). Growing Young. Bergin & Garvey: CT.
    6. ^ Choi, Charles Q. (1 July 2009). "Being More Infantile May Have Led to Bigger Brains". Scientific American.
    7. ^ Volkenstein, M. V. 1994. Physical Approaches to Biological Evolution. Springer-Verlag: Berlin, [1].
    8. ^ Ridley, Mark (1985). Evolution. Blackwell.
    9. ^ Whiteman, H.H. (1994). "Evolution of facultative paedomorphosis". Quarterly Review of Biology. 69 (2): 205–221. doi:10.1086/418540.
    10. ^ Schell, S. C. Handbook of Trematodes of North America North of Mexico, 1985, pg. 22
    11. ^ Ginetsinskaya, T.A. Trematodes, Their Life Cycles, Biology and Evolution. Leningrad, USSR: Nauka 1968. Translated in 1988, [2].
  12. Craig Payne

    Craig Payne Moderator

    A further thought on this .... the basic deformity in the talipes equino varus form of clubfoot is in the talus (except for the neurological versions of TEV) and is due to the talus failing to undergo its full ontological development (ie something stops its development very early in fetal development). I do not think anyone disputes that, so why is it unplausible that the "traditional" "forefoot varus" is not really just the most mild form of "clubfoot" in which the talus has just stopped developing very short of that normal development?
  13. And the worst thing is that the degree of inverted forefoot deformity (which includes both "forefoot varus" and "forefoot supinatus") will also depend on the following:

    1) How the examiner bisects the calcaneus (probably +/- 5 degrees),

    2) How the examiner positions the subtalar in neutral position (probably +/- 5 degrees), and

    3) How much force the examiner loads the lateral column with a manual dorsiflexion force (probably varies by a magnitude of 10X).

    So you can argue forefoot varus vs forefoot supinatus all you want but until a more reliable examination procedure comes along that has very good to excellent intraexaminer repeatability, then the amount of inverted forefoot deformity will be very examiner dependent, and therefore, this type of discussion is of little use.
  14. Where would one find the most definitive definition of "forefoot varus"?

    Come to that, what constitutes a definitive definition? If we worked on consensus then the use of Ff varus to cover any sort of FF invertus is probably accurate!
  15. Craig Payne

    Craig Payne Moderator

    Root vol 1 and expanded on in Vol 2 says something like: osseous cause of an inverted position of the forefoot relative to a bisection of the posterior calc and the MTJ is maximally (in the context of the reliability issues of measuring it alluded to by Kevin)

    I do not think there is any dispute or disagreement over the definition; its just like the in research that started this thread, they got confused between forefoot varus and forefoot supinatus (both being feet with an inverted forefoot).

    This confusion has been used to discredit "Root theory", when its a straw man argument.
  16. Because of the terminology problems of "forefoot varus" and "forefoot supinatus", John Weed, DPM, in his lectures to us as 2nd year podiatry students (1980-1981) said that he and Mert Root had decided to call both "forefoot varus" and "forefoot supinatus" by the name "inverted forefoot deformities". I think that John was right in making that name change.....31 years ago!!
  17. Rob Kidd

    Rob Kidd Well-Known Member

    I will save a proper reply for when I do not have to write from the Macca's car park (and no- I do not go in, one of my saving graces is that I find fast food disgusting). For the last three months I have been living in a campervaan in The Barossa, SA, while demonstrating anaatomy in Adelaide. However, this week, being intersemester break, I am back over east helping one of my kids move house - thus no internet (having lefft it with wife over there).
  18. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Well folks, maybe it is time to talk about Embryology 101, the course we all took in our second year of Podiatry training (I assume it is still being taught):

    Below I have delineated several key axioms that are presented in almost any embryological textbook you would care to reference:

    Axiom 1: In the developing limb, all torsional changes occur sequentially, centrally to distally (in the lower limb, proximally to distally).

    Axiom 2: Supinatus is the term used to described the inverted structural twist of the part relative to the midline of the body.

    The following two axioms are eluded to only. However, I developed these concepts more fully in my clinical research (Rothbart BA 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Jour Bodywork Movement Therapies)

    Axiom 3: When the heel bone goes through its ontogenetic development, it takes with it the lateral embryological column of the foot (which comprises the cuboid, the lateral half of the internal cuneiform, the intermediate and lateral cuneiforms and 4 lateral metatarsals and adjoining phalanges)

    Axiom 4: When the talus goes through its ontogenetic development, it takes with it the medial embryological column of the foot (which comprises the navicular, the medial half of the internal cuneiform, the first metatarsal and adjoining phalanges)

    Below I have summarized the keys events in late embryogenesis on the foot (approximately 6-8 weeks PO):

    The Clubfoot Deformity

    Around Carnegie Stage 21 (CS21) both feet (heel to toe) are in supinatus (see Axiom 2)

    If the ontogentic torsional development stops at this stage, the child is born with a clubfoot. (Bohm M 1929 The embryologic origin of clubfoot. Journal Bone Joint Surgery, 11:229)

    Remember, the calcaneus begins it ontogenetic torsional development before the talus does (See Axiom 1).

    The PreClinical Clubfoot Deformity

    Around CS22, If the foot's OTD stops, the heel bone would had partially unwound, taking with it, the embryological lateral column of the foot. However, the embryological medial column of the foot would still remain in supinatus (if you have forgotten what embryologists refer to as Supinatus, go back to Axiom 2).

    What would this foot look like?

    I suggest when this foot is placed into its anatomical standing (obviously post gestation) neutral position (STJ congruity, not Roots 1/3 - 2/3rds definition):

    (1) The heel bone would still be in supinatus (but less so as it was in CS21).
    (2) But the talar bone would not had started, or had just started, its OTD. That is, the talus would, more or less, still be in full supinatus.

    Now you could see the structurally inverted position of the heel bone but you would not be able to see the structurally inverted (i.e., talar torsion) in the talus. But you would see an elevated metatarsal head and adjoining phalanges. I refer to this foot structure as the PreClinical Clubfoot Deformity.

    To read more about this foot structure, go to http://www.RothbartsFoot.es/PreClinCFD.html

    The Primus Metatarsus Supinatus Foot Structure

    Around CS22 or possibly early CS23, If the foot's OTD stops, the calcaneus would have completed its OTD. However, the talus would not have completed its OTD (and with it the medial embryological column of the foot).

    So, in theory, what would this foot look like?

    I suggest that when one places this standing foot into its anatomical neutral position:

    (1) The heel bone would had completed it OTD (and with it the lateral 4 metatarsals and adjoining phalanges), but
    (2) The 1st metatarsal head and adjoining phalages would still be in some degree of supinatus (in Podiatry terms Valgus).

    I refer to this foot as the Primus Metatarsal Supinatus (foot structure).

    In the mid 1990s, I approached Dr Cummings and Higbie at Georgia State University. I suggested a study to see if this suggested foot structure could be clinically measured. You can read their results in the following paper: 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].

    Or if you prefer, you can read their findings on my research site at: http://rothbartsfoot.es/RFS.html.

    I find Lufler's study very interesting. However, I believe her conclusions are flawed for several reasons. The most important being that connective tissue in the living foot is very different in constituency than connective tissue in the postmortem foot. These changes would obfuscate the apparent correlation between the relative rearfoot to forefoot position and talar torsion. But the intent of her study is commendable.

    A study that would help prove (or disprove) the correlation between talar torsion and position of the embryological medial column of the foot would be:

    Measure for the Primus Metatarsal Supinatus Foot (as described by myself and Cummings and Higbie). Then take that same foot, after death, and measure the talar torsion. However, for obvious reasons, that would be a very difficult study to do.

  19. Brian A. Rothbart

    Brian A. Rothbart Active Member


    Where I am discussing the PMS Foot Structure, under appearance of this foot:

    (In Podiatry terms Valgus) should read (In Podiatry terms structural Valgus)

    Around CS22 or possibly early CS23 should read: Around late CS22 or early CS23

  20. davidh

    davidh Podiatry Arena Veteran

    Herman Tax did a good definition I seem to remember......

    Otherwise I can only comment on the fact that the research was done on 25 cadavers, too small a sample - therefore the study is not of much use, except to point us in the direction of further study.

    I was laughed out of school (not exactly, but a couple of people raised their eyebrows) when I suggested the term forefoot invertus was useful - that was on the old jiscmail sometime about 1994.

    Forefoot invertus. How many people, in a normal population, don't have a forefoot invertus?
    Rhetorical question - I already know the answer.
  21. Franklin

    Franklin Active Member

    A good point, and very well made :good: - just a hair-splitting point though - when you say 'ontological', I think you mean 'ontogenetic'. 'Ontological' means of or pertaining to 'ontology' - a branch of philiosophy which deals with the essence or nature of being; 'ontogenetic' means of or pertaining to 'ontogeny'. I have also made the same mistake in the past. ;) :empathy: :drinks
  22. Brian A. Rothbart

    Brian A. Rothbart Active Member

    You are correct. Ontogenetic, not ontological. Also another error correction:

    The embryological lateral column of the foot comprises the cuboid, the lateral half of the navicular, the intermediate and lateral cuneiforms and 4 lateral metatarsals and adjoining phalanges. That is the navicular bone has two embryological growth centers: lateral and medial.

    The lateral growth center goes with the lateral column. The medial growth center goes with the medial column. The internal cuneiform has one growth center only and it goes with the medial column of the foot.

    Sorry for the confusion, I wrote the above reply very early in the morning.

  23. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Originally Posted by Craig Payne

    A further thought on this .... the basic deformity in the talipes equino varus form of clubfoot is in the talus (except for the neurological versions of TEV) and is due to the talus failing to undergo its full ontological development (ie something stops its development very early in fetal development). I do not think anyone disputes that, so why is it unplausible that the "traditional" "forefoot varus" is not really just the most mild form of "clubfoot" in which the talus has just stopped developing very short of that normal development?


    Both the calcaneus and talus must both be in supinatus to have the clubfoot deformity, mild or otherwise.

    Embryologically, the term forefoot varum is an embryological oxymoron (read that - does not exist). That is the entire forefoot cannot be in supinatus without the calcaneus being in supinatus.

  24. I especially like this explanation of a "Rothbart's Foot". I don't think I could be quite so serious as Brian is here discussing something so ludicrous. This is almost as unbelievably incredible as his book Forever Free from Chonic Pain.

    Just one question, Brian......how do you sleep at night giving people false hope that you will be able to cure their chronic pain?!!

    Last edited by a moderator: Sep 22, 2016
  25. :mad: This is on you Spooner! Now look what you've done!

    :boohoo:Dearly beloved, we are gathered to mark the passing of another thread. This thread was still very young when it contracted an incurable case of marketing and sadly passed from this life. We greive with its parents and those who worked with it, and pray together that we might soon find a cure for this horrible and debilitating disease which has taken so many threads from us.

    Let us pray...
  26. I especially liked this webpage from Brian's website....almost fell out of my chair reading it........
  27. What's better to kill a thread destined to misery or to promote it? Restaurant analogy's not withstanding; you make the assumption that both eateries are actually serving "food" and that neither will poison the eater.
  28. Different thread. That one was already dead, and I was indulging my penchant for necrophila.
  29. Because of the cost of the phone consult?

    Did you see the cost of the actual cost for the distance treatment? With a pair of OTS insoles, sent in the post?

    http://rothb artsite.com/More_FAQ.html

    I've added the space because I didn't want to bump the google rankings. 20,000 Euros.

    But we digress.
  30. Do you think Brian is taking a little liberty by claiming accomplishments that he had nothing to do with in this webpage?

    Brian, you really are a work of art....:butcher::bash::bang:
  31. As the kids like to say:

    The man is our saviour. Or, just a big liar. Take your pick.
  32. You know that every time you link to his page you help his google ranking right? Free advertising...
  33. RobinP

    RobinP Well-Known Member

    I might as well further screw up this thread by saying that, in my opinion, forefoot supinatus is like religion

    They both require a reference point that, if one is of a certain persuasion, does not exist.

    Ergo, sub talar joint neutral is God(ly)

    Now if someone could just post something about this that is related to foot health practitioners, society vs institute, barefoot running and functional foot typing, then we can make sure this thread is closed down pronto......BECAUSE THAT IS WHAT THE PAPER THAT STARTED THIS THREAD DESERVES as a reponse
  34. Robert:

    I could care less. The medical professionals here on Podiatry Arena need to see what type of person Brian Rothbart is. Let him have some slightly increased "google ranking".....Rothbart needs to be exposed to the light of day....
  35. phil

    phil Active Member

    So, anyway, can someone give me a straighforward way to clinically tell a forefoot supinatus from a forefoot varus? And what to do with this information?

    My approach is to treat the person and their symptoms. Using this approch for the last 5-6 years, I've never used a FFVR post on an orthotic. Am I the only one with this experiance?
  36. Peter1234

    Peter1234 Active Member

    Hello all,

    just posing a question..amongst all the bigger animals...:D

    I have a thirteen year old boy, average weight height and development. However he has a very high forefoot varus, left foot 17 degrees as measured with goniometer. right foot 10 degrees forefoot varus. As you can imagine...he has pretty flat feet, and already has some crepitation at the knees. there is normal RoM at the STJ, however the midtarsal joints are hypermobile/a lot of mobility. he does evert at the rearfoot in gait, as you can imagine (has some achilles pain)

    the question is really, does anyone have any experience with posting a foot like this to the rearfoot mainly - ie a higher rearfoot posting....for the ligaments in the foot to eventually contract and the foot to become a more rectus foot?

    bit outside the remit of this thread..but hey..:rolleyes:
  37. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Hi Phil,

    The question is, what exactly is a forefoot supinatus or a forefoot varus. Embryologically, neither one is possible (if you have any questions about that, look at my previous post on this thread describing the normal ontogenetic torsional developement of the heel and talar bones).

    I believe Podiatrists use the terms forefoot varus and forefoot supinatus to describe connective tissue changes in the foot resulting in positional shifts.

    • When the forefoot is positionally inverted (relative to the rearfoot), they label it forefoot varus.

    • When the forefoot is positionally everted relative to the rearfoot, they label it forefoot supinatus.

    However, one must keep in mind that these terms are used to describe SYMPTOMS (albeit positional symptoms) but not primary etiology.

    My first tenant is to isolate the cause and treat that directly. If you treat symptoms, the patient will end up in a life long process of pain management. Something that is very frustrating and expensive for the patient, and should be avoided, if possible.

    So, the question remains, what is the cause of forefoot varus and forefoot supinatus. All the explanations I have read to date (including some of the complex biomechanical explanations) do not isolate primary causes, but instead describe a series of changes leading to the positional shift.

    In my clinical experience, I have found the positional shifts in the forefoot that Podiatrists frequently write about are secondary to one of the two abnormal inherited foot structures I have written about. However that discussion, most likely, should occur on another thread.

    However, if you want more information now, I suggest you go to my research website at http://www.RothbartsFoot.es

  38. [​IMG]

    Is THAT what you believe?!


    Speak to many podiatrists?!
    Last edited: Sep 25, 2012
  39. Hello again Brian. It's been a while but perhaps not long enough. Strangely I was thinking about you the other weekend whilst in a state of morphine-induced delirium. My surgeon pronounced I have a laterally deviated septum which - to the best of my knowledge - was not acquired. In your estimable opinion, could this be related to a rapidly developing compression stocking forefoot supinatus and if I were to start therapy with your insoles could my declining libido be reversed?

    Yours in anticipation
  40. Assuming it's a supinatus (sounds like it) then yes. I've had some good improvement in some of these. Try a device with a heavily inverted rearfoot (big ass medial skive works for me) and a forefoot valgus extension. Looks like a gait plate but not so rigid.

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