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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. I think you'll find thats exactly what I've been saying, yet an insert doesn't have to "brace" the foot to achieve that (see Griffiths and Spooner http://bjsm.bmj.com/content/52/6/350). To me, social media debate has always been about having the wit (or a lack of it) to admit when you are wrong, just like in day to day, face to face communication. Some people seem to lack such wit and always have had an inability to concede when their reasoning is wrong. Personally, in order to promote and educate others regarding foot orthoses therapy, I keep trying to publish peer reviewed articles on foot orthoses in good quality journals, just like the one above, since social media generally lacks scientific credibility. Each to their own I guess.
     
    Last edited: Mar 5, 2018
  2. Jeff Root

    Jeff Root Well-Known Member

    So why don't we try to come up with a definition of a foot orthotic that we can all, or a majority can agree on? In fact, let's come up with a layman's definition and a more technical one. The laymen's definition would be the type that a foot specialist could post on their website for the public, who may not have any real understanding of what a foot orthotic is. The more technical version could be used by foot and ankle specialists, researchers, etc. for more high level applications.
     
  3. Do you concede that your definition is no good then, Jeff? Just for once have the wit....
     
  4. Jeff Root

    Jeff Root Well-Known Member

    I agree that it could be improved so as to eliminate some of the concerns that have been expressed here by you and others. Until I have a better alternative then I will continue to use the PFOLA definition.
     
  5. Never mind.
     
  6. Jeff Root

    Jeff Root Well-Known Member

    You asked what I assumed to be a serious question and I gave you a serious answer. Unless and until have a a better option, than why should I not use the definition I have? I have the same attitude about heel bisection and a number of other techniques we use on a daily basis within the lab. Some have raised concerns about reliability and repeatably of heel bisections. However, until someone comes up with a better, more accurate and clinically useful technique, I will continue to defend the use of heel bisections in the manufacture of custom, functional and accommodative foot orthoses and AFO's.
     
  7. And that is why you fall down Jeff, you will defend something that is proven to be wrong because there is no alternative. But it's wrong... jump into the fact that no alternative is still better than an alternative that is proven to be wrong. "everything you know is wrong"; you don't see me losing any sleep because I'm happy to live with uncertainty... Science is full of uncertainty.
     
  8. Jeff Root

    Jeff Root Well-Known Member

    Tell me and prove to me how I can make a better orthotic for my customers with some other technique and I'm all in Simon. Until then, I will use the best techniques that are available to me. Doing otherwise would be foolish and irresponsible.
     
  9. drhunt1

    drhunt1 Well-Known Member

    We've all seen Simon's orthotics...no thanks. I believe Simon has "proven" himself to be nothing more than a blowhard shill for the TST adherents here. Very little has been proven or disproven in re to your fathers' work...and as you and Dr. Philips have stated ad infinitum, it was a work in progress. Problem is, these TST guys tried to develop a better mousetrap instead of improving upon what Merton laid out for all of us. Your question to Eric Fuller, for example, is still noteworthy: (paraphrasing) "Whom besides you and Kevin are teaching TST in the US"? Bingo!
     
  10. drhunt1

    drhunt1 Well-Known Member

    OMG...please...break out the two-toned brogues for another "happy dance", Simon. It truly is what you're good at.

    http://yournewswire.com/london-churches-mosques/
     
  11. Griff

    Griff Moderator

  12. Jeff Root

    Jeff Root Well-Known Member

    A number of people have posted links at the end of their posts that appear to have nothing to do the actual topic at hand. Although I never watch them, why is it that you only question this one and not any of the others?
     
  13. drhunt1

    drhunt1 Well-Known Member

    Griff-the link was copied and pasted to refute some of what Simon Spooner was droning on about. I guess I should've made that more clear for those among us that aren't as comprehensive in their understanding.
     
  14. Jeff Root

    Jeff Root Well-Known Member

  15. Griff

    Griff Moderator

    It was a genuine question as I couldn't make a connection. If I failed to make a connection to any other link posted I'd ask the same question.
     
  16. Jeff Root

    Jeff Root Well-Known Member

    I didn't post that in support of anything. If nothing else, it demonstrates how little progress is being made in podiatric education and illustrates how much work there is to do.
     
  17. In the USA, Jeff... In the USA alone. Seriously, the rest of the world has moved on from this at least a decade ago. We here in the UK, along with several countries in central Europe run Masters degree programmes and PhD programmes in podiaitric biomechanics and applied podiatric biomechanics. Are you guys caught in a time-loop? I've been asked to speak on the midfoot at an upcoming seminar in Spain- if I started talking about the midtarsal joint in terms of a longitudinal and oblique axis in anything other than an historical perspective I'd quite rightly be hauled off stage.
     
    Last edited: Mar 6, 2018
  18. efuller

    efuller MVP

    Daryl, I asked you that in a middle of the debate we were having at the ACFOAM conference in 2016. Have you changed your position since then.

    Back to the question at hand.
    Daryl, you said I sidestepped your question.

    I wrote further on this.

    Daryl this is the reasoning behind the "sidestepping" of your question. "Can the MTJ be stabilized (i.e. in a static stance) with the MTJ in the middle of its frontal plane ROM?"

    Daryl, I believe that you are sidestepping the question I have posed about the 2 axis model of the midtarsal joint. Your question only makes sense if you assume that there is an anatomical structure that is a fulcrum for the longitudinal axis of the midtarsal joint. Daryl, if I"m missing your point can you explain your question further?
     
  19. Jeff,
    In my life I've realised that travel is a really good educator and I'd recommend it to anyone. Don't be offended by this: if you do own a passport (google tells me that only 36% of Americans hold passports- like wow!), can I suggest that you attend a biomechanics based seminar in Europe and/ or Australasia and/ or South Africa; knock yourself out- go on a grand tour; if you don't own a passport, can I suggest that you obtain one and do as stated above (don't be one of those 64%). I'm sure people here can give you good guidance on the best meetings to attend. I'm sure that it should be an absolute revelation to you. Kevin and Eric are globally "well travelled" in terms of their invited speaking on podiatric biomechanics; I'm told that within the USA they are teaching something different to those that have not been invited to speak outside of the USA of late... what is this strange correlation?
     
    Last edited: Mar 6, 2018
  20. drhunt1

    drhunt1 Well-Known Member

    OMG..."words of wisdom" by Simon Spooner. In deference and opposition to my prior admonition that no one should respond to this idiot, I shall. Traveling more should allow for greater comprehension of Podiatric Biomechanics? I know you have me on ignore, Simon, because you simply can't handle someone who can "dish it out" like I do...but tell me...in all of your travels and lecturing on motion in the MTJ, (or STJ, for that matter), what problems have you ever resolved? Sounds like lecturing in Europe is like talking in an echo chamber, (or a big circle jerk, ultimately meant to pat each other on the back). What biomechanic problem have YOU solved? What have the TST adherents ever solved? We've all seen your orthotics and they are pathetic, at best. I'd rather have my patients in generic, OTC insoles than those abominations you call orthotics. Those insoles provide MUCH better support and comfort than anything you make, I assure you of that. Oh, the wonders of socialized medicine...and oh the benefits of living in the UK.
     
  21. Jeff Root

    Jeff Root Well-Known Member

    No offense taken Simon. My passport recently expired and I haven't yet renewed it because I don't have any current plans to travel outside of the U.S. other than the possibility of vacationing in Mexico in which case I need to renew it by next year. In order for me to justify the time away from work (I don't take much time off although I do enjoy my timeshare in Hawaii) and the cost from a business perspective, I would have to have the expectation that the attending one of these conferences would improve our products or services to our customers. In other words, I would need to see a benefit that went beyond education for the sake of education, that would make a difference for my company. The only other reason I could justify attending would to be able to take vacation at my company's expense, which is not something that I normally do. For example, I could never justify spending company funds to attend a conference in Hawaii even though I enjoy vacationing there because there is no return on investment for my business.

    I'm currently having a discussion on Kevin's Facebook page with a gentleman from Spain who tells me he doesn't need to use heel bisections because he uses STJ axis location. I asked him to explain to me how he orients his positive cast in the frontal plane if he doesn't use a heel bisection. This was apparently a conversation killer since he hasn't answered my question. My ongoing frustration with the cry for change is that I don't see practical application in foot orthtoic therapy, or at least in the way foot orthotic therapy is done in the U.S. If somebody as vocal and active a writer and lecturer as Kevin hasn't, by his own admission been able to change how podiatrists practice in the U.S., then what would be the benefit of me learning theories and techniques that I can't apply in my business?

    I have tried to derive educational benefit from the podiatry mailbase and the Podiatry Arena, which I have. I think it is important for me to understand, or at least to attempt to understand, those who have a different perspective on and approach to biomechanics and orthotic therapy then I do. I do this because it is important for my career and I enjoy it intellectually, perhaps more than most podiatrists I know do. One of the biggest criticisms PFOLA heard about our conferences was that they were too esoteric and they lacked practical content that practitioners could take home and implement in their practices. Outside of attempting to counter some of the anti Root rhetoric so that readers can see a different perspective, I try to glean bits of knowledge from the PA that will make me better at what I do. As for entertainment, there are much better ways I can spend my time.
     
  22. So, in the near future you won't be spending any time outside of the USA just for the fun of visiting new places, to experience new architecture, new works of art, new cultures, new foods, new peoples, new languages and to generally enhance your education and experience of humanity? In order for you to travel outside of the US (your passport must have run out some years ago now, because you gave me a similar answer, frankly: some years ago now) it somehow has to be tax and or work deductible? Wow. That's a shame. Never mind- your family would reap massive rewards from it. Shame. Out of interest, when was the last time you visited Europe to attend a seminar?
     
  23. Jeff Root

    Jeff Root Well-Known Member

    Tell me how many other lab owners or employees who are not podiatrists, do you see engaging in biomechancis discussions like we have on the PA? I think I have invested a lot more time and effort in my biomechancis education than most. When I attended conferences as an exhibitor I try to attend any lecture that relates to what I do, and even a good number that don't. I found the dermatology sessions at a recent conference very enlightening. The other orthotic lab exhibitors/owners almost never come into the lecture hall.
     
  24. What I'm saying Jeff, and I know you don't feel comfortable with the idea, is this: the USA is no longer the global leader when it comes to podiatric biomechanics (nor podiatry as a whole). The statements you make are only regarding meetings in the USA, because you don't travel outside of the USA (Canada at a push). I think you need a more global understanding of where we are at: social media aside, you need to step out of the hometown comfort zone. The conferences you attended were in the USA... the rest of the world has moved on and beyond the USA of late. Renew your passport, come see what the world has to offer. BTW, you didn't answer the question: when was the last time you visited Europe to attend a seminar?
     
    Last edited: Mar 6, 2018
  25. Jeff Root

    Jeff Root Well-Known Member

    Podiatry is very different in the U.S., in part because it has become an increasingly surgical specialty. So I would say that U.S. podiatry is a leader in some areas of podiatry such as surgery, but not in other areas because of the focus on surgery. While I haven't attended any conferences in Europe, I do feel like I have a fairly good understanding of what those seminars have to offer due to the nature of the discussions on the Podiatry area and from talking to people who have attended some of these conferences. I have also talked to a number of foreign lab owners and I was told that TST hasn't had any real impact on their operations as well. IFAB is in the U.S. this year but I don't plan on attending because I don't see it providing me with any real practical education that I can apply in the day to day of running of my foot orthotic lab. Perhaps I'm wrong, but I don't see it being a benefit unless it changes our manufacturing practices and standards or improves how we communicate with our clients.
     
  26. Jeff Root

    Jeff Root Well-Known Member

    Simon, what do you think I would learn that would enable me to justify the cost of attending a conference in Europe?
     
  27. I do give Jeff Root a lot of credit for being one of the custom foot orthosis lab owners here in the US that tries to stay current on biomechanics. He is probably more knowledgeable on podiatric biomechanics than 90% of US podiatrists, most of who are much more interested in foot and ankle surgery, than in being experts in foot orthosis therapy.

    Jennifer Smith, owner of Precision Intricast, is also quite knowledgeable and teaches even at the podiatry school in Arizona, in addition to having podiatry students rotate through her lab to teach them about orthosis manufacture. These are very valuable lessons for the US podiatry students of today.

    Jeff's continued interest in the subject of foot orthosis therapy and biomechanics, which is much more than the vast majority of US podiatrists, says a lot about how US podiatrists are gradually losing interest in biomechanics. Like Simon said, the US is no longer the leader in podiatric biomechanics, especially research-wise, but we certainly continue to have a few of us that continue to contribute. However, as far as podiatric surgery, the US is still the best in the world, as least in my opinion.

    All in all, it is my hope that this thread can continue in a constructive and positive manner for the good of Podiatry Arena. When I see that "NewsBot" occupies 75% of the recent threads here in PA, with so few people commenting, I'm afraid PA is not what it used to be, with people slowly losing interest. Too bad, because PA has been such a good friend to many of us for so many years.
     
  28. Jeff Root

    Jeff Root Well-Known Member

    Here is the reply I received to my above question:
    "I use current biomechanics, I recommend Dr. Kirby's books. I'm not going to give you classes on Facebook when the knowledge is in the books. I encourage you to read current bibliography, as well as scientific articles currently published of great scientific evidence".

    This exemplifies my frustration in trying to communicate with some of the people who subscribe to TST. I didn't mean to put this person on the defensive. I was sincerely interested in knowing how he would orient a cast in the frontal plane without the use of a heel bisection. It seems like a simple question that should have a simple answer for anyone prescribing or manufacturing orthoses.
     
  29. Jeff Root

    Jeff Root Well-Known Member

    Thanks Kevin, I appreciate that. I know we have areas where we agree and where we disagree. I do wish that the podiatry colleges in the states would do a better job of teaching biomechanics and that they would seize on the opportunity to do more real research and help find a better path forward.
     
  30. The problem with the US podiatry schools is, by the time podiatry students have done their four years of podiatry school are ready to go to their surgical residencies, they are all $100,000-$200,000 (or much, much more) in debt and only interested in trying to get a good surgical residency so they can pay off their student loans. In addition, unless the surgical residencies make a research project mandatory to graduate from the residency, the residents would probably rather do other things with their little free time. Then, by the time they finish their 4 years of podiatry school and 3 years of surgical residency, they haven't casted for but a handful of foot orthoses in the last 3 years, done little to no orthosis adjusting and been given little instruction in orthosis biomechanics. In other words, they lack confidence in their custom foot orthosis knowledge and don't know where to go and get good training in these skills.

    Therefore, it's not necessarily a lack of training in podiatry school but, rather, a lack of training in biomechanics and orthosis therapy during their 3 years of surgery residency that makes the current graduates so poor at biomechanics and custom foot orthosis therapy. And the only ones to blame are those podiatrists in authority here in the US that decided a few years ago that all podiatrists needed 3-year surgical residencies to practice podiatry here in the States. I expect that within 20 years here in the US that pedorthists and physical therapists will be better qualified to make custom foot orthoses than young podiatrists.

    Unfortunately, I hear from patients every week the comment that they are worried where they will go for custom foot orthosis therapy when I retire. I tell them that I will plan on training someone to take my place when I retire. However, in the back of my mind, I wonder if I will be able to find a young podiatrist who is interested enough in being a foot orthosis and sports medicine specialist to spend the time needed to be trained properly. We will need to wait and see what happens.
     
  31. Jeff Root

    Jeff Root Well-Known Member

    Kevin, I can't argue with any of that. In addition, the podiatry schools don't seem to have much money for research because they are small schools. By the way, I recently referred a podiatrist to contact you about possibly getting involved with you and your practice because he is interested in biomechanics and likes the area.
     
  32. Trevor Prior

    Trevor Prior Active Member

    Jeff, I hope this does not come across as arogant but, I have been to many conferences / courses and meetings over the last 35 years around the world and learnt much. These days, I rarely go to a meeting expecting to learn much more and, if I can take at least one thing away, then I feel it was worthwhile. HOWEVER, what I always gain is the imeasurable benefit of the informal discussions and dialogue that are had away from the presentations / in the bar (my preferred option). I never fail to gain from this as one can get so much more from a fluid discussion - one of the great failings of social media. If nothing else, it helps to crystallise my thought processes and often open up different avenues and, as much as anything, form an understanding with those with whom you are having the discussion.

    I would be very surprised if this were not the case for yourself and would encourage you to travel for this reason alone.
     
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  33. Trevor Prior

    Trevor Prior Active Member

    There is no reason a lab cannot use a bisection for manufacturing orthoses, it is just the releavnce. So, generally, we will take a corrected position cast when there is a more mobile foot type so that the cast captures the mobility available. We will ask the lab to balance the cast as it sits, i.e. not to apply any correction from that position. We ask for no cast dressing and may ask for some intrinsic midtarsal control depending on the amount of 'control' (this goes back to my original question on terminology) / the amount of force we want to apply to the foot. We will then ask for the degree of rearfoot control we require.

    The lab can apply a calcaneal bisection so they have a reference point about which to apply the control but whther or not this reflects the true bisection of the posterior calcaneus is irrelevant as it is only necessary to allow the adaptation. It is also does not rely on any stj neutral position. It still provides a device that could be provided by someone who follows Rootian assessment criteria but this needs no reference to STJ netural or accurate bisection.

    I use tibial varum, foot mobility and relaxed stance position to help me in my decision making process but do so without any need to reference STJ neutral.
     
  34. Petcu Daniel

    Petcu Daniel Well-Known Member

    I dare to think it is not mainly a problem of terminology but one of, let say, history / habit. Practically, it will not be used a 15 Shore material for high degrees of required control because it is intuitive it will be deformed under the body weight (in fact the orthoses will not produce enough ORF to counteract the action exerted by the weight force). Also, how "close" the material will be in relation with the foot will be easier to be internally represented and assimilated with "control" than with the "force" applied by the material to the foot, because at the end it is easier to be measured when the cast modification are done. But if the initial curricula and literature were focused on "control of motion" and the term was used a long period of time I think it will be hard to be easy replaced with something difficult to measure as the "force" is.
    I think it is something like a reflex. Probably with "support" it is the same situation
    Daniel
     
  35. If nothing else it would give you the opportunity to experience the state of play outside of America.
     
  36. Jeff Root

    Jeff Root Well-Known Member

    In the lab we need to use as exacting terminology and well defined techniques as we can so the practitioner can communicate the orthotic prescription to the lab. I don't know what "intrinsic midtarsal control" is in terms of how it could be prescribed on an Rx form.
     
  37. efuller

    efuller MVP

    Jeff, I've answered that question here on the arena. Do you remember what I said? Did you have a problem with what I said? I do find it interesting that Root theorists keep claiming that tissue stress is an extension of Root/neutral position biomechaincs. Yes, tissue stress uses some of the same tools as Neutral position biomechanics, but we use a different reasoning. Sometimes we arrive at the same prescription and other times not. Tissue stress does use orthotic shells, intrinsic forefoot valgus posts, the concept of a partially compensated and probably many more things. The tissue stress orthotic will look very similar to the neutral position orthotic. The major difference is just in the explanation of why it works.

    Jeff, would you like me to repeat how I would communicate with a lab without using a heel bisection? I can see how it would be hard to remember what I said. During the sagittal plane debate I kept looking at what they were saying through the tissue stress lens and just couldn't remember their counter argurment to a particular point.

    Eric
     
  38. Jeff Root

    Jeff Root Well-Known Member

    Eric, I know how you do it but I don't know of anyone else who uses your technique. The reason I ask others the same question is to see if they have a different method than you or the commonly accepted heel bisection method developed by my father.
     
  39. rdp1210

    rdp1210 Active Member


    So, Kevin, I decided to try to do something about the problem than just complain on PA and Facebook.
    1. I became a CPME residency reviewer representing the ABPM.
    2. I decided to become a residency director and submit an application to start a residency program.

    I am all in favor of all podiatrists receiving the same post-graduate residency program. All orthopedists complete the same residency and then do fellowship training. If you wanted to really do something about the problem, you have enough money that you could start a biomechanics fellowship and fully fund it. In fact you could fund more than one program Set it up as as the premier program. You were the recipient of others doing it for you, it's time for you to pay it forward.

    Daryl
     
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