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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. "Your game is old," Bala-Tik called out from the other end of the corridor. "you've played it too many times. your excuses wore thin many years ago. So many times, so many excuses. Everyone knows them now. I stand here before you and can recite in my head the excuses you are going to make before yourself can speak them. You are tired, Han Solo. Tired and old, just like your game. There is no one in the galaxy left for you to swindle." Only the names are changed to protect the non-innocent.
     
  2. Trevor Prior

    Trevor Prior Active Member

    Yep but we have precious little of that for our assessments. That's why I quite like assessment 'tools' that have demonstrated reliability and give an idea about position / direction and motion (i.e. FPI, Navicular or midfoot drop, change in midfoot width or navicular drift etc.) as this helps people appreciate the functional capacity; estimating positions such as tibial varum or the overall rearfoot position etc. which are unreliable to measure can also be useful in the process - feet and legs at the extremes are easy to appreciate, the less extreme, the less easy. I do not actually get people to draw lines when I teach as I prefer to take the approach that if you are not sure if it is inverted or everted for example, then if it is either way it is by a small amount so assume it is relatively straight.

    If I have a foot that I would perceive to function in a specific way based on my assessment and it does not, I want to find out what is influencing it to function differently. Then I might have a method of determining how my intervention may affect other structures.

    What is required is a logical and systematic way of determining this which can then be evaluated scientifically and refined as required. The concept that pure structure will determine function was destined to failure as there are so many factors that provide the resultant function - if we can determine a method that is reliable to help 'predict' function in this way, then we can really move forward.

    I do not wish to go over old ground but would prefer to look to see how we can move forward and start to provide a basis around how to predict what our interventions do to the structures we are not treating as only then, can we fulfill the 2nd and 3rd aims of tissue stress and perhaps manage more proximal problems..
     
  3. Jeff Root

    Jeff Root Well-Known Member

    A reference point with some degrees of variability is better than no reference point at all. I was on a hike a few weeks back. As we passed groups of people heading in the opposite direction we ask each of them how far it was to our destination. We got answers ranging from 1/4 of a mile to about two miles. Turns out it was two miles according to a Fitbit. It was much better having an estimate as to the distance to our destination than having none at all. For all we know, it might have been five miles had we not relied on the estimates of others. Most put the distance at 1.5 to 2 miles. A young girl, perhaps 12 years old was the one who estimated it at 1/4 of a mile. The experienced hikers had a good appreciation for the distance.

    While experience, in and of itself is not necessarily beneficial, the right experience can be. I have witnessed very experienced clinicians who could bisect the heel and estimate ff to rf very accurately and others who were not very accurate. For 20 plus years Root Lab would always record the ff to rf measurement that was measured by the lab on the Rx form that was sent back to the doctor. Sometimes the doctor would bisect the heel but in most cases, it was done by the lab. So the lab was usually blind to the doctor's findings. We had some clients whose measurements were consistently, extremely close to those reported by the lab. Other clients were not as close. So yes, even a monkey can bisect the heel accurately, so long as the monkey listens, studies and applies the same technique.
     
  4. Dude, a reference point which is invalid, unreliable and unspecific is of no use at all- that is what the Jarvis study and numerous other studies have shown regarding your father's measurement system... get over it, move along, your dad was wrong. And ya'll wonder why I get disappointed. "Science is the antidote to the poison of enthusiasm and superstition." How much longer are you going to defend when the science says the opposite, Jeff? You and your ilk are holding my profession back. Time to move aside, don't you think?
     
    Last edited: Jun 6, 2017
  5. Great as long as you are not teaching them Root, that's cool with me.
     
  6. Jeff Root

    Jeff Root Well-Known Member

    So you're saying that the Jarvis study, which was based on an unreliable measurement (a heel bisection) is a valid study? If the heel bisection is unreliable, then so is their study and we can't accept their data or their conclusions. Please tell me how you create a valid study based on unreliable data?
     
  7. So you finally admit that your father's protocol is unreliable and cannot be used for scientific study then, Jeff? Reality check, your father's whole protocol is unreliable, invalid and unspecific.. as numerous studies have now shown; give up the argument. Accept the overwhelming weight of the scientific evidence... Except that you can't do that while the name brings you an income- right Mr Fireman? Anyway.. back to the question : an unreliable, unspecific, invalid measurement system that you state we should still use... because...? You ain't got nothing, fella. Perhaps you should think your next response through before posting it... yet answer the question.. you won't obviously.

    ABOVE ALL, STOP HOLDING OUR PROFESSION BACK FOR YOUR OWN FINANCIAL GAIN, MR FIREMAN.

    "Your game is old," Bala-Tik called out from the other end of the corridor. "you've played it too many times. Your excuses wore thin many years ago. So many times, so many excuses. Everyone knows them now. I stand here before you and can recite in my head the excuses you are going to make before yourself can speak them. You are tired, Han Solo. Tired and old, just like your game. There is no one in the galaxy left for you to swindle." Only the names are changed to protect the non-innocent.
     
    Last edited: Jun 6, 2017
  8. drhunt1

    drhunt1 Well-Known Member

    Blah, blah, blah....will the REAL Kevin Kirby please stand up? You point to an article you wrote 25 years ago...BEFORE you jumped on the TST train, and then expect u8s to forget what you've written and lectured about since you did? Gimmee a break! What you, Eric, Nester, Simon Spooner, (God Bless his tortured soul) and Payne have essentially done, is throw the baby out with the bath water...that, and "talking" out of both sides of your mouths. You can't have it both ways. Jeff asked you, Kevin...a very simple question...repeatedly...and that was: how many Podiatric lecturers here in the US are discussing/promoting TST besides you and Eric? A simple question, actually...but still no answers, (even though some of us KNOW it already).

    Can you direct me to a citation, paragraph, chapter or line when Dr. Root stated that his ideas would be "replaced" in 10-15 years? I was of the opinion that his work was to be EXPANDED upon and refined...NOT replaced. And fwiw...the UCBL is, (at least here in the US), as popular as medial skives to the positive casts.

    You continue to have a serious problem with calcaneal bisections. As I wrote above, few Pods I know actually take the time to perform this. As a learning tool, it should still be taught...until that student feels comfortable assessing the patient(s) without it. Like I wrote about in my article, (which, btw was peer-reviewed prior to publication...unlike most of yours listed above), a calcaneal bisection is a relative measurement...and forefoot varus by Root's definition should be replaced by the concept of forefoot to ground relationships. Is this way of thinking abandoning Root biomechanics...or is it further defining the foundation he laid out? Hmmmm....pretty easy call there.

    [BTW-I forgot that you trained under Donald Green...so no wonder you've avoided answering my questions about the "bullet-hole sign" that he previously wrote about].
     
  9. drhunt1

    drhunt1 Well-Known Member

    Tsk, tsk, Simon...pot, kettle, black? I believe it goes deeper than that...you've painted yourself in a corner using the broad strokes of TST...and you're in so deep you can't back away. While you'd like to make non-believers believe that they're not as smart as you...the reality is it's quite the opposite.
     
  10. Do y'know what? I've been really negative here. i should focus upon the positive rather than the negative: Jeff under the following headings 1) validity 2) reliability 3) specificity, could you please list the references which support your dad's "system" in each of these three key areas, then list the references which refute these...
     
  11. I see the tit-fiddler is back. Off of Podiatry Arena again then, we'll continue this privately, I've no doubt. This fella admits that he performs a breast examination which he states is necessary before foot surgery... your choice. I rate Trevor Prior as being among the best foot surgeons in the UK; Trev, when was the last time you performed an examination of the breasts of one of your patients who had elected for surgery on their feet, like Dr Hunt aka Matthew Sciaroni does? This fella just shows up to kill a debate; like Jeff wants him on his side right now. For the record, while Jeff and I don't agree I still respect him, as for Matthew Sciaroni- I wouldn't trust him to sit the right way around on a toilet seat- you just keep feeling those tits before you cut open their feet, fella. Weirdo. Google: Matthew Sciaroni
     
    Last edited: Jun 6, 2017
  12. drhunt1

    drhunt1 Well-Known Member

    Only in your world, Simon, is that reference line of "no use at all". To the rest of us, it's a starting point. One must acknowledge, however, why you, Kevin and (not so much Eric), is so "passionate" about this topic...why get so defensive? I'll tell you and everyone else why...it's exactly like Jeff stated...all of you have a vested interest in promoting this newer mouse-trap...and you perceive that Jeff is dipping into your rice bowl. However...let me remind you that Jeff just follows the Rx of other Podiatrists with minimal feedback...so he is NOT holding you back. Here's a News Flash: YOU are holding yourself back...quit blaming others for your deficiencies, (although I must admit your two-tone brogues you wore when you danced with Kevin were smashing). Look...don't worry about others rice bowls...just concern yourself with solving huge problems...like what I did. Don't get wrapped up in clever drive-by's when the reality is, we're supposed to be working for a common goal(s). <sigh>...I don't believe this will occur though...based on how you treated me years ago before you put me on ignore. Your ego is the problem, Simon...not Jeff, not me, not Merton Root. Take a hard look in the mirror....you still believe "fake news". But for sure...you demonstrate very transparent tendencies when anyone backs you into a corner. Thank you, again, for making that so obvious.
     
  13. Google: Matthew Sciaroni
     
  14. drhunt1

    drhunt1 Well-Known Member

  15. Jeff Root

    Jeff Root Well-Known Member

    For the record Simon, I was a firefighter (the term fireman is sexist and outdated) for eleven years. I was a volunteer for about a third of that time before I became a chief officer and the fire district insisted on paying me. I don't know what my experience as a firefighter has to do with this topic but I did become and EMT/D and gain a lot of experience in emergency medicine. The fact that I own an orthotic lab doesn't mean that I'm arguing to preserve a vested interest. Your motives and my motives are irrelevant anyway. What is relevant is the content our debate and discussion and the strength of our individual argument. Let's stay focused on that and leave personal attacks, insults and condescending behavior out it.

    Back to the debate. If Jarvis e.t. a.l. believe that heel bisection is unreliable, then how can they use an unreliable technique in their study and expect to produce reliable data? In the limitations section of the study the authors wrote:
    "Our reliance on one assessor to define the foot deformities therefore reduces the external validity of our study. However, controlling for known sources of variability in data is a prerequisite for quality research. If we had allowed more than one clinician to define the deformities the research outcomes might have been due to our inability to consistently define the deformities being investigated, and consistency is known to be better within one assessor than between several assessors [22]. Indeed, the fact that the assessments vary so much is simply a further problem with the Root model rather than an issue in our research. Indeed the presence/absence of the deformities concerned can be dependent upon the clinician a patient sees rather than that actual arrangement of foot structures [13]. The high prevalence of some deformities likewise could be a result of bias in the assessor. However, given the poor reliability of the measures, this is again an issue with the reliability of the Root model rather than our research design. Involving more assessors to account for any assumed bias would have compromised our ability to identify the deformities as the independent variables in our research design".

    As you can see, there are serious questions about the validity of the study's design and the results are dependent on one clinician's findings. By the author's own words, the deformities they identified may be different had a different examiner done the examination. If they can't get a consensus of opinion that the deformities they identified actually exist, what does that say about the design of the study? This is indeed problematic.
     
  16. The fact that I own an orthotic lab doesn't mean that I'm arguing to preserve a vested interest. Your motives and my motives are irrelevant anyway. [/QUOTE]
    It's not that you own the lab, it's that you own the name, surely? If it were my dad (and this is why I pointed out your lack of ownership of parentage previously) I'd fight my father's corner to my last breath. Which is what you have to do. It's a fucker Jeff but there it is. Anyone who knows the score and you, understands the cross that you have to bear and realises the position you are in. Do I support my dead father's legacy or try to branch out on my own? As a in your words "fire-fighter"; everyone knows that you didn't follow your old man into the game Jeff, and to be honest, who'd blame you? but your Dad wasn't always right, science has moved on, and it might be time to let go of certain ideas for the good of the profession.

    You must see that your argument now is that your fathers protocol is not good enough to perform a scientific study... well that's got to be the end for the protocol, surely?

    Fella, the fact is that multiple studies have now shown that your father's ideas were inadequate. We can argue the minutia, but at the end of the day, the weight of evidence falls to your dad's ideas being wrong. I'm sorry, but that's just how it is. Any chance we can move forward now without having to perform breast examinations on our patients in order to define the rearfoot posting angles on our orthoses?

    Anyway, back to the plot before that breast examining podiatrist Matt Sciaroni aka Dr Hunt got involved: Jeff under the following headings 1) validity 2) reliability 3) specificity, could you please list the references which support your dad's "system" in each of these three key areas, then list the references which refute these... I think this is important here.

    Anyway, we can finish this conversation privately without the likes of the breast examiner Dr Hunt being involved.
     
    Last edited: Jun 6, 2017
  17. efuller

    efuller MVP

    Jeff, we have been offering an alternative. You are right that we have not officially published the alternative. However, the alternative has been written about here on podiatry arena.

    One of the concepts in the Root prescription writing protocol is to not try and evert the foot farther than it can go. I agree with this concept. This idea is not related to neutral position. I disagree with the notion that you can figure out how much eversion range of motion there is from the Root measurements. This is because the forefoot to rearfoot measurement is done in neutral position and when the STJ is more pronated than neutral, the forefoot to rearfoot relationship will be more everted. So, when the STJ is not in neutral postion, in stance, it would be wrong to use a forefoot to rearfoot measurement done in neutral position. This is why I proposed the maximum eversion height measurement. This is a stance measurement looking directly at how much eversion range of motion there is of the total foot. When you see eversion range of motion you add an intrinsic forefoot valgus post that is equal to that height. There is still measurement error with maximum eversion height, but it is so much less than with heel bisection measurements.

    Another measurement that is done with tissue stress is palpation of the location of the STJ axis. There have been studies on the repeatability of this measurement. You can rate the position of the axis as more medial than average, around average, and more lateral than average. Those that are more medial than average, get a medial heel skive and those that are more lateral than average get a lateral heel skive.

    How to communicate what I want as a clinician to the orthotic lab: Say I send a cast that the lab technician would have determined that there was a perpendicular forefoot to rearfoot relationship. If I saw a maximum eversion height of 3mm, I would ask for a 3mm intrinsic forefoot valgus post. When you put that forefoot valgus post on the cast the heel bisection will evert. Say I saw a medially deviated STJ axis in this individual. I would then ask for a 4mm medial heel skive to overcome the three degree everted position of the heel and the net effect could come out to what would look like a 2mm medial heel skive, on a vertical heel bisection cast, as you set the cast on the table.

    Not every foot should be treated the same. Different feet need different orthotic variables. This is another good idea that comes from Root biomechanics. However, the neutral position measurements are not the best ones to use to explain why feet are different. That is what the Jarvis study is telling us. There are already some studies looking at STJ axis position and prediction of supination resistance. This is why tissue stress is, at this point in time, a better system to use than the Root paradigm.
     
  18. Trevor:

    Here are the goals of Tissue Stress Theory that I have excerpted from the book chapter written by Eric Fuller and myself (Fuller EA, Kirby KA: Subtalar joint equilibrium and tissue stress approach to biomechanical therapy of the foot and lower extremity. In Albert SF, Curran SA (eds): Biomechanics of the Lower Extremity: Theory and Practice, Volume 1. Bipedmed, LLC, Denver, 2013, pp. 205-264).

    "Third, a mechanical and therapeutic treatment plan must be formulated that will be most effective at accomplishing the following goals of treatment for each patient: 1) reduce the pathological loading forces on the injured structural components, 2) optimize overall gait function, and 3) prevent any other pathologies or symptoms from occurring. The appropriate use of the tissue stress approach allows the astute clinician to efficiently and effectively treat even the most difficult mechanical pathologies of the foot and lower extremity."

    1. How do we determine that pathological loading forces have been reduced on injured structural components with foot orthoses?

    Answer: The patient reports less pain with weightbearing activities over time, there is less swelling, less signs of inflammation, increased strength to testing and/or improved pain-free range of motion on clinical examination.

    2. How do we determine that overall gait function has improved with foot orthoses?


    Answer: The clinician determines if there is decreased antalgic gait, increased gait symmetry and the patient reports improved endurance to ambulatory activities over the course of orthosis treatment.

    3. How do we determine that other pathologies or symptoms have not occurred as a result of foot orthoses?


    Answer: The clinician follows the patient over the ensuing months and years to assess for any new subjective complaints or objective evidence of gait pathology that could have resulted from foot orthosis therapy.

    I don't understand, Trevor, why you believe that Tissue Stress orthosis goals #2 and #3 "remain unanswered". All clinical medicine is about making educated guesses about how a patient will respond to a specific treatment, trying to predict whether that outcome if positive or negative, and then following up on the patient over time to see if the treatment plan is helping the patient or not. I know of no branch of medicine that can predict 100% the results of their treatments. Then why should we, as specialists of the foot and lower extremity, be expected to be able to predict 100% how patients will respond to our foot orthosis treatment?

    When you make foot orthoses for your patients, Trevor, do you know, all the time, how the gait will change or whether new pathologies will result over time or not? How then are the three orthosis goals listed above any different than what most of us already try to accomplish in podiatric practice?
     
  19. cpoc103

    cpoc103 Active Member

    Finally thank you Eric, this is exactly what I was after. Whilst I do not do many of the root measurements anymore i.e. Ff varus/ valgus- rearfoot, heel/ leg bisections etc etc, I still use some of the static measurements for ROM and QOM, so that I can use this to determine better joint position motion etc. but I will use heel to leg bisection angle (as a guide) as a reference point, but use my gait analysis software to do it, and during gait rather than static, as has been stated above for where to start, then add or decrease correction.

    Eric you have been the first to actually show some form of a measurement to aid you in your prescriptions, rather than just picking an angle out of thin air.

    Kevin I am very grateful for the articles, and Trevor very grateful for your insights. As something you said (and I think Kevin mentioned) really hit home for me and reassured me as to what I'm doing clinically is in fact not complete bullshit lol.
    Which is 1)clinicians need to have a solid understanding of anatomy and physiology, to enable them to Dx exactly or close to what is going on/ causing pain. I see too many pts who have seen lots of clinicians but have never had a Dx. 2)the basic understanding of mechanics to determine the root causes of the issues, 3) the sufficient knowledge and skills to enable us to prescribe a Rx plan to solve the issue. I pride myself on these 3 aspects, I try and give every pt a Dx and if I cannot refer to who can!!

    Also Trevor, not sure what you mean about not sure points 2&3 have been answered. Surely this can be based on pain reduction, return to normal daily and sporting activities, improved gait symmetry, just saw Kevin's post lol WHAT he said.
    As an outsider to the internal nuances between certain clinicians on here, I have to say that I can see where and what Jeff is saying also, to me it appears that he also does not follow Root et al theory to the letter as he states uses skives exts and so on!!

    Cheers
    Col.
     
  20. drhunt1

    drhunt1 Well-Known Member

    It's not that you own the lab, it's that you own the name, surely? If it were my dad (and this is why I pointed out your lack of ownership of parentage previously) I'd fight my father's corner to my last breath. Which is what you have to do. It's a fucker Jeff but there it is. Anyone who knows the score and you, understands the cross that you have to bear and realises the position you are in. Do I support my dead father's legacy or try to branch out on my own? As a in your words "fire-fighter"; everyone knows that you didn't follow your old man into the game Jeff, and to be honest, who'd blame you? but your Dad wasn't always right, science has moved on, and it might be time to let go of certain ideas for the good of the profession.

    You must see that your argument now is that your fathers protocol is not good enough to perform a scientific study... well that's got to be the end for the protocol, surely?

    Fella, the fact is that multiple studies have now shown that your father's ideas were inadequate. We can argue the minutia, but at the end of the day, the weight of evidence falls to your dad's ideas being wrong. I'm sorry, but that's just how it is. Any chance we can move forward now without having to perform breast examinations on our patients in order to define the rearfoot posting angles on our orthoses?

    Anyway, back to the plot before that breast examining podiatrist Matt Sciaroni aka Dr Hunt got involved: Jeff under the following headings 1) validity 2) reliability 3) specificity, could you please list the references which support your dad's "system" in each of these three key areas, then list the references which refute these... I think this is important here.

    Anyway, we can finish this conversation privately without the likes of the breast examiner Dr Hunt being involved.[/QUOTE]

    Once someone lowers themselves to the point of ad hominem fallacies...it only means they have lost. In your honor...just substitute falling for calling:
     
  21. cpoc103

    cpoc103 Active Member

    Here is a really good article I found some time ago on the net, for anyone following this debate other than above.
    I found it useful.
     

    Attached Files:

  22. The Root system of foot function assessment is invalid, unreliable, lacks specificity and lacks sensitivity. That is what the weight of scientific evidence tells us. That's not just me saying it, that's many, many research studies from around the globe, carried out by some of the most highly regarded individuals: Invalid, unreliable, lacks specificity, lacks sensitivity, yet people still want to use it- mental. Only in podiatry would the evidence base be so blatantly ignored. Incredible.
     
    Last edited: Jun 7, 2017
  23. I do understand your point Eric, but maybe we need a different approach Sure I have not been on this duscussion for 20 or 30 years, but the 10 I have been I am quit bored of it, so maybe starting a discussion at another starting point may lead to somewhere.
     
  24. I will make a point here, of the 10 000´s of devices made in the world weekly, how many use a system that helps define the prescription values?

    Probably not that many once you scratch the surface, the patient may get information, and the person prescribing the device may think they have all the answers, but they probably don´t.

    But here is the issue, patients get better, 10´s of 1000´s of them. Bent bits of plastics, formed bits of EVA and other materials, even rolled up bits of toilet paper.

    The way I like to think of what we a really debating here is prescription protocols, not Biomechanics , anyone who thinks there needs to be Poditric Biomechanics is missing the point, there is Biomechanics, the international field plan an simple.

    So if there are 10´s of 1000´s of devices given out weekly around the world not using any system but working, the next question should be why are they working?

    Reducing the load on damaged tissue, would be probably the answer of most here ( I assume)

    Then the next step might be How is the load being reduced? and this is where I think using mechanics is the only way to move forward. But people might want to look at it through the Root system, but there will be huge issues.

    The reason I like the Tissue stress approach is it can be used to look at how a rolled up bit of toilet paper has a positive result on a patient because it looks at mechanics/Physics as a ground.

    So while if I say 1000´s of successful devices are prescribed daily world wide that do not use Root system and many go against what Root et al have written on how to design a device indicates to me that the Root system is not the way forward.

    The argument will of course be that Tissue stress was not used either, no it wasn´t but the mechanical thinking is Tissue stress is much more likely to be able to describe how the the device " worked " .

    So while Root et al work is very important in Podatric history it is just a small drop in the world of devices that " work " everyday for patients world wide
     
  25. drhunt1

    drhunt1 Well-Known Member

    cpoc-my experience in private practice is: keep it simple. Biomechanics is not as hard as many want you to believe...especially the TST advocates. We now have entered the digital era, and have been here for some time, (something Dr. Root never had a chance to appreciate before or during his research). Since you appear to be impressed with Kevin's contributions in Podiatry Today, Podiatry Management and Intracast newsletters, (all non-peer reviewed articles, I might add), let me offer you something I wrote and had published a couple of years ago.

    www.podiatrym.com/pdf/2015/4/SciaroniHight415web.pdf

    Here's a couple of digital animation videos I produced, (which I was excoriated for by the TST advocates, btw), that demonstrate how simple foot function really is:



    And here's the second:



    Production of these videos cost me a lot of money and time...yet the TST people couldn't bring themselves to appreciate my efforts. Think of the possibilities here. You'll see a couple of motions and sequences never before seen by Podiatry students or Podiatrists. It takes simple Root biomechanics a step further than what was available at the time Dr. Root et al., were writing/preparing their books. I believe it's a very good start...and the paper above offers a roadmap on how to successfully diagnose and treat GP's in children and RLS in adults. No other doctor and/or scientist has made the connection between the two before myself and Dr. Hight accomplished that...no one. A problem that was 194 years old has been identified and revealed. Am I done? Nope. Much more to do. Hope these help...
     
    Last edited: Jun 7, 2017
  26. Griff

    Griff Moderator

    Dr Hunt believes foot function is simple. Sure.
     

    Attached Files:

  27. Jeff Root

    Jeff Root Well-Known Member

    As an orthotic manufacture who needs practical solutions I asked Kevin if heel bisection is such an unreliable technique, what is a more reliable technique for orienting the positive cast in the frontal plane. When we manufacture a functional type orthosis, we use a heel bisection to determine the degree of forefoot varus or valgus in the cast and to place the heel bisection at a prescribed angle in the frontal plane. Placing the heel bisection in a prescribed inverted, vertical or everted angle not only determines the relationship of the plantar surface of the heel to the floor, it also influences the angle of the forefoot to floor and relationship of the medial and lateral arches to the floor.

    Kevin said that when he prescribes an orthosis he instructs the lab to place the forefoot at a prescribed angle to the floor and doesn't need to use a heel bisection. Let's assume that I was trying to advise a client who had not heard of Root theory and wanted to practice TST how to prescribe an orthosis for a given patient. What angle should I advise them to place the plane of the forefoot at and more importantly, since this is a hypothetical question, what should I tell them is the reasoning for placing the forefoot a given angle, what does that angle represent anatomically other than a random position (because I can't use ff to rf without a reference in the rearfoot) and how should the practitioner position the patient's forefoot and rearfoot when making a cast or scan of the patient's foot and what is the reasoning behind it?

    In the pharmaceutical world, there are many drugs with significant negative side effects. However in spite of those negative side effects, clinicians still prescribe these drugs and will continue to do so because of the benefit until a better drug, with fewer or no adverse side effects is made available. The same is true for Root theory. In spite of variability in technique, heel bisection's give practitioners a better alternative for assessing foot type/structure and prescribing functional type orthoses than simply abandoning a technique that has served them and patients very well for over fifty years. Since there is no practical alternative there is no reason clinicians should abandon clinical techniques that are proven effective. Fortunately for patients practitioners with common sense still prevail.
     
  28. If the drug company make a drug that kills people as a side effect, it's usually withdrawn. If the drug company makes a drug which doesn't work- it never makes it to market. Invalid, unreliable, not fit for purpose; that's what the evidence tells us about your fathers assessment technique as outlined in Vol. 1

    20+ years of this tired old debate, during which time the published evidence has grown which refutes Root's ideas; I can't think of one research study which has been published during this time which supports your fathers ideas. But you will never change your position ever Jeff (for obvious reasons) so it's like talking to a brick wall.

    The problem is, you are making a number of assumptions regarding foot orthoses due to you viewing the world through a certain lens. For example, you assume that a forefoot balance is necessary, you assume that said balance is having a kinematic effect on the foot, you assume custom orthoses are the only form of foot orthoses of clinical value, you assume that there are no other techniques to examine foot structure than those described by your dad I could go on, but I'm wasting pixels here. Anyway, pour the cast, use the top of the positive as a reference plane, rotate cast by the desired number of degrees- no heel bisection necessary...
     
  29. Jeff Root

    Jeff Root Well-Known Member

    Should foot and ankle surgeons also stop preforming surgery because there is variability in technique between surgeons and because there can be adverse side effects? The fact that a technique can have a degree of variability isn't justification within itself to not employ the technique. The totality of the situation needs to be considered. How many people have been seriously harmed by the use of foot orthoses made using heel bisection and how many people have been helped?

    At Root Lab we use the top of the cast as a reference and we know that it is perpendicular to the heel bisection when the cast is poured vertical or angle to the heel bisection by the degree of inversion or eversion of the heel bisection when the cast is poured inverted or everted. However, if you just pour the positive cast as it rests on the counter top and use this as a reference, it has no anatomical significance. So if you just pour the cast and use the top to orient the cast, what is the significance of that? How do you determine what angle, if any, to place the top of the cast at and what is the anatomical or other justification for that?
     
  30. A surgeon has to audit their outcomes, if a procedure did not work and was not fit for purpose, they would cease to use it. Invalid, unreliable, not fit for purpose- that is what the weight of evidence shows regarding the assessment techniques described by you father. It is not just the lack of reliability, nor the variability between examiners, it is that they are not not valid nor fit for purpose- this is what the Jarvis study and other studies over the years have demonstrated.

    You pour the cast so the heel bisection is vertical- what is the significance of that? (there's that lens again) When it comes to angles we guess- just like everyone else is doing, yourself included because foot orthoses are kinetic devices and angles aren't equal to forces. Ultimately by rotating the cast one way or the other we are manipulating the shape of the superior surface of the resultant orthosis and its stiffness; this along with several other factors will influence the reaction forces at the foot-orthosis interface.
     
    Last edited: Jun 7, 2017
  31. Jeff:

    If it makes you feel any better, I still use calcaneal bisections for one of the labs I use to order my custom foot orthoses. The problem is not the individual, experienced podiatrist using calcaneal bisections that they drew themselves to then use as a reference by which to order foot orthoses. I have no problems with using calcaneal bisections to order foot orthoses for patients and have been doing so for over 34 years with great success.

    The problem is that this calcaneal bisection, which may be +/- 5 degrees in error from one podiatrist to another, can't be used to accurately determine "forefoot to rearfoot deformity", "resting calcaneal stance position" or "neutral calcaneal stance position" since the calcaneal bisection measurement is, in itself, unreliable. Your father believed that there was only one true calcaneal bisection. However, the research has shown that for every podiatrist, there is so much inter-examiner error in drawing heel bisections, the measurements advocated by your father listed above that rely on an accurate calcaneal bisection are useless for predicting pathology and predicting gait function.

    That means your father was wrong about his idea that there was only one true calcaneal bisection. In addition, this also means that the other measurements that he based on the calcaneal bisection are unreliable and probably only useful for the experienced podiatrist who can use these measurements to get an idea of the patient's foot and lower extremity structure, compared to the other patients they have seen over the years.

    I do think that there are measurements and tests that can be done to help us better prescribe foot orthoses. Ankle joint dorsiflexion, position of subtalar joint within range of motion in relaxed bipedal stance, supination resistance test, maximum pronation test, subtalar joint range of motion and subtalar joint axis spatial location and, of course, gait examination findings are all tests/measurements I still do to better prescribe foot orthoses for my patients. I currently make about 70-90 pairs of foot orthoses per month in my practice.

    In the final analysis, we should all appreciate what your father did for us. However, we must also realize that some of his ideas about foot function and foot orthoses are erroneous. With that in mine, if we want to improve ourselves as a profession, we need to come up with better ways to evaluate foot structures so that we can continue to move forward intellectually in understanding the biomechanics of the foot and lower extremity and the biomechanics of foot orthoses.
     
    Last edited: Jun 7, 2017
  32. drhunt1

    drhunt1 Well-Known Member

    It's certainly more simple than YOU make it out to be...that's for sure. Like all people involved in any industry, we tend to make "things" far more difficult than they really are. That's a well known fact. For instance...when I presented this info to my cousin for editing...he reviewed the entire 42 page manuscript, plus all of the videos I had produced. He wondered why no one had figured this out previously. When I mentioned that professionals tend to make function more tedious and complicated than it really is...he laughed. He's an architect...the same rule applies to his colleagues.

    Perhaps foot function IS difficult for you. Oh well....
     
  33. Jeff Root

    Jeff Root Well-Known Member

    Kevin, your wrong about that. Mert believed that there was one good technique for bisecting the posterior surface of the calcaneus (anatomically that is what we are doing when you use Root's bisection by palpation technique, not bisecting the heel per se) and that an acceptable margin of error was plus or minus one degree. He believed that was an acceptable margin of error because he felt in most cases, making the orthosis within a reasonable range of the desired position (+1, 0, -1) was clinically adequate. Frankly, I'm disappointed and sometimes shocked when I see how poorly some practitioners bisect the heel. That's because they are not following the recommended technique and they aren't finding the shape of the posterior surface of the calcaneus via palpation. The are just eyeballing the shape of the posterior heel, not palpating the calcaneus, and that leads to huge errors.
     
  34. The problem, Jeff, is that it is impossible to be consistent "bisecting" a pear-shaped bone covered by skin and fat. The research proves that. Do you have any data that supports your father's idea that the margin of error of heel bisection was +/- 1 degree? I won't hold my breath. There is none.
     
  35. Yet we now know that actually we can get good clinical results without even taking a cast nor any measurements from the patients foot by simply employing a prefabricated device. How the knowledge base has changed in the last 50 years... move along, move along... in fact I'd wager that more off-the-shelf prefabricated devices are now employed globally per annum in the successful management of foot and lower-limb pathology than are made to measure custom devices. No measurements, no heel bisection, yet successful outcomes... what kind of biomagic is this?
     
    Last edited: Jun 7, 2017
  36. The mechanical angle finders employed back then probably weren't even accurate to within a couple of degrees, let alone anything else.
     

  37. And do they get positive results ? if so they is helps to answer the question of how important the Heel Bi-section really is, I get back to my point above, 10´s of 1000´s of devices with positive patient results are made not using Root techniques

    Personally I have not used a heel bi-section in 20 years
     
  38. Nor me.
     
  39. Jeff Root

    Jeff Root Well-Known Member

    Simon and Mike, do either of you use an outside orthotic lab or do you manufacture your own devices?
     
  40. Jeff, I use a selection of prefabricated devices, semi-customised or straight of the shelf, and I manufacture my own devices. Nearly 30 years of experience now in manufacturing. How long have you been involved, Jeff? Do you make your own? Or do you use a lab? Seriously, do you do any plaster work, any grinding? Anyway, that's your question answered. Jeff, perhaps now you could answer some of mine to you? Over the last couple of days I've asked you numerous questions, I don't think you've attempted to answer any of them.

    Here's a few you might like to address:

    Any scientific papers published in the last 20 years that support your dad's theories?

    Why do you employ a heel vertical bisection of the cast?

    etc etc.
    One more: how do prefabricated devices work without a heel bisection?
     
    Last edited: Jun 7, 2017
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