Clinical Measures/ Indicators

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Learned Colleagues,
I am interested in the clinical measurements that biomechanically minded Podiatrists around the world use.
There are numerous studies which suggest that measurements such as calcaneal bisections and RCSP/ NCSP are not accurate... and may not be valid anyway.
However I know that many people around the world still use these... and report good clinical results based on these measurements.

So... my question is this-
What clinical measures do you use? and Why?- how do the measurements you take (if any) influence your treatment/ prescription?

For example-
I measure STJ inversion/eversion in a NWB position. Why? I like to have an idea if there is any instability or laxity and see if there is any apparent assymmetry. If there is restricted ROM, I know that are likely to be less tolerant of aggressive rearfoot corrrection.
I still measure RCSP and NCSP. Why? I do not really pay too close attention to the absolute values, but am interested in the relative values- How far does the subject move from 'neutral' into the resting position. I also look at how much further the subject can pronate... are they at end ROM?
I also look at supination resisitance, ankle dorsiflexion and static WB restriction of the 1st MTPJ, but there is no clear measurement of these.

I am wanting to put together a foot assessment as part of a screening protocol for elite and sub elite athletes. This has the potential to be turned into a prospective study.
I have access to such tools as a Vicon system, Emed and Pedar, however I want to make this as 'real world' as possible. I am interested in ideas from clinicians, researchers and all those in between...
Do you have a couple of favourite measures? even if you cannot measure it... I am still interested!

Please don't be shy, and if you are, then you can always PM me.

Cheers

 

We now don't measure anything because:

1. They are almost all unreliable
2. They are not predictive of dynamic function or orthotic responses
3. Even if we did measure, we don't actually use the numbers for anything
4. In most cases we do not even know what normal is (eg the myth of 10 degrees at the ankle), let alone sport or activity specific numbers
5. We treat patients with symptoms and don't treat numbers.
6. There is no evidence that you get better outcomes if you measure vs not measure

We do make a number of observations and collect impressions that go into explaining dynamic function, deriving an orthotic prescription and (hopefully soon) predict orthotic responses.

 

Thank you for your quick response Craig!
However, in your eyes, just because there are no accurate or valid measurements currently, does that mean that there cannot be??
What about variables that cannot be measured? If you could easily measure Supination resistance or Jack's Test would you do it? Or is this just the domain of research?
Are there any variables that you wish you could measure??
Cheers,

 

Craig T

>However, in your eyes, just because there are no accurate or valid measurements currently, does that mean that there cannot be??

To be fair to Craig , he did give a direct answer to your question. I am certainly in total accord with his response.

>However, in your eyes, just because there are no accurate or valid measurements currently, does that mean that there cannot be??

I suppose the probability is current models are not appropriate and the absence of valid and reliable data means a return to the drawing board to rethink the kinematic and kinesiological models if more dependable data is required. It may be the answer does noit lie here however.

To continue to ignore poor data in the hope one day it can be shown to be something else, would be none scientific and a nonsense. I had the experience of working with a colleague who spent his entire professional life collecting random data about childrens feet only to realise at the end of his career as an acknowledged podopaeditrician, he could do nothing with the data. To be fair to him his data collection followed the conventions of the time.

>What about variables that cannot be measured?

Variables beyond measurable parameters would necssitate a rethink of the hypothetic model.

>Are there any variables that you wish you could measure??

Yep, the placebo effect of foot care.

toeslayer

 

Craig T

I have evolved to doing these measurements.

ASIS to the Ground in neutral and relaxed position
PSIS to the Ground in neutral and relaxed position
Passive dorsiflexion with the foot in neutral position

I don't get numerical data, even though it is easy to get the values. The reason is let's say I find a low ASIS and PSIS in relaxed position and restricted dorsiflexion on that side, this tells me to check for a subluxed cuneiform or less commonly another foot subluxation. Correcting this will change the values, so the original numbers don't really matter.

Regards,

Stanley

 

Foot Posture Index

 

We measure a lot as part of out research to see which measurements are related to predicting dynamic function and which one can be used for prescription variables in foot orthoses that do change outcomes. Translated into clinical practive, these measurements become observations. We are looking for the 'holy grail' of a few that are really predictive.

For eg, at the ankle, they either have subject specific adequate or not-adequate range of motion for their specific activity levels. Who cares what the actual value of ROM is? We treat the adequacy/inadequacy, not the number.

 

I have no problem at all with Craig's response- I am well familiar with a lot of the studies that he has been involved in and fully expected a reply along those lines.

Perhaps I should have worded this differently...
Are there any characteristics that as a clinician you look for, but do not or can not measure?- it may be due to difficulty with accuracy, time, or perhaps because it is subjective.

I am sure there are many hypothetical models floating around in the minds of practitioners out there that may never see the light of day unless they decide to publish their ideas. A good example could have been Kevin's STJ axis location and rotational equilibrium theory had he not gone to the effort of publishing. I am sure there are more out there that we may not be familiar with.

I am not aware of any prospective studies that includes variables such as supination resistance or resistance to dorsiflexion of the hallux (correct me if I am wrong)- generally they look at kinematic variables when it comes to the foot which have questionable validity. Perhaps we can address this?

 

Stanley,
I find the ASIS/PSIS landmarks to be very unreliable- especially PSIS. More than 2/3 of my patients are too "meaty" to palpate any part of the pelvis. Also. placement of the tape measure is inaccurate, given the subtle differences that usually exist. What device to you use to measure??
Nick

 

Craig,

I agree with you and only use my goni on radiographs. However, I still teach the measurements to students because it forces them to look closer at the angular relationships between segments and understand the geometry. Telling students to "eyeball" something will ultimately result in a cursory glance and less thought. I could be wrong, but I found that my biomechanical exams were more thorough when I took the time to measure. How do you incorporate "visual estimation" into your teaching?

Nick

 

Nick,

First of all if you are using a tape measure, I assume you are measuring with the patient lying down. This is very unreliable.
There are a few tricks to finding the PSIS. First of all if you expose the back, it acts as a double check for the PSIS, as a line connecting the PSIS's is perpendicular to the spine. Have the patient bend over, and the PSIS becomes more prominent. Press your thumbs in under it and move upwards until you hit the shelf. Have the patient stand erect, with your thumbs in the same place so you can evaluate for blockages of sacro-iliac motion. Now look and see if the PSIS's are parallel to the ground. For measurement of the difference, place a prescription pad under the heel on the side of the low PSIS. Remove part or add another prescription pad until the PSIS's are level. Then measure the thickness of what you placed under the heel.
I have been measuring the PSIS out of habit, and have recently stopped using it. The PSIS is an indication of the levelness of the sacrum, is the important measurement for lift therapy.
The ASIS is also palpated the same way with the patient standing. I have never placed lifts under the heel to evaluate the amount of shortage, as this is not an important number. This ASIS is used in conjunction with the PSIS to determine what is occuring at the Ilio-sacral joint. Currently, I find this to be the important measurement with the foot in neutral and relaxed stance position. Correlating this with the side that has the restriction of dorsiflexion gives the whole picture.

Regards,

Stanley

 

I do some and some. As much as i would like to abandon numbers all together the powers that be insist on some form of what they think of as hard data and i don't have the heart to tell them just how unreliable / unrepeatable those measurements are.

LLD, Sup resistance, RSCP, NSCP, muscle strength etc i do not try to put a number to. As Craig says one number or another makes very little difference to my treatment plan and these are elements i find particularly difficult / unreliable to measure.

Pain scales,Tibial varum, Sagital plane ankle dorsi, Sagital plane ankle dynamic catch, HAV angle i do measure and ascribe a number to (although with a healthy cynicism about the reliability of the measurement). I choose these mainly because these are values which might well change through the course of treatment so it's good to be able to track them.

However i agree with Scorpio that there is value to teaching students to try to measure these things. Eyeballing can be an easy and useful technique with experiance but until you have a vague idea what abnormal looks like it is a tricky one and in the meantime i find a goniometer helps people to get their heads around it.

A good magician can amaze you with a pack of cards. When you start out you need the mirror boxes, collapsable rabbit, box with stars on it etc.

But thats just me

Regards
Robert

 

Colleagues:

I cannot agree with those who want to do away with all measurements. I feel it is very valuable for both podiatry students and for podiatrists to be taught to make measurements on the patients they evaluate biomechanically. This does not mean, however, that you need to measure the hip range of motion to within a degree, or that you need to measure the subtalar joint range of motion to within a degree. However, I do believe it is very helpful to have a systematic approach for the recording of data on a patient's foot and lower extremity structure, range of joint motion, muscle strength and gait function.

Why is the recording of measurements important?

1. It allows the podiatrist to compare one individual's structure and function against another in a systematic, numerical fashion.

2. It provides for a quick method for the podiatrist to systematically check for normal and abnormal structural and functional parameters within their patient's foot and lower extremities.

3. It proves that biomechanical measurements were performed for insurance company reimbursement and medical-legal purposes.

If podiatry wants to go back to the Pre-Root days of "1st, 2nd and 3rd degree flatfoot" as the standard method to quantify the structural and functional anomalies of the foot and lower extremity of the human population, then so be it. However, this would be a huge step backwards for podiatry, in my opinion.

In my own hands, these measurements allow me to compare one foot against another in a systematic fashion, are reliable and reproducible, and only take about 5 minutes to perform. That is not to say that my measurements are the same as another podiatrist's measurements. But my measurements are useful for me (and my patients) as a way to determine which structural and funcitonal parameters are most abnormal in a specific patient and then allow me to have data by which to make the most informed decision on how to mechanically treat the patient's specific mechanically-related pathology of the foot and/or lower extremity.

 

Hi Kevin,

What measurements would you take as part of your biomechanical assessment?

Thanks

Declan

 

Supine examination:

1. Internal and external hip rotation (estimate to within 5 degrees)

2. Malleolar torsion (estimate to within 2-3 degrees)

3. Ankle joint dorsiflexion with knee extended and flexed (no assistance from patient, STJ neutral, approximate 30 pound load on anterior forefoot, estimated to within 2-3 degrees)

4. Hallux dorsiflexion without first metatarsal plantar loading (relative to plantar foot, approximate 10 pound load on plantar interphalangeal joint)

5. Reduction in hallux dorsiflexion relative to #4 above (with approximate 10 pound load on plantar first metatarsal head)

6. Estimate plantar fascial bowstringing (to within 1 mm, 10 pound load on both plantar first metatarsal head and plantar hallux interphalangeal joint, with MPJ dorsiflexed 10 degrees)


Prone examination:

1. Calcaneal inversion/eversion relative to tibial bisection (tibial bisection = knee joint center to ankle joint center)

2. Forefoot to rearfoot relationship (relative to heel bisection, STJ neutral, lateral forefoot loaded with approximate 10 pounds of force)

3. First ray range of motion (using approximate 10 pounds of force on first metatarsal head, measure maximally dorsiflexed first ray position, maximally plantarflexed first ray position and resting first ray position)


Standing examination from posterior:

1. Resting calcaneal stance position (to 1 degree)

2. Maximal pronation test (estimate number of degrees from maximally pronated STJ positon)

3. Posterior superior iliac spine assessment.


Standing examination from anterior:

1. Estimate STJ axis spatial location.

2. Estimate medial longitudinal arch height.

3. Anterior superior iliac spine assessment.

4. Supination resistance test.


Walking/running examination: (See lecture notes below)

In-office gait evaluations are kinematic analyses of the patient performing the weightbearing activity that may be the etiology of their symptoms or pathology.

In doing a gait evaluation, what structures should have their movement patterns (i.e. kinematics) analyzed?
 Feet
 Lower extremities
 Trunk
 Upper extremities
 Head

How should these motion patterns be analyzed?
 Analyze in reference to what would be present in an individual with a normal gait pattern
 Analyze in reference to history of presenting complaints of the patient
 Analyze in reference to findings on physical examination

What is the best method to perform in-office gait evaluations?
 Have the patient walk both barefoot and in shoes
 Have the patient walk looking straight ahead, arms/hands in normal position
 Have the patient walk at their normal walking speed
 Make sure the hallway is adequately illuminated so that accurate observations may be made

Method of clinical analysis of gait evaluation is important. Every gait evaluation should be performed in a methodical manner to ensure completeness by analyzing the following parameters in a stepwise progression:
 Position and movement of head
 Position, movement and asymmetries of shoulders
 Position, movement and asymmetries of arms and hands
 Position, movement and asymmetries of hips
 Position, movement and asymmetries of knees
 Position, movement and asymmetries of legs
 Angle of gait
 Base of gait

Position and movement pattern of calcaneus relative to the ground and leg should be noted during the stance phase of gait:
 Contact phase
 Early midstance phase
 Late midstance phase
 Propulsion

Position and movement pattern of the area of the foot inferior to medial malleolus in the medial midfoot should be noted since the area is a good indicator of talar head position
 Talar head position is excellent indicator for spatial location of subtalar joint axis
 Talar head movement indicates subtalar joint and midtarsal joint movement patterns

Important to note the timing of certain gait events:
 Heel lift relative to heel contact of contralateral limb
 Point at which maximum medial talar head position occurs during stance
 Point at which maximum everted position of calcaneus occurs during stance

Propulsion should be classified according to length of time the forefoot is bearing weight without the heel on the ground
 Apropulsive gait
 Moderately apropulsive gait
 Mildly apropulsive gait
 Propulsive gait

Movement patterns noted during gait examination can be used to analyze possible physical cause of injury that is occurring in the structural components of the patient’s foot and lower extremity
 Helps determine the abnormal forces and/or moments which may be causing the patient’s pathology or injury
 Allows trial-and-error determination of optimum foot and/or shoe modifications necessary to establish more normal movement patterns of the foot, lower extremity and rest of the body
 Allows clinician to observe and clinically quantify the functional result of therapeutic modalities such foot orthoses, in-shoe padding, taping, and shoe modifications
 Allows clinician to observe and clinically quantify progression of healing from injury

 

Wow Kevin Thats a lot more than I do. Very impressive.

Do you make it home in time for dinner??

Nick

 

I don't always perform the maximum pronation and supination resistance tests, only sometimes. If the patient is significantly obese, I use the iliac crests instead of ASIS and PSIS during standing to assess leg length.

The supine, prone and standing examination takes about 5 minutes. The gait examination takes 1-2 minutes. On busy days I am doing these procedures along with plaster casting for orthoses 7-10 times a day. However, after 22 years of doing this and teaching it to many other podiatrists/students, I am very quick and efficient.

BTW, dinners are never missed.

 

Kevin,

After reading your posts, there are several questions that are raised by it.

Why would you want to compare it to someone else? If someone else has a patellar tendonitis of his left and your present patient has a plantar fasciitis of the right, how does one help the other?

Reimbursement is individual to the insurance companies and most do not pay for it, so most podiatrists I know in my area do not do it or bill for it. If the tests are not reliable, then billing for something that is not meaningful is not ethical. What concerns me more is the idea of a medical legal problem. I have never heard of anyone being sued for not doing a biomechanical exam for making orthoses. To be sued, the plaintiff has to have an expert who tells the jury that the defendent is not within the standard of care. An expert is usually a flea brained parasite that thinks his is the only way to do it and everyone else is not as smart as he is and doesn’t care what everyone thinks about him. He would have to get up and tell the jury that it is the standard of care to perform a biomechanical examination, even though the flea brained parasite might be the only other one in the country doing it besides you. There are many experts like this exists in surgery, but I don’t think there is anyone in biomechanics that fills all of those requirements.

With all the talk about how motion and position is old and not useful, how do you quantify each of your measurements to your modern concept of rotational equilibrium

For some reason, I have a hard time thinking it would take me 5 minutes to do your examination. I notice you said you evaluate the iliac crests in patients that are too large to palpate the PSIS and ASIS. These patients take 2 minutes just to lay down prone from a seated position, and take another 2 minutes to stand up. It takes a minute to explain that they have to walk barefoot on the floor without slippers. Then there is the 30 seconds to tell them to be quiet and pay attention so the tests can be performed. Walking? Unless you get all the information in one pass, it would take two minutes to do this. How do you get them to move so fast. Do you give them free coffee? Do you have your staff do all you writing?

I didn’t notice the muscle strength test. Where are they in your 5 minute examination?

What exactly is your ASIS and PSIS assessment? After 22 years of doing standing evaluation of the ASIS and PSIS, have you ever noticed they are not high on the same side? If so what do you do about it in your orthosis.

Obviously you can be asked the following type of question for each component of your exam, but I will ask only about the first thing mentioned in your exam. If one patient was to have 60 degrees of external hip rotation and the next patient had the exact same exam, except he had 55 degrees of external hip rotation, how would your orthosis be different?

I am also sure you have the skill to make a perfect cast. If the cast captures forefoot to rearfoot relationships, then why check the forefoot?

Sincerely,
Stanley

 

Hi Kevin,

Thank you for your detailed answer,

Declan

 

Hi Kevin,

I know its a big ask but could you please explain how the results of your biomechanical examination influence your treatment plan. You obviously measure / assess many parameters when treating a patient but I'm interested to know how each of these parameters affects your treatment or orthotic prescription.

many thanks

Amanda

 

Firstly- thank you all for your responses.
Kevin- That is exactly the sort of thing I was looking for... actually even more detail than expected!

I would suggest that this information on its own probably means very little- but it may make you suspicious of some kind of hip pathology or simple muscle tightness- you may then test further to see if there is any asymmetry or if it may simply be an error of estimation.
I can't speak for Kevin, but I also do an assessment of a lot of these parameters... but I would not necessarily note down all of my findings. I would, however, note down anything that may be significant. These may not necessarily affect the orthotic prescription directly, but may be very important with respect to adjunct therapies, and even whether other practitioners may need to become involved (if they are not already).

My original question was to try and get an idea of things that Pods observe that make them think 'I can help this person'. I would like to think that most contributors on this forum have gone beyond 'I can help because they have a RCSP 4degrees everted so they must have 4 degrees correction on their orthoses'.
There are many practitioners out there that, through experience, have devised therir own tests that may not nessecarily have been taught.
I want to focus on one test mentioned...

I am interested in your technique here Kevin. I think I do a similar test where I ask the patient to try to pronate their feet without lifting their toes or bending their knees. Some subjects with find this difficult irrespective of the height of their arch- I suggest that this indicates a foot functioning at close to end ROM ie: bad. Agree or disagree anyone??

 

Craig:

The maximum pronation test was first described in the chapter on flatfeet that Don Green and I wrote for Steve DeValentine's book back in 1992 (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992). I believe we have discussed it several times here on Podiatry Arena. When I lecture on the test, I say that if the patient can pronate less than 2 degrees, then you can assume they are maximally pronated. It is helpful at determining what the STJ rotational position is during relaxed calcaneal stance position.

Here is an excerpt from the chapter (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992):

The photo below from 17 years ago illustrates the technique.

 

Dear All

I'm not sure why there is a trend towards not measuring and recording the measurements. When using the term measuring I mean using formal or standard international values such as SI, Metric, Imperial etc. However if one simply looks or feels and records a visual / palpable estimate as a grading or guide peculiar to the examiner EG High, medium, low, or 1,2,3,4,5,6,7,8,9,10. a little bit, not much, a lot. etc etc, how is this better or more useful than a standard measurement. How does today’s 'not much' or grade 2 ankle dorsiflexion compare to tomorrows 'not much’ or grade 2 on a different subject, or next year when one's perception of the quality of a certain parameter has changed. Surely these are far more ambiguous than using a formal or standard measurement system. Sometimes it is not easy or convenient to measure with precision and a more general grading may be useful eg the stiffness or compliance of a joint is not easily measured but the clinician can by convention or experience record an estimate of how it feels.

However when we treat our patient we are all trying to change some parameter or other. In order to make a quantified change we must have a point of reference.
In order to have that point of reference we need to measure from somewhere to somewhere else. How we express this measurement does not matter but at the end of the day any grading system is a measurement. The usefulness of a standard system is that it can be communicated with precision even if the original recording was not precise or even accurate. If we need to make a further change to the same parameter then we again can make a more precise statement of the amount of change required.
We need to communicate our data inter and intra personnel. When we review our recorded data 2 months later will we know what we meant by 'not much' ? When a student reviews a mentors notes how will they interpret 'a low' 1st mpj? How does a 'slightly valgus' forefoot equate to the amount of posting required for an orthotic prescription?

Here's an example.

Today I had a patient, a 60year old female, who suffers chronic inflammatory demyelating polyneuropathy (CIPD). She has loss of motor control of peroneals and dorsiflexors but GSC is strong. I grade the muscle strength relatively and according to my experience. EG GSC strong = 10 peroneals = 0-1 dorsifexors = 3-4. You can probably get an idea of the muscle strengths. But what about the rearfoot position and the rearfoot to f/foot alignment.
Because of the muscle imbalances the malleoli are internally rotated on the left leg. (do you know how much if I do not communicate a precise measurement. Lets say ‘normal’ torsion is 20dgs external. This subjects is 10dgs internal IE 30dgs total internal rotation. The ankle complex and foot is therefore adducted and inverted. At max eversion the calc is still inverted IE:-
Left calc very inverted f/foot extremely valgus - what does that mean?
Many different pictures in the minds of all those reading I suspect.
But now how about if I say calc 12dgs inverted and f/foot 20dgs valgus.
Does this give a similar picture to everyone? I suspect it does. I scan the semi weight bearing foot and add or reduce by millimetre and degree the amount of correction I want too the scan model. This is recorded and I can repeat this prescription precisely time and time again.

BTW she has seen many specialist previous to me who have made Boots, AFO, ankle braces, FFO and none of them stop her foot from supinating onto its lateral border, causing pain and very difficult walking. No one seemed to realise that the STJ axis is extremely lateral to the point of heel ground contact and any lateral heel posting, even on the boots as a flare is useless or worse since GRF or the heel - boot interface force always produces supination moments.. None had thought to post the fore foot, which is lateral to the STJ axis and the only point that pronating moments can be applied by GRF. (I may have to eat my word but we will see when the orthoses are fitted) Maybe they didn’t measure anything, by what the woman told me they did not. Maybe that’s a tale in itself.

So I believe that, where possible to use, a formal measurement system allows for, useful reference points, precise inter and intra personnel communication, less ambiguity, repeatable changes.

I think the reason for shying away from formal measurement is that there is a perception that as inter and intra clinician formal measurements are / may not be precise IE not reliably repeatable then they are invalid and not useful.

I believe this is a red herring and until we can come up with a system that is precise, standard measurements are still very useful and reliable enough for our purposes providing we use then as a flexible guide and not as a rigid dogma.

At the end of the day whether we characterise a certain parameter with precise measurement or a perceived / empirical grading system they are / can both be useful. Perhaps this is what we should ask ourselves was the data collected reliably, what are the limitations of our data and data collection and most important is the data useful.
All the best Dave Smith

 

I timed myself today doing two biomechanical examinations his morning. The first one was a 35 year old female school teacher with medial tibial stress syndrome during running and second one was a 69 year old retired man with plantar fasciitis. Time taken to perform supine, prone and standing exam above, including writing in all values (done by myself with no assistance) = 4:00 minutes. Time taken to perform gait examination = 1:00 minute.

Sorry, I'm a little faster than I said that I was previously.

 

As always David- you are someone who clearly thinks a lot during an examination! I think the saying 'Don't throw the baby out with the bathwater' could apply.

I would like to go back to the Maximum Pronation Test

Do you agree that a foot does not have to be in obvious valgus to be maximally pronated? I often see pathological feet which are not picked up because they are not 'flat'. Unfortunately the Foot Posture Index does not really

The thing I like about this measurement is that it is not necessarily an absolute measurement. Much of the error with RCSP and NCSP depends on the bisection line, and then the assessment of neutral.
In this case, the number of degrees from RCSP to Max Pronated Position (MPP) should be relatively repeatable so long as it is measured from the same line. If, at a later stage, you measure again, and your bisection is not the same, you should still be able to repeat the measurement accurately as you are looking at the number of degrees between the 2 positions. If you looked at the value of the final position of the MPP (ie how valgus the heel is) you would have the standard problems of repeatabilty because of the bisection.
Is anyone aware of any reliabilty studies related to measurements of the MPP?

 

Craig, I am unsure about your point about the error from RCSP to NCSP compared to RCSP to MPP. If you are measuring a difference, then the bisection accuracy is equally unimportant in both cases. Your point about the assessment of neutral seems relevant only to non podiatrists, as we are supposed to be able to find neutral.

Regards,

Stanley

 

Hi Stanley
I agree- but the problem is that 'neutral' is a position where you are relying on finding a position, and then getting the subject to hold while it is measured. I am confident in my accuracy and I am sure that you and most of the contibutors to this forum also are. However reliability studies suggest there are inherent inter-rater innaccuracies, and part of this is due to the discrepencies in finding neutral. I would expect that the process of finding the maximally pronated position would be less infleunced by the judgement of the practitioner.
Another issue, that Craig P often mentions, is that there are also questions as to how relevant the STJ neutral position actually is. Perhaps this is a more relevant clinical measure?
Cheers

 

Craig,
We are 99% in agreement . I agree that having a patient hold any position adds to inaccuracies, and I agree that everyone thinks they know where neutral is, and I agree that everyone's neutral may be different. I also agree that finding MPP does take out the influence of the practitioner, and I agree that STJ neutral may not be very relevant. The only thing I disagree with is that MPP is more relevant than NCSP. I don't understand how knowing a foot can pronate more or less from relaxed stance will make you change your orthosis.
NCSP to RCSP position, even though there is inter-rater unreliability, shows the relative amount of pronation (even though the examiner may not be accurate, one can tell if there is a mild, moderate, or severe amount of pronation). If nothing else, it can tell you not to correct more than the perceived difference of NCSP and RCSP, even though you may never obtain this amount (and even though inaccurate). I can see how NCSP to RCSP would be meaningless if you will not change the position of the foot with your orthoses. This brings up the questions: 1. Why cast in neutral if it is debatable that the doctor really knows where neutral is and this position is irrelevant? 2. If the forefoot evaluation is dependent on neutral position, and STJ neutral is inaccurate and irrelevant, then what is the relevance of this test. 3. If the dorsiflexion evaluation is dependent on neutral position, and STJ neutral is inaccurate and irrelevant, then what is the relevance of this test . I guess this brings us to: 4. If the biomechanical examination is inaccurate and its basis (STJ neutral) is irrelevant, then why measure?


Regards,

Stanley

 

Craig

I feel that this is an important question and one I revisit periodically.

A couple of indicators not previously discussed which I place considerable weight on when ranking a list of differential diagnosis for certain conditions utilize high resolution diagnostic ultrasound and regional plantar force measurement.

There have been enough studies done to establish normal values of dimensions and appearance for many musculoskeletal foot structures including ; plantar aponeurosis, tendo-achilles with associated bursae, and posterior tibial tendon.

This allows for fairly unequivocal judgments to be made regarding the integrity of these structures.

The value of regional plantar foot measurement for force/time integral, peak pressure and temporal spatial determination I think is less certain.

Normal values have been acquired for many facets of these investigations but they are far fewer in number and I do not feel provide, in most cases evidence, which to date can confidently be regarded as unequivocal.

I have however found some of these measurements useful to quickly identify potential sources of musculoskeletal overload.

An example is examination of midfoot force/time integrals.

Dorsal midfoot pain is a relatively common problem which can be caused by a variety of injuries. Particularly with intermittent episodic pain I find physical exam may provide insufficient clues on which to start a treatment plan.

Plantar pressure measurement allows for very useful examination about how the metatarsal/cuboid calcaneal/cuboid joints might be functioning during stance and I feel give me insight which would otherwise be hidden.

Clinical use of plantar pressure measurement I feel would benefit some discussion on this forum, and I would love to get into some discussion on this if there is anyone out there who might feel similarly, perhaps we could look at midfoot force/time integrals as a starting point for more detailed discussion.

More broadly is it necessary or desirable to take these measurements?

Sometimes I can say that the results have surprised me by contradicting my prior notions and my treatment plan has been modified according, sometimes the results have confirmed the impressions from pre-existing physical exam, sometimes it has caused me to consider something completely new. It is certainly helpful when treatment plan is not working to be able to add or subtract useful evidence from the equation.

Hope this adds useful grist to the mill

Regards

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
Phone [204] 837 FOOT (3668)
Fax [204] 774 9918
www.winnipegfootclinic.com

 

Stanley,
I don't know whether of not it is more relevant... it is simply something that I have been thinking about due to research (see Craig Payne's posting above) which questions the importance of RCSP and NCSP.
I still assess NCSP and RCSP!

Calling Bruce Williams, come in Bruce Williams!

 

Hi Craig! Please bring me up to speed on what you would like comment wise from me!

Sorry, only had a small amount of time to browse this thread.
Bruce

 

I would be interested if someone could follow up this component of the thread.
What evaluation method(s) is/are used to determine hip range of motion?
What information is gained from hip range of motion(ROM) evaluation which will alter orthotic variables?
Following from above does 5 degrees of hip ROM alter orthotic variables?

DaFlip
L.A - “If ya ain’t got it in ya, ya can’t blow it out.”

 

Hi Bruce,
I thought you might want to add something to Mart's post above about force/time integrals... a topic dear to your heart!
Cheers

 

First, thanks to Craig T for pointing this post out to me. My skimming of this thread blew right by it, and I thank Craig for the shout out.
Second, Martin raises some great points with this post. Namely, there is not enough literature out there to quantify the observations of many who regularly use plantar pressure measurements. This is unfortunate and hopefully will begin to be rectified in the future.

I think that there is quite a bit of data that has been collected by in-shoe pressures users like myself, Howard, George Trachtenberg, Simon, Craig and many others.

The nice thing about the collection of the data is that in general, the in-shoe collection without an orthotic will give data that can be examined in many ways that could be uniformly identified. The same goes for the recording with an orthotic device.

Howard has been teaching about the importance of F/T curves for many, many years. The 3 box technique that he utilizes gives a large amount of quantifiable data as to the sagital motion of the foot at it's 3 primary pivoting points, the heel, the ankle joint, and finally the mpj's. There is a 4th pivot point as well, as Martin talks about above, and that is the midfoot or midtarsal joint(s).

I recently delivered a presentation at the Western Podiatry Conference on motions at the midfoot and how they can be affected by a limitation of motion at the ankle joint or at the MPJ's. In fact, I was able to isolate a patient with heel pain who improved well from that only to end up with knee pain on the same limb! Once I utilized the in-shoe pressure system it was obvious that her motion at the mpj was fine, but she had stoppage of motion in the ankle joint / midfoot region. Video showed me that this was not due to a limb length discrepancy, but to a limitation of ROM at the Ankle Joint which then was compensated for by an early knee flexion. Once I utilized Howard's technique to manipulate the AJ, the patient immediately had a change in her F/T curves and has been free of her knee pain ever since.

I would love to work on a thread of this nature with you Martin and anyone else that would like to contribute. I know that Simon Spooner has alluded to an upcoming lecture at PFOLA on what I think is in-shoe changes caused by orthotic modifications. I'm not sure how a new thread gets started, but I would be happy to contribute my 2 cents along that line.
Cheers all! Thanks again to Craig T for the heads up! Stay cool Craig! ;-)
Bruce

 

DaFlip

Personally I check routinely,
1) Internal, external rotation hip RoM and
2) Hip flexion / extension RoM in terms of muscle length with extended knee and flexed knee.
3) Adduction Abduction in terms of muscle strength and active length. Passive RoM itself is rarely a problem I find here.

1) In terms of orthotic design, I am not interested in absolute magnitude of RoM only that there is enough Internal or external rotation available for normal gait and that the orthosis will not inhibit this.

3), 2) &1) In terms of a holistic intervention I would determine why there is restricted RoM or low strength and how it may affect the descending and ascending biomechanics then and give treatment or refer as necessary, usually physio or osteo.

In terms of orthotic design again, for example, often a functional LLD as a result of variations of hip position due to soft tissue changes can be resolved by a heel lift for a short period.


Cheers Dave

 

Dave makes a very interesting statement here. When observing LLD, functional or structural, I usually will see a certain type of compensation pattern. That being, somewhat supinated foot position, or less calcaneal valgus on the short limb vs long limb.

This does not alway hold true, as I'm sure Craig P. will chime in with results from his study!

Another interesting compensation that falls into David's thread is the patient that will have an external foot position on the short limb side, and / or a forward pelvic position ont he short limb side as well.

I fully agree with David that accomodating for the LLD will usually take care of this compensation depending on age of the patient, available hip and knee ROM, and any extent of hip or knee arthritis pain. Otherwise, the patients tend to do well with orthotic management of this less than standard LLD compensation.

Sincerely;
Bruce Williams

 

I sat on the fence for approx 10 years before deciding to take the plunge into use of plantar force measurement as a diagnostic tool. I was and now less so, skeptical regarding the value of this outside of research and marketing hype.

After talking to several critical thinking users, realised that it will likely be a while before the definative "users guide" for clinicians which I sought would be possible.

It still seems to be the case those using the technology responsibly (not as a way of impressing vunerable public with pretty coloured but otherwise useless computer generated foot patterns) are presently paving the way and some have been sharing interesting ideas.

I have over the past year of studied much of the published literature which uses plantar pressure measurement and have been attempting to integrate some of the ideas generated into my practice.

I still struggle somewhat in determining when my data interpretation is accurate and quite often what other measures are neccessary to validate the data.

I will be out of town for a couple of weeks, if no one else does so, I'll start a new thread when I get back to examine a case study which utilises plantar pressure measurement to mull over.

I will be interested to see how interpretation evolves with different viewpoints and what kind of limitations might become apparent.

cheers


Martin

Winnipeg

 

Bruce,

This is a common compensation seen in faster runners. A short leg can have an equinus compensation, which over time will result in pronation. An additional equinus compensation is an abducted gait. When this occurs, the result is a short leg with pronation. If this were to occur without some other factors, the result would be an even shorter leg. Fortunately this occurs rarely, and is accompanied with a severe trochanteric bursitis. What we see more commonly is an anterior innominate which functionally lengthens the leg at the Iliosacral joint. So the sacrum now levels. The problem this causes is some pain just below the ASIS. Treatment is to raise the heel and add orthoses, but for fun, just manipulate the lateral cuneiform and see what happens.

Regards,

Stanley

 

When I first started podiatry I worked for a practice that demanded everything be measured. Did this for 2 years. It really seems nonsense to me now, especially after beginning my surgical training. The exam should be specific to the complaint. Why do the same pelvis to foot exam for patient (a) who has ITB syndrome and patient (b) who has a plantar plate tear??


I find my consultations rely almost entirely on patient hx/ medical hx, radiographic assessment and specific physical examinations to make a Dx. All gait and joint ROM assessment I use visual observation.

 

Stanley;

you guys ( Howard, and Kevin M. ) keep talking about this one manipulation I have not yet witnessed. I look forward to seeing and utilizing this.
Bruce