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Combination plantar fasciiitis and PTTD

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podtiger, Dec 10, 2011.

  1. podtiger

    podtiger Active Member


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    Hi All.

    Case Study for perusal.

    Background.
    47 year old policeman. 185 cm tall. 98kg. By his own admission he is unfit. You don't need to be fit to be a policeman these days.
    Spends a lot of time on his feet. Not much exercise outside of work hours. Has had heel pain(left) for 3 months. Feels it is gettin worse.

    Subjective

    Heel pain for 3 months. Sore in mornings and upon walking after rest.
    No other symptoms.
    Heel pain is strongest in area of med calc tub ad also posterior plantar surface of heel
    Had similar pain 10 years ago in same foot. Treated by another podiatrist with primarily orthotics and this seemed to resolve problem. He stopped using these orthotics once symptoms completely resolved. Now they are lost.


    OBJECTIVE

    First impressions are of a person with a high BMI


    Stance

    Very flatfooted!
    Abducted feet in transverse plane(L>R)
    Everted calcs(L>R)
    Verly low MLA's both feet. Navicular drop and drift(L>R)

    Gait
    Apropulsive. Left foot even more abducted. No resupination whatsoever.
    forefoot on left foot seems to be even more abducted on rearfoot.
    Eversion of calcs even more evident. Some teondoachilles bowing



    Joint ROM
    STJ. average ROM in right. slightly restricted in left
    Ankle Joint : below average dorsiflexion b/feet
    Midtarsal joint. L<R. right almost normal range of motion


    first rays. both feet normal range of motion. Seem to be in alignment with lesser MPJs

    Forefoot varus both feet very obvious

    Palpation

    Palpation of area of med calc tub ilicited strong pain response.

    Diagnosis

    Plantar fasciitis is immediate cause of pain in heel. Tib Post tendon Disfunction and extreme flat foot would be the root cause of this. I have not ordered Xrays yet but I think they may be appropriate considered biomechanical changes in both feet



    ACTION
    Stretches: Both calfs. MLA stretches

    Shoes. change from blundstone boots to laceup shoes both feet. Brooks laceup walkers would be appropriate.

    Applied adhesive padding to left shoe(varus wedge)12mm. This worked for 3 days and diminished plantar fasciitis type pain until padding squashed down. Obviously a lot of force coming through this area.

    Orthotic therapy discussed with patient. Happy to proceed.

    I have explained to patient my diagnosis of plantar fasciitis. He said he was diagnosed with this 10 years ago.

    I am in 2 minds as to orthotic therapy. Inverted or modified root with heel skive? I am definitely conscious of need to address significant biomechanical anomaly in feet but would like to resolve plantar fasciitis. Believe both are possible.



    Thanks for your time. Even if I don't get replies it has been nice to get off chest.
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. podtiger

    podtiger Active Member

    Thanks Admin 2. Thought I might have got a few more replies here. Hope the quick referral to previous threads hasn't veered people off from contributing.
    Cheers
     
  4. I would say that treatment for these 2 conditions is quite easy to achieve

    if we go back to what is causing the stress on the tissue and work from there

    Plantar fascia pain
    - elongation of the plantar fascia past what is normal elongation for that patient or excessive tensile load, also can be increased tensile loads at the wrong time or a combination of both

    - Kevin wrote about this the other week in Podiatry Today- ( point-counterpoint-recalcitrant-plantar-fasciitis-fasciotomy-ever-necessary ) - Compression at the insertion of the fascia

    Tib Post Pain

    Excessive loads on the tendon and muscle during gait - ie increased tensile loads which may lead to plastic deformation of the tendon a PTTD

    Causes of Plantar fascia and Tib Post issues - including


    - excessive pronation moments acting on the STJ
    -Elongation of the Medial longitudinal arch - which can be the result of or occur from many things such as increased tensile force in the Triceps Surea, decreased forefoot dorsiflexion stiffness, increased dorsiflexion moments, reduced midtarsal joint stiffness, increased dorsiflexion stiffness at the MTPJ medial to the STJ axis
    -medial rotational position of the subtalar joint axis.


    Treatment-

    Increase the height and stiffness at the MLA - BUT not too excessive that it causes compression pain.
    External STJ supination moment- BUT not so that is causes increased compression at the insertion of the Plantar fascia
    Decrease Dorsiflexion stiffness at the MTPJ medial to the STJ axis - but most importantly the 1st MTPJ due to the size of the Met head - Drum and due to the fact the medial band of the plantar fascia is more often injured.
    - decrease the forefoot dorsiflexion moment.

    How

    - Medial skive, with EVA external stabilizer.
    -Silicon or PPT/Poron under insertion of the plantar fascia to reduce compression at this area
    -increase arch height and contoured device
    -reverse mortons extension
    Forefoot Valgus Posting
    Triceps Surea stretching program

    the height the how much etc is up to you the practitioner to determine.

    Hope that helps and what you were after
     
  5. RobinP

    RobinP Well-Known Member

    Not much more to say than what Mike has already stated.

    The main thing that i would criticise in your case presentation, which was otherwise laid out well, was the lack of any information about kinetics. You are concentrating heavily on kinematic information to form a treatment plan.

    What causes plantar fascia(PF) pathology on the whole? As Mike stated, increased tensile load on the plantar fascia that takes it outside of its zone of optimal stress(ZOOS - has that been trademarked?) is the main culprit. The everted calcaneus or the forefoot abduction may well indicate pathological plantar fascia tension, but then again, they might not. How can we estimate how much tensile load there is on the PF?

    If there is PTTD, how can we determine what the residual forces are that the tib post is unable to provide?

    Both are kinetic tests that will give you an idea of the amount of force that will be required to reduce the forces on the pathological tissues. The next thing is to determine how best to provide the change in force. Using a specific device is just potentially limiting your ability to provide the necessary force.

    What prescription variables in an orthotic device will deal with the list of things that Mike made earlier
     
  6. musmed

    musmed Active Member

    Dear All
    Regarding the PF, just rely on history. I ahve over 40 cases where the thickness of the PF is less than 0.30mm. Radiology says 4.8 is the diagnostic point. I have seen a 10mm thick PAINLESS PF

    A question is how long does it take to develop? ThePF just will not go from 2.8+mm to 9 mm over night.

    shockwave therapy fixes about 60% of souls. When you watch demonstrations of their magic pulse machine, they say that they are on the PF. In fact they are on the abductor hallucis muscle.

    Last friday I fixed 7 cases of PF all of 3 to 9 years duration by dry needling the abd hall.
    Place an acupuncture needle in the belly of the muscle, leave it for 2-4 minutes, remove and stretch the muscle. You will will more than you lose!

    As regards PTTD. The tib posterior muscle does NOT hold the foot together. It is there to protect the joints it subtends. Nothing else.
    The foot is already shot. The short plantar ligs are already shot and there is nothing left to hold the foot together. Here the tib post works harder due to the increased distance it has to work over and eventually fails.
    The fibula in non mobile in all the cases I have seen. No on thinks about this but immobility changes the way the interosseous membrean works and thus how the tibialis posterior muscle works.
    Happy thinking

    Regards
    Paul Conneely
    www.musmed.com.au
     
  7. CraigT

    CraigT Well-Known Member

    Good post Paul!
    The important point is that the Abd Hall trigger point is often overlooked!
     
  8. CarlosJerez

    CarlosJerez Active Member

    The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis.

    Kogler GF, Veer FB, Solomonidis SE, Paul JP.
    SourceOrthopaedic Bioengineering Research Laboratory, Southern Illinois University School of Medicine, Springfield 62794-9652, USA. gkogler@siumed.edu
     
  9. CarlosJerez

    CarlosJerez Active Member

    Low dye tape is a really good treatment until you have made your foot orthosis
     
  10. markjohconley

    markjohconley Well-Known Member

    Goodaye Mike, this always gets me, apparently conflicting treatments, to both decrease STJ supinatory moments, and to ‘cushion’ the proximal plantar fascia attachment. I’ve never been happy when I use these together, should I be?
    I assume this would be through the use of the midfoot ‘arch’, but does the forefoot valgus (which I use a lot) lessen this?
    thanks, Mark
     
  11. Why not ? I don´t do it often but it depends on the palpation results and feed back, I usually add soft material at a review - but an extra tool in the tool box dependent on what is required. Changing the stiffness at the foot device interface can have positive results.


    only where the forefoot Valgus pad is not where the material is will increase the dorsiflexion stiffness the thicker and stiffer the material to greater the increase in stiffness.

    Happy New year Mark
     
  12. efuller

    efuller MVP

    It's hard to say whether the plantar fascia pain came before the posterior tibial pain. If you had post tib pain there might be less activation of the muscle creating a faster pronation velocity so that the plantar fascia would be stressed more when the medial forefoot hit the ground. Alternatively, the plantar fascia hurts and the person chooses to use the posterior tibial muscle more to relieve the pain in the plantar fascia....

    So, both orthotic choices should give you a varus wedge heel cup in your orthotic and you have already seen that this helps. The difference between these two treatments, depending on what the lab does, is the height of the medial arch. An inverted cast technique can have a much higher arch depending on the amount of arch fill in the cast. I've seen some high arched devices actually increase pain with posterior tibial dysfunction. The question is what is the source of supination moment in the high arched orthosis. The high arched orthosis can cause discomfort in the arch and this will cause the patient to use their posterior tibial tendon more. In feet with just plantar fasciitis this may be a good thing. However, in feet with post tib dysfunction this may be a bad thing. When the patient is in the chair, find the STJ axis. If the axis is extremely medially deviated, pushing up on the arch will not cause supination. In other feet, with more average position of the axis, pushing up on the arch will cause supination. The higher arched orthotic has a better chance of working in these people.

    Eric
     
  13. markjohconley

    markjohconley Well-Known Member

    Mike, doesn't adding cushioning decrease the medial wedge effect?
    and could you rephrase the second part of the reply, as i'm not sure i understand, thanks, mark
     
  14. Hi Mark
    from a phone so short message

    1.if you add ppt to your medial wedge it will add to the effect it can not descrease it. the softer material will compress more but it will still add to the wedge effect.

    2 if we are discussing reducing the dorsiflexion moment from GRF. Then if we add material we will have increased the dorsiflexion moment

    it all comes back to changing the GRF with a ORF

    hope that helps
     
  15. markjohconley

    markjohconley Well-Known Member

    Doohhhh, of course, what a drongo! And I've been worrying about this for years!!!!

    No worries with this one

    Yep, just couldn't click with point 1), as I was thinking that the PPT would decrease the force, whereas it changes the rate of loading

    Certainly has, thanks, Mark
     
  16. drsha

    drsha Banned

    PodTiger:
    Before I can comment on your very fascinating case, I could use the following updates where possible.
    I will post, no matter what so please accommodate where you can or feel pertinent.

    1. Is there a positive Helbing' sign on either side or relative assymetry?
    2. Is there pain underneath the navicular at the areas of the PT insertion or distally at its fan?
    3. Is there fhl and can you give me a grading I-IV?
    4. Is there a level of Ankle?STJ Equinus, pseudoequinus?

    Weightbearing x-rays would also be very helpful.

    Thank you, in advance.

    Dennis
     
  17. drsha

    drsha Banned

    I have waited three+ days for a reply from Podtiger, including a request by private message. I will proceed somewhat in the dark without his/her cooperation.


    Podtigers Case Study for perusal.

    Background.
    47 year old policeman. 185 cm tall. 98kg. By his own admission he is unfit.
    Spends a lot of time on his feet. Not much exercise outside of work hours.
    Has had heel pain(left) for 3 months. Feels it is getting worse.

    Subjective

    Heel pain for 3 months.
    Poststatic dyskinesia.
    No other symptoms.
    Heel pain is strongest in area of med calc tub ad also posterior plantar surface of heel (No pain under navicula or along PT Tendon)
    Had similar pain 10 years ago in same foot. Treated by another podiatrist with primarily orthotics and this seemed to resolve problem.
    He stopped using these orthotics once symptoms completely resolved. Now they are lost.


    OBJECTIVE

    First impressions are of a person with a high BMI


    Stance

    Very flatfooted! ( Are they flattening in the rearfoot, the forefoot or both ...perhaps a FFTing at this juncture may offer information)
    Abducted feet in transverse plane(L>R) (Asymmetry)
    Everted calcs(L>R) (Assymettry)
    Verly low MLA's both feet. Navicular drop and drift(L>R) (Perhaps a FFTing would at this juncture offer information).

    Gait
    Apropulsive.
    Left foot even more abducted. (Asymmetry)
    No resupination whatsoever. (PT Inhibition or PTTD?)
    forefoot on left foot seems to be even more abducted on rearfoot. (Asymmetry)
    Eversion of calcs even more evident. Some teondoachilles bowing (Helbings?)



    Joint ROM
    STJ. average ROM in right. slightly restricted in left (This is the most telling statement because is these ranges of motion reflect The Rearfoot SERM and PERM Tests of Functional Foot TYping then these feet, especially the left CANNOT PRONATE!! They would need higher ranges of motion in order to got beyond vertical in stance. This says to me that The Rearfoot Type (asymmetrically) is RIGID or Stable, not Flexible).
    Ankle Joint : below average dorsiflexion b/feet (There is Compensatory Equinus)
    Midtarsal joint. L<R. right almost normal range of motion (In what position? As changes in grf change the motions of the MTJ, this statement has little clinical significance for me. A Forefoot SERM-PERM at this juncture would offer more information).


    first rays. both feet normal range of motion. Seem to be in alignment with lesser MPJs (Accepting this as an examination of the first ray remains to be evaluated but for me, A forefoot FFT SERM-PERM test at this juncture is Mandatory. IMHO, Biomechanically it reflects the RF bias of West Coast USA Biomechanics and need upgrading)

    Forefoot varus both feet very obvious (For me, this adds no clinical significance as to treatment or pathology. A Forefoot SERM-PERM would be much more informative and blows away this Rootian diagnosis).

    Palpation

    Palpation of area of med calc tub ilicited strong pain response.

    (I requested it but there seems to be no pain under or around the navicula or the PT Tendon. So why PTTD)


    Diagnosis

    Plantar fasciitis is immediate cause of pain in heel.

    Tib Post tendon Disfunction and extreme flat foot would be the root cause of this.
    (I don't even think that there is PTTD in this case but on the other hand, probably PT failure or inhibition [see Melamed's comments]. I question where Podtiger..amd the other posters talking about PTTD and even PT pain (Eric:rolleyes:)
    Now here comes another highlight for me in Podtiger's presentation.
    Extreme Flat Foot as the root cause. Could this be any more infantile or biomechanically and clinically impotent?
    Stable rearfoot/Flexible forefoot FFT or Flexible rearfoot/Flexible forefoot is so much more clinically appropriate and much more universally understood by those participating, even if there is no evidence to prove it....compare the evidence at this moment for Extreme Flat Foot to an FFT diagnosis or etiology if you will!


    I have not ordered Xrays yet but I think they may be appropriate considered biomechanical changes in both feet

    (I asked for x-rays.none taken or presented ???...perhaps they are now available).



    ACTION
    Stretches: Both calfs. MLA stretches
    So architecturally, lets take this foot which is extremely flat and flatten it some more with stretches, night splints, EPF's, TAL's, etc. The tissue stress (TS) will reduce at the insertion of the plantar fascia and patient's chief complaint will be "cured" (like 10 years ago) and as a present to the patient and his future quality of life, his feet will become biomechanically weaker providing me with more chief complaints down the road in the plantar plate, t. achilles, knees, hips, lower back, 1st ray and digits as well as compensatory muscle engine pathology but I will deal with those new tissue stressed areas as they arise.

    Shoes. change from blundstone boots to laceup shoes both feet. Brooks laceup walkers would be appropriate. (I see no reason for any shoe modification in this case).

    Applied adhesive padding to left shoe(varus wedge)12mm. This worked for 3 days and diminished plantar fasciitis type pain until padding squashed down. Obviously a lot of force coming through this area. (The varus wedge ads 1/2 its thickness as lift so Podtiger what I think is TIP, short right with added lift, left. (He offered no treatment to the forefoot (Root, SALRE mental blockade. He offered no Vaulting. IMHO, Foot Centering Pads applied foot type specific would begin a biomechanical treatment, breakin and a test drive for how well I have diagnosed and how much and where my ORF;s shoudl be....no cookbooks here).

    Orthotic therapy discussed with patient. (What orthotic therapy? What's the plan? My FFT gives me a starting platform for my casting, Rxing, Compensatory training and Monitoring that I would discuss with the patient on the IOV and explain in my consultation letter to the referring sources)
    Happy to proceed. With What? a SALRE or TS cure for extreme flat feet?

    I have explained to patient my diagnosis of plantar fasciitis. He said he was diagnosed with this 10 years ago.

    I am in 2 minds as to orthotic therapy.
    Inverted or modified root with heel skive? (So I have a foot that has normal or reduced ROM on the frontal plane of the STJ...it can't PRONATE... and I am correcting is with supinatory moments with inverted, heel skived orthotics! Brilliant!
    I am definitely conscious of need to address significant biomechanical anomaly (what is the significant biomechanical anomaly? FFTing would tell you where and how much and give starting parameters for care) in feet
    but would like to resolve plantar fasciitis. Believe both are possible. (NOT WITH STRETCHING!)
    (Both are not possible as you are stretching these extremely flat feet even more. What would make this possible is if you could get these feet into a more Optimal Functional Position and then train the weak/inhibited muscle engines (Mesamud again) to be more powerful obviating the need for compensatory action (i. e. the TA).

    (I would add that there is P. Longus inhibition or poor leveraging as an immediate cause as opposed to a PTTD. There is PT inhibition or poor leveraging, there is T achilles overcompensation, tightness and major influence).

    Once held in a more OFP with a Foot Centering Prop, I would initiate P.Longus closed chain strengthening, PT strengthening and monitor the patient @ 2 weeks, 4 weeks, 8 weeks at which time, I would retest for PL and PT power and motor control and add physical therapy or addition vault or forefoot leveraging to my care (no cookbook here Wedemeyer, I am stating in my stalking tone:rolleyes:)

    Prop Casting:
    Frontal plane RF Correction technique
    Rearfoot vaulting technique if FFT rearfoot is Stable
    Forefoot Vaulting Technique
    Plantar plate correction (hammertoe) technique

    Prop Rx:
    Polypro 2-3 mm
    Plantar arch fill with 35 durometer crepe
    0-1 degree Rf varus posting
    1/8 heel lift, right
    Moderate to Aggressive 1st Met cutout, prn ROM's B/L
    Possible 5th ray cutout, B/L
    3-5 degree 2-5 FF Varus posting

    Compensatory Threshold Training:
    PT
    PL
    FHL
    AbdH

    Gait training and first mound counseling.

    Prognosis:
    excellent for plantar fasciitis
    Mild to moderate for correction of FFT

    If failed Surgery:
    Lapidus FFT specific
    Possible P. Longus shoring procedure

    Stretching or EPF or TAL negligent care IMHO in this case.



    This case of extreme flat footedness presenting with an iceberg tip of recurrent insertional plantar fasciitis, Podtiger is stating that it has a forefoot and rearfoot sagittal and transverse plane pathology and needs little to no frontal plane rearfoot care! yet that is what is being offered by the consensus posting here.

    Our opinions. testing, conclusions differ so much that one of us is clinically more powerful:rolleyes:.
    I await the judgement of time
    Dennis
     
  18. podtiger

    podtiger Active Member

    Hi DRSHA,

    Apologies for not getting back to you.
    Thanks for your contributions here. Along with everyone else
    I hadn't heard much after Mikes original post.I actually followed Mikes advice in terms of orthotic prescription and so far the results have been good. Thanks Mike. I realise now I didn't thank you for your original post.
    Will be seeing patient this Friday but I have talked to him via phone and he is happy with progress. I think it was one of those cases where I knew the direction of what I wanted but needed some fine tuning and reiteration.Your advice has helped this patient alot.

    This thread was a slow burner from the start and I had moved on until checking tonight. I have been on holidays and have made myself not check the internet to clear the head a bit. Works wonders. Now refreshed and ready for some more podiatric action.

    Happy to got through your points with you. You've performed quite an extensive breakdown here of my assessment notes that I've offered. You've shown extraordinary humility and I appreciate the time you've taken.
    I would also like to reply to other posters here too but tonight at 9:40 is not the time.

    Thanks again Drhas,
     
  19. Glad to have been a help
     
  20. drsha

    drsha Banned

    In rejecting my offer to debate in open forum Eric Fuller DPM and his pathology driven Tissue Stress Theory vs. Shavelson and my Foot Centering Theory of Structure and Function, a foot type driven theory as to their clinical applicability in a patient based moment, (i.e. clinical practice).
    He suggested that we debate our clinical skills on The Arena, offering him a huge "home field" advantage compared to an open forum.

    On this thread, I accept his challenge, not just him but to all Tissue Stress advocates that have already or will participate on this site to practice Evidence Based Medicine as Sackett described it
    Using a clinical question, a patients particular (custom) needs, the skill level and experience of the practitioner and the available evidence gathered on populations of patients and not just one and graded as to importance, validity and applicability solve the question. .

    I have presented my "take"of Podtigers presentation in this fascinating case (without his reply to my questions because he was unattached to the internet and could not respond timely).
    The title drew me to participate because when practicing Wellness Biomechanics, I rarely see patients presenting with both Plantar Fasciitis and PTTD, it is usually one or the other.
    Rigid/Stable Rearfoot, Flexible Forefoot Functional Foot Types = Plantar Fasciitis
    Flexible Rearfoot, Folexible Forefoot Functional Foot Type = PTTD


    I believe that I have presented a case that strongly suggests that there was in fact, no PTTD in this case.
    Eric Fuller has posted above that he wonders whether the PF or the PTTD (pain?) came first when in reality, there is no PTTD present.

    Furthermore, an etiology/biomechanical cause is presented and accepted by TS as Extreme Flat Foot as opposed to a Functional Foot Type.
    Extreme Flat Foot, for me, has almost no clinical significance or application.
    There is level weak level 3 and level 4-5 evidence for my statements regarding Functional Foot Typing tying the foot types to both plantar fasciitis and PTTD.
    I would like The Arena to present its evidence for Extreme Flat Foot as part of this debate


    The apparent TS goal is to relieve or "cure" recurrent PF and in doing so, IMHO, suggests stretching of the MLA and T. Achilles which goes directly against the treatment suggested by my foot type diagnosis (remember, the Plantar fasciitis in this case if recurrent and therefore not cured.
    The goal of Wellness Biomechanics is to maintain or improve performance and quality of life, prevent new chief complaints from developing while "curing" the existing chief complaint, once and for all.


    I await the debate "TS vs Foot Centering" in this fascinating case and invite the internet and the world to participate.

    Dennis
     
  21. Tissue stress approach is already getting results ;) Debate over
     
  22. drsha

    drsha Banned

    In rejecting my offer to debate Eric Fuller DPM and his pathology driven Tissue Stress Theory vs. Shavelson's Foot Centering Theory of Structure and Function, a foot type driven theory in open forum as to their clinical applicability in a patient based moment, (i.e. clinical practice), he suggested that we debate our clinical skills on The Arena, offering him a huge "home field" advantage.

    On this thread, I accept his challenge, not just to him but to all Tissue Stress advocates that have already or will participate on this site.

    I have presented a complete critique of Podtigers presentation in this fascinating case. The title drew me to participate because when practicing Wellness Biomechanics, I rarely see patients presenting with both Plantar Fasciitis and PTTD, it is usually one or the other.
    Rigid/Stable Rearfoot, Flexible Forefoot Functional Foot Types = Plantar Fasciitis
    Flexible Rearfoot, Flexible Forefoot Functional Foot Type = PTTD

    I believe that I have presented a case that strongly suggests that there was no PTTD in this case.
    Eric Fuller has posted queried whether the PF or the PTTD (pain?) came first. This has no clinical import if there is no PTTD and exposes weakness in Eric's TS when compared to FFTing as a treatment platform.

    Furthermore, an etiology/biomechanical cause is presented and accepted by TS as Extreme Flat Foot as opposed to a Functional Foot Type.
    Extreme Flat Foot, for me, has no clinical significance or application and never has.

    The apparent TS goal is to relieve or "cure" recurrent PF and in doing so, IMHO, suggested stretching of the MLA and T. Achilles is contraindicated in Centering.

    I await the debate "TS vs Foot Centering" in this fascinating case.

    Dennis
     
  23. efuller

    efuller MVP


    There's your first mistake; Proceeding with imperfect information.

    Dennis, your post was very interesting. I initially felt like I did not need to reply because your initial post was barely coherent and that I would win by a greater margin by not replying at all. But, you have called me out, so I will show you the problem with your arguments.

    Dennis, you were doing so well in identifying your reply from the original post. You slipped a little in this post. I'll assume your additions are in bold, up until the point they are not.

    You don't know there are no other symptoms, but you inserted that here.

    Finally, trying to apply FFT to a case. So without getting circular, what does it tell us that the rearfoot is rigid or stable. (Circular reasoning, if you now the rearfoot is stable then you know that PERM is inverted or perpendicular)

    So what information would a forefoot SERM-PERM offer?


    I'd agree that forefoot varus doesn't provide a lot of information. However, in the STJ neutral pardigm it offeres more of a guide to treatment than functional foot typing does. People have described what they would do to a cast that has a forefoot varus.

    To blow something away, you have to do more than just say so. Dennis, here is your challange. Explain why functional foot typing blows away Rootian diagnoses. If you can't, FFT just blows.


    My earlier post was explaining, with tissue stress, how it is possible to have both PTTD and plantar fasciitis at the same time. I've seen feet with both. Both pathologies are theoretically caused by a high pronation moment from the ground.

    Dennis, do always insult the people you try to help? So, Dennis what do you do differently for different foot types?

    So, Dennis it appears that you use different pads for different foot types. Could describe how these differ?

    Self congratulate much?




    Dennis, it appears that you think this is brilliant. Did you forget to add the roll eyes? If you don't think that it is brilliant can you explain why?


    Dennis, the paragraph above is gibberish. The bottom paragraph reveals your paranoia.


    Dennis it looked like you got tired at the end of your post and stopped bolding your comments. As the fatigue sets in, you also make less sense.



    Dennis, you filled in missing information with your assumptions and then you started congratulating yourself on your diagnostic powers. Truly amazing.

    I was just going to quote your last line and let your giberish speak for itself, but I've been critical of you for not explaining your reasoning. So, I've responded to the understandable parts of your post.

    Eric
     
  24. drsha

    drsha Banned

    I hope that all students and practitioners of Biomechanics are reviewing my debate with Dr's Weber and Fuller with an open mind and a revisit of the call for evidence from The Arena Masters that they claim to apply clinically.
    Dr. Weber's claim that "It works" is about as low level and anecdotal as can be and he is a Moderator on The Arena.
    History tells us that tissue paper and arch supports work too.

    Eric has converted this debate from a patient presenting with a problem and a practitioner asking for clinical opinions by providing us all with equal information as a starting point to something else.

    He commented on this thread with the same given information we all recieved, IMHO, incorrectly that there was PTTD pain. I called him on that.

    He states that my argument is false because I "proceeded with imperfect information". Dr Fuller proceeded with the same information when he replied to the posting, didn't he. Why call me on that in debate rather than respond to my clinical challenges and opposing recommendations?
    Let's debate them please.

    All clinical encounters involve incomplete information. This one represents Podtiger and a patient. The test of a clinician is how well we solve the dilemma before us with each patient, custom, with the best tools and evidence at hand. We have no time to wait for level V evidence when applying care to this police officer trusting us to do our best as his doctor in our offices and clinics.

    So as doctors and patient advocates, I ask in debate:

    Is there PTTD in this case (the thread is entitled PF and PTTD)?

    Is there PTTD pain in this case as you have indicated (Podtiger, please respond)?

    Is Extreme Flat Foot an accepted and evidenced diagnosis in Tissue Stress?

    Is the major etiology in this case rearfoot or forefoot located?
    The recommended treatment seems to focus on the rearfoot and I debate it lies in the forefoot.

    What evaluation of the forefoot do you advocate in this case?
    I recommend FFTing which has been described, investigated and successfully applied. I stated the correlation of FFT with PF and PTTD and stated that in most cases, they do not occur together.
    The fact that you (and I) have seen isolated cases of PF and PTTD together does not hold evidentiary weight in this debate.
    Where are the high pronatory moments for PF and PTTD from the ground you reference located in this case (or the majority of them for PF or PTTD?)

    Is stretching a valid treatment in this case.
    It was recommended and accepted by all (except Mesmud) and I am saying it is contraindicated.
    Architecturally, you don't take a building (or a car that is mechanized after being built) that is collapsing and weaken it further by collapsing it more to treat a complaint unless it is last resort. IMHO, That is only momentarily effective witness the recurrent nature of the heel pain in this case.

    Why don't we start from here Arena.

    On the aside Eric, using your logic, is it even remotely possible that your opinions and calls of failure that you tagged to my work from day one are based on the fact that you "proceeded with imperfect information":rolleyes:

    Dennis
     
  25. efuller

    efuller MVP

    Dennis, the quote you refer to (below) I was providing generic information. The original poster said there was PTTD. My post was written with the idea that the PT tendon may have been symptomatic at one time, but was not at the time of the post. If you really want it, I will concede the point to you.






    Dennis, we will never know if the patient had PTTD at the time of the post unless he happened to get an MRI.

    Pes planus had an icd-9 code so flat foot is an accepted diagnosis. Is there a correlation between arch height and anything. I use measurement of arch height in my application of tissue stress becuase an arch height that is too high can cause discomfort. However, I put a number to it and would agree that extreme flat foot is not that helpful of a diagnosis.

    If the pathology is pain at the medial calcaneal tubercle that is caused by tension in the structures of the medial arch then this case is both forefoot and rearfoot. In tissue stress, I use rearfoot varus wedge orthotics and forefoot valgus wedge orthotics in an attempt to reduce tension in structures of the medial arch. I don't see how you can isolate this pathology solely to the forefoot or solely to the rearfoot.

    Dennis what is your logic that this lies in the forefoot?

    So what if you successfuly typed the foot. What do you do with that information?

    Your writing was not clear. It appeared that you were saying that PTTD occurs in one foot type and plantar fasciitis occurs in another type. The fact that you can see both PTTD and plantar fasciitis occur in the same foot would demonstrate the ineffectiveness of functional foot typing in predicting pathology.


    We don't know without examining the foot. In some feet high pronation moments come from the ground. Specifically, the center of pressure of ground reaction force is lateral to the STJ axis.

    Sometimes, high pronation moments can come from the peroneal muscles. This may cause plantar fasciitis.

    Regardless of the source high pronation moments will tend to cause increased tension in the plantar fascia and this is the tissue stress explanation of the cause of the pathology.

    How does foot typing explain plantar fasciitis.

    No. Functional foot typing is incomplete. I've pointed out the deficiencies and you haven't answered them. How does foot typing alter treatment? How does foot typing explain pathology? I can't believe how many times that I've asked those questions and you haven't answered. Your inability to answer those questions is why you have failed, Dennis.

    Eric
     
  26. drsha

    drsha Banned

    I am not looking for concessions as this is not a war but a clinical debate. I am hoping for others to enter as for me, this is not a personal debate for me either.

    In my practice, I differentiate between PTTD and PT Exhaustion without an MRI on the initial visit quite often. I only MRI on a small number of my PTTD cases as they resolve without the need.

    There are diagnostic tests for PTTD such as insertional pain of the PT tendon, pain along the course of the tendon, pain in these areas on activity that accompany as well as heat, redness and clinical swelling that are adjacent to MRI investigation.

    Are you actually saying that you cannot make a diagnosis of PTTD without an MRI?

    That justifies using it but does not give any power to its clinical strength.

    In Wellness Biomechanics as opposed to Tissue Stress, we document much more frequent complaints with arches that have collapsed in either the rearfoot, forefoot or both as opposed to those that are too high in the more rigid foot types.
    Certainly, you are not trying to say that in this case, the patients arches are too high?

    1. As a clinician, do you have a better diagnosis than EFF that is more useful?
    2. Are you investigating alternatives to this diagnosis that may be more helpful?

    Here is where I bow to your engineering skills and would love to collaborate but IMHO, it would seem that the center of gravity of the foot, once located, would be in different locations for each clinical case and not always the same.
    If have found anecdotally that when the cog of the foot is more proximal, the weakness and therefore the treatment is be more proximal and if the cog of the foot is more distal, the weakness and treatment would be more forefoot related. Finally, when the cog is more central, both the rearfoot and forefoot are weak, in the case of the flex/flex or both strong in the case of the rigid/rigids.
    A bell curve develops for the cog of the foot and the foot types that point to custom care as to plastic, degrees, cutouts, etc.
    For me, this gives functional foot typing diagnostic and treatment value than the cog of the STJ Axis.

    Podtiger has stated that the ROM of the STJ was not high enough for this patient to "pronate" on the frontal plane, so the bulk of the problems, until proven otherwise for me exist on the sagittal plane of the STJ and in the MTJ, muscle engine exhaustin of PT and P. longus and forefoot sagittal plane pathology.
    This is where I would focus my care in this case as opposed to the frontal plane of the rearfoot.

    Answered above.

    Let me clarify,
    Foot Centering is a starting platform for the care of structural and functional related questions that arise over ones lifetime. It examines large populations of subjects and profiles them into subclasses in order to make clinical evaluation more focused and organized when faced with an isolated case that involves a practitioner and a subject.
    It is patient based not population or evidence based using the current definition of evidence and how The Arena uses it.
    I am a clinician, not a research scientist.
    It has no always, nevers, no doubts just like I assume Tissue Stress.

    You demonstrating the ineffectiveness of Foot Centering and me countering with the ineffectiveness of Tissue Stress does not obviate those components of either paradigm that are effective.
    I admit that for 40 years, I have been practicing TS, whether I called it that or not and I have and continue to learn so much from The Arena but you have no ability to say that as a clinician, you have your own personal typing system that leads you to a starting compartment of how you cast, Rx, monitor and adjust your care that you try to place every patient into from which you then customize care and that you are practicing functional foot typing and there is something to be learned from me.
    IMHO. Functional foot typing is part of the art (notice, I did not say science) of "foot typing methods" and I (and my U.S. Patent) have not heard any upgrade to it nor any reason to stop promoting it from The Arena.

    I place much less value as you, especially in this case, to the cog as it related to the STJ axis for correlation and more to the cog of the foot as that correlates better to the functional foot type and my treatment paradigms.

    That's true Eric but in this case, your statement has limited validity if I am correct and the P. longus is too exhausted to provide enough of a pronatory moment to create the TS needed for PF.

    It would seem more logical to me that it is the combination of a high plantarflection stiffness moment of the STJ
    (I once said on The Arena that Kevin would have to come up with this name and he never has, so I hereby self-proclaim Dennis Shavelson DPM, " The Father of The Plantarflection Stiffness Moment of the STJ):rolleyes:
    and a high dorsiflectory stiffness moment in the forefoot that would seem more culpable.

    Yes it will but there are other sources of increased TS created by the PF as above.

    As someone who knows Foot Centering as well as I, I'm not sure why you would ask these low level, beginning student type of questions that you continue to ask?:rolleyes:

    As always, this comment, that you and The Arena repeat and repeat and repeat and repeat.....
    has no place in this or any other debate.
    and fortunately for me and the clinicians practicing and patients suffering from foot and postural problems throughout their lives you my STJ fixated young man, are not the judge of my failure as there are those who I am proud to say, disagree.

    Dennis
     
  27. efuller

    efuller MVP

    Actually, this an academic debate. Neither of has examined the patient.

    No, what I was saying was an MRI would be the proof that one of us was right. One can make a diagnosis, but how does one know one is right.



    Dennis, I don't know what you mean by center of gravity (cog) of the foot. A center of gravity of a body is where it's average point of mass is. It can be considered to be where gravity acts on the foot as whole. The force of gravity on the foot is very small compared to ground reactive force and the force from body weight above the foot, so the center of gravity is not very important in terms identifying stress on the foot. That's the first reason why your above paragraph makes no sense.



    Dennis, you wrote some words, but they did not answer the question. The foot is a three dimensional structure. If something happens in one plane, it happens in all the planes. You might not be able to see it, but it happened.

    No you didn't answer that. Prove me wrong by pointing it out.





    My point is that foot typing does not make clinical evaluation more focused and organized. There is no point to making all these observations if it does not alter your treatment. Obviously you are not a research scientist. A research scientist would have used the classification system and then made observations and then correlated the observations with the classifications. For the classification system to be useful some observations would occur in one class more frequently than in another class if you wanted the classification to help with diagnosis. If one class seemed to get better with a particular treatment and another class didn't the classification system would be useful in choosing a treatment choice.

    The difference between tissue stress and foot typing is that we are making predictions based on our observations. For example, tissue stress predicts that posterior tibial tendon dysfunction will occur in feet with medially positioned STJ axes and not occur in feet with laterally positioned STJ axes. There is a logic to that. Foot typing has no logic. You might as well classify feet based on eye color or whether or not they have polish on their toenails.

    There is an "always" in the tissue stress approach. Damage to structures is caused by excessive stress, either cumulative or single event, to that structure. Allowing that structure to heal is dependent on reducing stress on that structure.

    Dennis, when I read your patent I was hoping to learn something. But you have taught me nothing. The reason that you have taught me nothing is that you have not done the research that I described above.



    There is a difference between center of gravity and center of pressure. Center of pressure is the average point of ground reactive force. Center of gravity is the average point of mass. The center of pressure, relative to the location of joint axes, will determine which way the ground will push a joint.

    I fear that you cannot explain the relationship to cog and foot types.


    Dennis, you got tired again. You just threw some words together that don't make any sense.

    The reason that I'm sure that I know foot centering as well as you is that you can't answer the low level, beginning student questions either. Why do we type feet? How does foot typing make clinical evaluation more focused and organized?

    Dennis, this the debate. Is there any value to functional foot typing. I say no for the above reasons. Dennis, you have shown that you cannot answer these criticisms. Perhaps, you should show these criticisms to someone who agrees with you so that they can help you formulate an answer to these criticisms.

    By the way, tissue stress is more than just the STJ.

    Eric
     
  28. podtiger

    podtiger Active Member

    Hello Dr Sha,
    I agree it is unusual to have PTTD combined with plantar fasciitis. In fact I have never seen this before either. This was probably the underlying reason for the thread.
    Helbings sign was present. On both sides more so on the left side.
    FHL present? Not sure what you are asking here. Definitely has a FHL(he he)
    No pain at all anywhere near insertion of navicular. Does this discount PTTD? I agree PT inhibition may be a better description. My mistake there.
    Definitely ankle ankle equinus on both sides. More so on left. Glaring omission from original assessment report.
    I referred patient for weightbearing x ray but he declined to get this done.
    I saw the patient on Friday and he is happy with the result. His pain has almost completely subsided and he is able to walk more during the day. More inclined to exercise more which probably wouldn't hurt him.
    Thanks again for your interest in this case. Have enjoyed the sparring between you and Eric. I will definitely follow your posts in future as I feel you have a lot to contribute.

    Cheers
     
  29. drsha

    drsha Banned

    So now podtiger has assayed that there was no pain indicating or conforming (or I assume by his statement, no redness, swelling or heat) and he conceded that "perhaps PT inhibition would be a better term".
    Do you still need an MRI?

    You made his incorrect diagnostic term even more incorrect by adding the fact that there was PTTD pain. That is a red herring in this discussion and an exposure of poor clinical judgement on your part. ?

    Since there is no PTTD here, the original thread should read:
    PLantar Fasciitis and PT Inhibition or exhaustion. Right Eric.

    .

    I prefaced by stating that I was weak in the engineering here but what I mean is that there is a Rearfoot cog and a forefoot cog (the weightbearing surfaces) in play here and that you are focusing on the rearfoot as the only cog of importance here because you are tunneled by the cc which exists in the rearfoot.
    I am theorizing that if we took the rearfoot cog and the foefoot of gravity and combined them to form one cog that would be of "the foot", then it would reflect my functional foot types in that those that were rearfoot faulted would have a pedal cog towards the rearfoot and those with forefoot fault dominance would have a cog closer to the forefoot and that would make cog (and foot typing more relevant clinically and in research.)

    I will send in a diagram tomorrow that I have concieved of but must create.

    [Quote}]
    Dennis, you wrote some words, but they did not answer the question. The foot is a three dimensional structure. If something happens in one plane, it happens in all the planes. You might not be able to see it, but it happened.[/Quote]


    That's exactly what we do but this has nothing to do with the clinical question.

     
  30. efuller

    efuller MVP

    Yes, but what is the relevance of Foot Typing to this clinical case? Or to any clinical case?

    Dennis, any treatment that alters the environment around the foot will change the stress from one location to another. This is true for all arch supports (=centerings) Just because you don't look for the changes doesn't mean that they are not there.

    No, you don't always have to have pain to apply tissue stress. If you determine that the PT needs a rest, you can decrease the pronation moment from the ground to give it a rest.

    Eric
     
  31. drsha

    drsha Banned

    We are not debating the clinical relevance of functional foot typing (or of TS for that matter), we are debating this clinical case and my ability to be a better clinician than you and the other posters on this thread.

    My problem with TS is that without evidence or reason, it accepts introducing new stresses in the form of ORF's that may eventually produce compensatory problems while rejecting other treatments that may be less damaging (or even corrective) in the long run.

    Foot Centering has as its primary default to leave the foot and posture stronger and more capable of defending itself against tissue stress as it eliminates the chief complaint.

    So Eric: which of our works follows the golden rule of "thou shalt not harm" more admirably in its core, Foot Centering or Tissue Stress?

    Have you read Kevin's four postulates of TS that I have seen on these very pages?
    1. Accurately identify the anatomical structure which is injured or symptomatic.

    2. Determine the structural and functional characteristics of the individual's foot and lower extremity.

    3. Determine the most likely type of abnormal tissue stress which is causing the pathology within the injured anatomical structure (i.e. compression, tension or shearing stress).

    4. Design a treatment protocol to reduce the abnormal tissue stresses on the injured structure and reduce the local inflammatory response so that more normal gait and weightbearing function can occur.

    How does your statement that "you don't always have pain (or injury) to apply tissue stress fit with his TS postulates.

    So far, I see Dr Weber "prove" TS by stating that "it works" and now I see you treating Posterior Tibial Inhibition with "give it a rest" by decreasing the pronatory moment under the navicular.

    I hadn't thought of that as my desire as a caretaker of the foot is to place the foot in a more Optimal Functional Position and train the PT to provide a greater supinatory moment to the midfoot in order to offset the inhibition. In other words, I am activating it.

    So what methods do you use to give the PT "a rest" and what do you do after it is sufficiently "rested"?

    Dennis
     
  32. Here I was thinking that it was a patient presented by Podtiger we were meant to be discussing in a way which might help Podtiger and the patient, but all of a sudden it Dennis verses the world again.

    Would not your time be better spent writing that peer reviewed Journal article.

    That is what all orthotic devices do - plan and simple yours, mine, podtigers, Erics.

    It is a fact.

    Prove it - I bet you can not - these massive statements are just statements with no facts attached to them, nobody knows the long term effects of any bit of plastic in a shoe - nobody.

    We have also shown that if a patient has medial OA you have stated that you using FFT would provide a device which would increase the loads on the medial knee - not really wellness .

    But any device will change the force acting on 1 tissue and put it on others - simple and factual - could this have a detrimental result in a patient in the future - Yes. this applies to every single person walking around with a orthotic device.
     
  33. drsha

    drsha Banned

    If this is a discussing involving podtiger and the police officer then why are you not discussing it in your posting?

    You have finally given me the opportunity to answer this question.
    No. My time is better spent advocating for patients and DPM Biomechanics and explaining them to the world.
    The evidence will come at my pace, not yours, no matter how much you prod. So get over it or don't.

    So where is your open mind to another fact. Dananberg, Glaser, Shavelson and others have followings in both the patient and professional world that may be worth investigating instead of bullying us to do things only your way?

    So in an EBM level, applicabilty and validity statement, none of us will ever prove our pieces of plastic.
    If so, the fact that your main argument of my work is that it is unproven holds little to no weight.

    .
    When the medial knee was hurting where in your system you apply a valgus wedge, I would add consultation and additional non operative and operative therapy to the knee proper, proclaiming it to be the weak link in an otherwise stronger postural chain that needed to be strength end rather than to eliminate the pain at the detriment of the system.
    That's why we have total knee implants for knees that hurt.

    My system involves Foot Centering pads that expose areas of compensation before making the orthotic. I place the pads, foot type specific and now if they get knee, hip, back or hallux pain in caring for their plantar fasciitis, I alter my Rx and cast or I don;t make the device and send them to consultants for the compensatory problem i order to care for that before the orthotic.
    It also involves Compensatory Threshold Muscle Engine training that can offer moments into the mix reducing the need for the orthotic to provide all the change.

    In this case I would strengthen P. Longus and PT as in Mesmud's suggestion that was not regarded.

    Dennis
     
  34. Dennis what are you taking about

    I have looked at Howard work and use similar orthotic designs sometimes

    I also have looked at Ed´s work and use high arch devices sometimes as well

    Now I may or may not have been influenced by these 2 men but use tissue stress to describe why I am using that device, but I do not use the same design for all as Ed does, not sure if Howard does I would expect not.

    I am not Bullying you I am just pointing out flaws in your arguments - you seem to think this is personal it is not

    People are always pointing out my mistakes - I learn and move on

    As for you having Followers it does not make you correct
     
  35. blinda

    blinda MVP

    Off thread, I know....but wise words.

    `Lesson learned and the wheels keep turning` - The Killers, The World We Live In (not their best, but stuck in my head for some reason)
     
  36. efuller

    efuller MVP

    Dennis, Functional Foot typing is on topic. In your discussion of treatment of this foot you mentioned that you would type this foot. If you were a great clinician you could explain why you took your valuable time to perform those measurements. Or you could just admit that typing the foot didn't change what you would have done. Well, maybe foot typing was off topic.


    Back to discussion of paradigms used to treat the foot, err this specific case:

    Dennis, where have I said that I would reject a treatment which has evidence shows that it works. Foot centering is an arch support. You can choose to ignore what stresses your arch support causes, but they are still there. Are you saying that your arch supports don't touch the foot?

    I would reject your contention that foot centering leaves the foot stronger etc. Not only is there not any evidence, there is no explanation of how it would do it.


    Well, under tissue stress, you admit that your treatment is designed to shift stress from one structure to another. Part of the tissue stress paradigm is that you have the patient come back to evaluate their treatment. You should know where to look if you are concearned that your treatment will put too much stress on some other structure. When it does you modify your treatment. I had a patient last month with a stress fracture of the second metatarsal. I gave her an orthotic with an extension sub 1 and 3-5 and told her that it may bother her bunion. She came back 4 weeks later and said the 2nd met felt fine, but she was feeling discomfort with her 1st MPJ. I altered her orthotics accordingly with the instructions to come back in if any symptoms develop. I was able to predict that this might occur because I understand tissue stress. By the way this is a non STJ focused tissue stress treatment.

    Foot centering is an arch support based treatment paradigm. Everyone needs the same arch support whether it harms them or not.



    Posterior tibial "exhaustion" is a symptom.

    Inhibition? Last post you called it exhaustion. If it was exhausted, I would give it a rest by incressing supination moment from the ground.
    A medial heel skive will increase force on the medial side of the calcaneus and not the navicular. Sometimes, I will increase the height of the medial arch, if I want to add force under the navicular.



    I believe that any arch support can work by increasing activation of the posterior tibial muscle. I noticed this in my own feet soon after I got my orthotics. The icreased arch height of the orthosis would be uncomfortable in the arch if the posterior tibial muscle did not work to raise the arch. However, if the posterior tibial muscle is damaged, increasing the activity of the muscle is a bad thing because it will increase stress and not allow healing. So, sometimes I will use a relatively low arched device with a medial heel skive to treat a damaged posterior tibial tendon.


    Eric
     
  37. drsha

    drsha Banned

    Okay, so you use various casting techniques and not mine.

    Now what about responding to the rest of my posting to you.
    instead of making believe they don't exist.

    Dennis
     
  38. Dennis I was going to respond, then I looked at Compensatory Threshold Training

    and a little of me died on the inside so I thought it better not too respond.

    Dennis Smoke and Mirrors Shavelson.

    I too give patients programs to strengthen muscles - except I just call it strengthening program and don´t bother with a tm.

    Smoke and Mirrors.



     
  39. Gbade

    Gbade Member

    Your presentation of the patient is good, you have given a lot of information to reach a working diagnosis of plantar fasciitis and PTTD. In this gentleman of his height and weight are contributary factors, his occupation makes the matter more challenging.
    There is a place for orthoses considering all the paradigms, (Tissue Stress paradigm) appears to be the prominent one in this case. The soft tissues in his lower extremities have be taking a lot of stress and he now at the typical age when the soft tissues begin to fail. I will consider him for a functional orthoses bearing in mind his weight and his occupation; the footwear might need a review.
    Gbade

     
  40. drsha

    drsha Banned

    Dr Weber:

    I would like to thank you for participating in this academic debate.

    Your last post seemed to have nothing to do with this thread, podtigers info or the policeman who is the patient. It remains a critique of me and my work and not of my ability as a clinician and podiatrist as I have admitted that I am not a very good research scientist.

    In the clinical debate at hand, Eric has conceded that he added PT pain based on "an assumption of pain in the past" and podtiger has conceded that "PT inhibition may be a better diagnosis than PTTD" meaning that I confirmed the flaw in the title of the thread as I suspected.

    How I got these concessions or what methodology I used for the moment is moot in the discussion.

    I was correct and they were wrong on these calls.

    So to proceed, assuming we both know how to strengthen and stretch a patient, we differ as to the clinical care of this patient that we have recommended.

    You suggested stretching the MLA and T. Achilles and I suggested strengthening the PT and P Longus as to the PT piece of this case.

    Strengthen one set of muscle engines or stretch another.

    When we determine which of us is correct in this case, then we can discuss the side issues you appropriately raise.

    Stretch vs Strengthen?

    Dennis
     
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