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Do you take measurements during orthopaedic examination?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Griff, Aug 6, 2009.

?

Do you routinely record numerical measurements during orthopaedc examination?

  1. Yes

    33 vote(s)
    34.7%
  2. No

    62 vote(s)
    65.3%
  1. Griff

    Griff Moderator


    Members do not see these Ads. Sign Up.
    Following on from another thread, I wonder what the most common practice is out there... do people draw various bisections and record numerical values/angles (e.g. RCSP etc), or not?

    Haven't had a poll on here for ages...apologies for the typo in its title
     
  2. Foot Doc

    Foot Doc Active Member

    Hi Ian,

    The following questions are asked with the most sincere of intentions. I've only

    been practicing (practicing LOL that always cracks me up) for the 2 years and i

    understand that the vast majority of you have bucket loads more experience than i do...........

    If you don't measure, Ian (and others), how on earth do you prescribe your

    orthotic?

    What do you base your corrections on? How do you justify the amount

    of correction you put in to an orthotic?

    Do you look at the Pt's foot and say "well, it looks like you need 10 degrees of

    correction"? Of course i understand that you examine the Pt's foot.....but, how do

    you conclude the amount of correction required in an orthotic?

    And when you cast the Pt? If you don't recognize "the STJ neutral theory" then

    what position do you hold the foot in? Do you just hold it in the position you

    think the foot would best function? Is it a case of "eye-balling" the Pt's foot type and prescribing a device with mild, moderate, or high correction?

    What system do you use?

    I know the system that i use (Root biomechanics) is full of holes, and is not, by many standards (some would say ANY standards), scientific and so i'd like to know of other systems.........particularly this one where no measurements are taken.

    Very much looking forward to the answers and thanks for the interesting post!!

    Cheers,


    FD
     
  3. Sammo

    Sammo Active Member

    To counter your argument Foot Doc,

    How do you justify drawing lines on the foot when it is fairly widely accepted that you error margins will be so large that your prescriptions might as well be based on eyeballing.

    Do you post 2 or 4 degrees of varus wedging at the heel?? Ho can you know if your error margins for heel bisections are 3-4 degrees?

    I use POP bandaging and an external lab for most of my orthoses, although I use foam impression boxes for casting children and fabricating my own insoles for them onsite. When I use POP i put the foot into "neutral" as it is a reference position where I write my prescriptions from. When I use the foam box I put the foot into the position I think it best. I find I get better results with my foam boxes than I get with the PoP casts.

    I feel (and may well receive flak for this, probably deservedly) this insole prescription and manufacture is where the art meets the science. Often I go on what I feel will work best in a particular case.

    I really like the tissue stress theory, and believe that if you apply it to whatever injury you are seeing (as long as it is not some crazy systemic illness or pathogen having a moving in party), combined with a good understanding of ab/normal anatomy and the bioengineering principles, you can get great results in often really awkward cases...
     
  4. Foot Doc

    Foot Doc Active Member

    Hi Sam,

    Just to be clear, i was not arguing any point, just seeking clarification and understanding. As i said, i am fully aware of the holes in Root biomechanics and the lack of scientific evidence to support its clinical application.

    I am very interested in understanding how you, Ian, and others precribe a device based upon observation. What parameters do they and yourself use? Is it a case of prescribing a device with mild, moderate, and high control.........or are there other factors? Tissue stress makes a lot of sense, but again, how much control/correction do you use and how do you come up with it?

    I don't want to argue.......i want to understand.

    Thank you for your reply. It was very helpful.

    Cheers,

    FD
     
  5. Sammo

    Sammo Active Member

    Hi Doc,

    Sorry, didn't mean to get on the argument trail.. probably not paying enough attention as I keep getting these people (some call them patients) knocking on my door demanding to be seen..!!

    I eyeball all my measurents. The only thing I regularly quantifiably measure is tibial inclination angle in the lunge test.

    My take on prescribing insoles is more about what force am I trying to apply to the foot, when and how. I think it does pretty much fall into the Mild, moderate, high "control" types that you say but perhaps a better way to look at is how much force needs to be applied and where on the foot to reduce pathological forces and thus injury.

    In a typical garden variety plantar fasciitis case with an excessively pronating person then a pair of magic shovels (OTC insoles) often work wonders. But in a patient with plantar fasciitis that has a rigid cavoid foot, limited calcaneal eversion and a medial column that only contacts the floor after a very fast internal rotation by the leg after as the lateral column loads I might choose to do a high arch profile polyprop with a slight forefoot wedge.. if 2degrees doesn't work.. add a little more. Sometimes, to critique myself, I often have (but also like) to tinker with the prescription once it is back.

    I've always tended to work a little more intuitively than methodically so i'm struggling to explain exactly what I mean.. I try to make the insole fit the foot and pathology I see.... so rather than try to return the foot to an arbitrary norm, I will look to make an insole best design to reduce the pathological forces... it might even just be a block of adhesive felt attached to the patients Croc.. if that is all I have to work with.. it is a rather freeform approach...

    hope this makes things a little clearer... which in truth I'm not sure it will.....

    Kind regards,

    Sam
     
  6. Foot Doc

    Foot Doc Active Member

    Hi Sam,

    Thank you very much for the reply. It makes a lot of sense. And when all is said and done the way you prescibe your devices is probably much more accurate and customised than using the Root model. I guess, in part, the philosophy is very similar, but the approach and technique is rather different. And i think that the technique one applies makes a big difference to the overall efficacy of a device.

    Clinically there are no real guidelines when it comes to prescribing orthotics and that, i think, is a reflection of the lack of science. So, at the end of the day, we use what works for our Pt's based upon our current understanding (which varies considerably), right?

    Once again, mate, thanks for the reply.

    Cheers,


    FD
     
  7. Sammo

    Sammo Active Member

    You are more than welcome.. :drinks:drinks

    "Clinically there are no real guidelines when it comes to prescribing orthotics and that, i think, is a reflection of the lack of science. So, at the end of the day, we use what works for our Pt's based upon our current understanding (which varies considerably), right?"

    This is right too.. People get results with all sorts of methods.. but we all try to do right by the patient. I think sometimes the most important thing is to know what not to do with regards to insole prescription. Like mortons extension in the wrong cases, or varus wedging with genu varum leg type.

    The good thing about methods like Root, however right or wrong, is that they give a frame work and impose a criteria by which to work. Without trying to sound in any way negative, it does simplify things which makes the whole prescription process easier. Where it falls down is what do you do when a patient falls outside these parameters, or if you do all your measurements and assessments perfectly and then the insole doesn't work.. Where do you go from there..?

    In all honesty, one of the things I didn't like about the root method when we were taught it was having to draw all those lines...
     
    Last edited by a moderator: Aug 7, 2009
  8. Foot Doc

    Foot Doc Active Member

    :drinks Cheers,

    I would have to agree with you. However, i think the Root method falls harder and faster when we look at the science behind his theories. There is no real evidence that any of his measures, much less the "important ones" (RCSP, NCSP, STJ neutral), are valid and reproducible.

    We were taught it at uni, i work in a practice that uses it to some degree, i've read papers (published) that encourage using it even when that very study found no supportive evidence...........i guess its all i know, really.

    Don't ask me why, but even though i know this, i still use his method. Maybe because it is simpler and has a very succinct framework to go by, like you said. And perhaps the most persuasive reason why i use it is because it works and Pt's are happy with the outcome of their treatment. And it is very clear that the techniques used by yourself and many others yield the exact same results.

    LOL those lines............they're a pain in the @#$ to be honest, but what can you do?

    Cheers again,

    FD
     
  9. Mr, Mrs, Miss, Ms. "Foot Doc",

    How do foot orthoses exert their therapeutic effects?
     
  10. Griff

    Griff Moderator

    Hi Foot Doc,

    How do I prescribe a device based upon observation? I don't. I base it on the force required. As Simon asked: How do you think orthoses exert their effects? By 'realigning' the heel bisection exactly by the number of degrees you have written on the prescription?

    Can't speak for anyone else but I would say one of the biggest factors I consider (amongst others) is the supination resistance

    You prescribe a device which you feel will reduce the pathological load/stress on the injured structure. [Tip: Dont say 'control' around Spooner...]

    I'm not saying there is a right or a wrong with respect to taking measurements during examination - each to their own. But in reality, whether we draw lines or not we are all pretty much doing the same thing if our patients are getting better (i.e. changing kinetics)

    Ian
     
    Last edited: Aug 7, 2009
  11. Foot Doc

    Foot Doc Active Member

    Hi Simon,


    Mr. "Foot Doc",

    I could venture an educated guess, Simon, but i'd be happier to hear it from a much more experienced colleague.

    Looking forward to the your next post.

    Cheers,

    FD
     
    Last edited: Aug 7, 2009
  12. Foot Doc

    Foot Doc Active Member

    Hi Ian,

    Thanks for the reply.

    Just to reiterate, i am asking and inquiring to enhance my understanding.......not at all to argue.

    Just in relation to the parameters you use, what other tool/tests do you employ other than supination resistance?

    Thanks in advance,

    Cheers,

    FD
     
    Last edited: Aug 7, 2009
  13. Griff

    Griff Moderator

    Hi Foot Doc,

    Do you mean what other things do I consider when writing an orthoses prescription instead of taking measurements?

    If so then I would say the other 2 things in my 'top 3' would be the STJ axis location/deviation and the Lunge Test. But remember all of this is subject specific - it depends on the pathology being treated.

    If you want to understand more get yourself booked onto one of Craig's Bootcamps. They are the shizz.

    Ian
     
  14. Griff

    Griff Moderator

    As I said in an above post I don't believe there is a right or a wrong with regards to taking measurements - each to their own and all that. I personally do not take them. When asked why (by Foot Doc or others) my answer is generally the same -> it does not influence my diagnoses nor my orthoses prescriptions, therefore I do not do it.

    Are any of the voters who do take measurements (currently almost 40% in the poll) happy to discuss on here their rationale for taking them?

    Ian
     
  15. Foot orthoses exert their therapeutic effect by altering the location, magnitude and temporal patterns of ground reaction force acting on the plantar foot during weightbearing activities.

    So how do the measurements performed for a Root based prescription protocol relate to the above? If you really do want to enhance your understanding as you state, you'll need to at least venture an educated guess to this one Mr "Foot Doc". It might also help if you used your real name, then you might get Prof. Kirby to join in this discussion as he seldom replies to anonymous posters.

    Further, what difference would it make to the location, magnitude and temporal patterns of ground reaction force acting on the plantar foot if my Rootian examination revealed that I should post the rearfoot by 4 degrees varus (surprise, surprise), but I actually posted it by 6 degrees varus?
     
  16. Foot Doc

    Foot Doc Active Member


    Thank you for the insightful reply, Simon.

    It is largely accepted that this is the way orthotics exert their effect, even though there is little evidence in the literature to support this. And even though Root et al may not have known it at the time, in effect this is what his orthotics do.
    For one to alter location, magnitude, and temporal pattern of GRF acting on the plantar foot one must ALTER the position of the foot to some degree, because the surfaces we are walking on aren't going to change, right? So a Root based prescription protocol is intricately tied to the way in which orthotics exert their therapeutic effects. The underlying philosophy of Root's biomechanics may be WAY off but his protocol is pretty much the same hit and miss "science" that has been described so far. Now don't get me wrong, Simon, im not saying that either are right or wrong...............i just want to know what parameters people use to prescribe a device if not using the Root approach.
    Just because i find it a little bit foreign to prescribe a device without measuring the foot does not mean i am arguing for or against Root's, your or anyone else’s methods.

    So back to the original discussion.................what prescription parameters do you use if you don't take measurements of the foot? Or do you go with what you feel will be best for the Pt at the time also?

    Looking forward to your next post.

    Cheers,

    Sam (FD)
     
    Last edited: Aug 8, 2009
  17. Griff

    Griff Moderator

    Hi Sam,

    Don't want to step in and interrupt your discussion with Simon, but just wanted to comment on one thing you said:

    I don't agree with this. Much research has shown orthoses to have little if any kinematic effects (i.e they dont alter the position of the foot), if they do it seems to be subject specific, and when they do this is not linked to positive outcomes. Certainly this is what I see clinically also.

    You can alter kinetics (GRF patterns) without altering position. It took me a while to grasp this, and it was gold old Dr Spooner who actually made me understand it. I read a post on here about some fat kids on a see-saw and it all fell into place for me. If he's in a charitable mood he may well repeat it for you.

    Ian

    Williams, D. S., McClay Davis, I., & Baitch, S. P. (2003). Effect of inverted orthoses on lower-extremity mechanics in runners. Medicine & Science in Sports & Exercise, 35, 2060-2068.

    Stackhouse, C. L., McClay Davis, I., & Hamill, J. (2004). Orthotic intervention in forefoot and rearfoot strike patterns. Clinical Biomechanics, 19, 64-70.

    Stacoff, A., Reinschmidt, C., Nigg, B. M., van den Bogert, A. J., Lundberg, A., Denoth, J. et al. (2000). Effects of foot orthoses on skeletal motion during running. Clinical Biomechanics, 15, 54-64.

    Zammit, G. V., & Payne, C. B. (2007). Relationship between positive clinical outcomes of foot orthotic treatment and changes in rearfoot kinematics. Journal of the American Podiatric Medical Association, 97, 207-212.
     
  18. Right and wrong, we can change kinetics by changing the position of the foot, we can also change kinetics at the foot-ground interface by lifting our arm out to the side, without any perceptible change in foot or lower limb position. We can also change kinetics by altering the geometry and load-deformation characteristics of the supporting surface. Why do you think the surface when wearing orthoses are not changed compared to a shoe only or barefoot condition?

    Absolutely. Root is just hit and miss. This is the point I wanted you to make. The question is which hit and miss science is more efficacious? The key is in understanding the mechanics of foot orthoses. What is the mechanical effect of increasing degrees of rearfoot posting angle? i.e. what does it do to the orthosis? If Root's philosophy of biomechanics is, as you say, "WAY off", why employ this philosophy when there are models which appear to be less "WAY off"?

    Who said that I don't take measurements? In addition to several widely used biometric measures I also use a battery of measurements based around load-deformation characteristics using a measuring device I invented for the purpose and finite element modelling.
     
    Last edited: Aug 8, 2009
  19. Back from my week off. What a great thread! Cheers Ian :drinks.

    To answer the OP, I voted with the no column. I just don't trust the numbers.


    With respect, and a due sense of foreboding and dread I'd have to disagree with the above as a complete definition (although I agree with the point).

    What of insoles with a high medial wrap? The medial -> lateral force they exert on the medial aspect of the foot is not really GRF nor is it acting on the plantar surface of the foot.

    What of changes to muscular function caused by a changes in the surface (like Kevin's Spikothotic)

    Is the vector of the GRF covered by "location".

    And stuff.

    Thats a very good question.

    For me its wrapped up in the way we think about the device. Root theory is based on moving the foot / function TOWARDS an ideal. To do this we need to know two things. 1. Where we are and 2. Where we want to be. The latter is offered by the model (STJN). To know the former we must take measurements. The difference between the two is the prescription.

    I have three problems with this. 1. The measurements for "where we are" are inaccurate to the point of uselessness. 2. The "where we want to be" may not be where we want to be and 3. The orthotic does not have a kinematic effect equal to its prescription.

    My approach is more based around moving the foot AWAY from the pathological situation. Now often (though not always) this will be towards roots "ideal". However if moving away from a pathological situation one need only know which direction to push. Reduce the tissue stress enough and your patient will get better. Send them too far and you may have issues with tolerance and / or creating tissue stress pathology in different tissues.

    I think root orthotics (and indeed pre fabs) will generally work, or at least help because as I said towards STJ is generally away from the pathology. However I don't see that measurements are particularly relevant. As Simon says if the root derived prescription is 5 degrees will making it 7 degrees really render it ineffective?

    Regards
    Robert
     
  20. CraigT

    CraigT Well-Known Member

    So you use FEM clinically day to day? Interesting...

    So common biometric measures- do you mean judging subjectively things such as supination resistance, navicular drift and drop, Jack's test?
     
  21. Lawrence Bevan

    Lawrence Bevan Active Member

    [For me its wrapped up in the way we think about the device. Root theory is based on moving the foot / function TOWARDS an ideal. To do this we need to know two things. 1. Where we are and 2. Where we want to be. The latter is offered by the model (STJN). To know the former we must take measurements. The difference between the two is the prescription.

    I have three problems with this. 1. The measurements for "where we are" are inaccurate to the point of uselessness. 2. The "where we want to be" may not be where we want to be and 3. The orthotic does not have a kinematic effect equal to its prescription.


    Regards
    Robert[/QUOTE]

    Actually Robert I may be wrong but I think this is a common misconception. Mert Root and co-workers did devise a set of ideals for the morphology of the lower extremity and some of these ideals still make some sense. BUT they did not espouse placing every foot "closer" to the ideal. This is said time and time again but it was never said By Mert Root or co-workers. The use of orthotics in practice was different to this I believe.

    The purpose of the "Root" orthotic was to "lock the midtarsal joint" and posting was used to achieve this goal NOT to put the foot nearer to STJ neutral. Thus to answer Simons question if a 4 degree post was measured as necessary but "something"was found eg an entity previously known as a "high midtarsal joint oblique axis" (which at that time was a deformity thought to particularly destabilise the midtarsal joints) then higher posting would be used, or a wider shell or longer rearfoot post etc.

    A further example of the "Root model" in practice was alluded to at a lecture I heard Bill Orien give when he said that "an orthotic may only require 1 degree of posting - as long as that degree of posting is sufficient to reduce ligament strain" (paraphrased BTW). I believe the "Root model" in practice by its originators was more "tissue stress" orientated than we now have come to think.

    To place the foot nearer STJ neutral (nowadays using a method of finding STJ neutral that Root himself did not use!) is not the Root model. Its probably better described as the East Coast USA Largest Orthotic Laboratory Influenced Model which I think was run by a chap called Leldon Shanger :D

    Nowadays we call "locking the midtarsal joint" other things - "increasing rearfoot dorsiflexion moments" or "decreasing forefoot dorsiflexion moments" or "preventing late-midstance pronation" or "facilitating motion in the 1st MTP" or "preventing lateral avoidence in propulsion" or "encouraging high gear propulsion" or "enhancing the windlass" or "smoothing the progression of the COP".

    And now I have taken the discussion off-topic and completely brought it to a halt I will step back. :D

    :drinks
    L
     
  22. It's still GRF in my book as it is at the interface between the foot and the ground. You could call it orthosis reaction force if it makes you happier Robert.

    And magnitude
     
  23. I use FEM when designing custom foot orthoses. I use objective measures of various characteristics including navicular dorsiflexion stiffness, hallux dorsiflexion stiffness etc. Also if I think it necessary I'll measure leg length etc. depends on the patient.
     
  24. Very interesting discussion we have here. I've been up in the mountains enjoying some cooler air up at 6,000' compared to the hot summer here at sea level in the Sacramento Valley and thought I would like to comment.

    Yes, I do take measurements on every patient that make custom foot orthoses for. I do the standard (i.e. Root et al) measurements that I was trained on during my time at the California College of Podiatric Medicine as a podiatry student and Biomechanics Fellow. In addition to the standard measurements, I estimate subtalar joint (STJ) axis location, determine how many degrees the foot is from the STJ maximally pronated position when in relaxed bipedal stance, and qualitatively evaluate the patient's gait.

    Here are the reasons I do these measurements and note them in my patient's medical record:

    1. They allow me to get a better idea of how the individual's foot and lower extremity structural variables compare relative to the thousands of other individuals I have evaluated.

    2. They allow me to detect small structural abnormalities in the foot and lower extremity that I would have not otherwise noted.

    3. They provide a reference in the future if I need to review what the structural variables of the patient are.

    4. They provide medical/legal evidence that I have indeed performed a full orthopedic foot and lower extremity examination should an insurance company or attorney ever need proof that I did perform a full orthopedic foot and lower extremity examination on the patient.

    5. Performing and noting the the measurements in the chart demonstrates to the patient that I am carefully evaluating their condition (nearly always much more thoroughly than other podiatrists that have made foot orthoses for them) so that my patients can be more certain that I will also take the same care in customizing their orthoses for their specific condition and for their specific structural and functional variables.

    Do I need to do all these measurements to always make the best orthoses for my patient? Not really. However, have I picked up on the patient's diagnosis that many other podiatrists could not diagnose by simply performing these measurements? Yes, many times.

    You must then ask yourself, if you weren't a podiatrist, which podiatrist would you most want to spend your time and money seeing for custom foot orthoses: the one who doesn't take any measurements, or the one that does take the time to make careful measurements of the structure and function of your lower extremity and does note them in your medical record?
     
  25. A fair point Lawrence. I've never had the pleasure of learning root "from the horses mouth". I (in common with most I suspect) learned root as a process of compensating for deviations from the norm. It may well be that this is apostacy born of false profits (or should that be prophets? I'm never sure).

    Call it "what most people practice as rootian" if it is more accurate ;).

    Never heard of a leldon but I know that the LANGER ORTHOTICS lab release biomechanics training manuals which make me scream and froth at the mouth a'la jekell and Hyde!*

    Regards
    Robert

    *
    or am I not allowed to say that? ;)
     
  26. Griff

    Griff Moderator

    Hi Kevin,

    Thanks for posting a thorough rationale for why you still take standard (Rootian) measurements. It is difficult to find fault with any of it, with the possible exception of this:

    Do you mind explaining further how these measurements may help with a patient's diagnosis?

    Thanks

    Ian
     
  27. Ian:

    Easy.... amount of STJ range of motion in the diagnosis of tarsal coalition.
     
  28. Griff

    Griff Moderator

    Touche Prof Kirby. :eek:
     
  29. For some reason it wouldn't let me edit this post: should probably add line of action if you want to be really pedantic, and you obviously do ;) You've been learned too well.
     
  30. Lawrence Bevan

    Lawrence Bevan Active Member

    Kevins recent posting on rationale for measurement ^^ should be pinned as a classic!

    A really cool post.
     
  31. How do they relate to your prescription protocol, Prof. Kirby?

    How does the Root measurement system tell you when to use a medial or lateral heel skive? Why 15 degrees on a medial heel skive? And other stumps we've run around before...:dizzy::dizzy::drinks
     
  32. Can't think who might have done that!:rolleyes:.

    Still not sure about the GRF / ORF thing. I'm thinking of a UCBL where the medial flange and the lateral flange resist pronation by limiting the distance between the lateral part of the foot and the medial. Thats not just redirected GRF is it? Its resisting the foot changing shape. Hypothetically it would do so even in the absence of GRF (were another force to attempt to widen the foot).

    Its a GOOD definition. I like it. I just think its a bit limiting thats all;).

    Regards
    Robert
    Pedant in training.
     
  33. Not sure what you mean by "limiting the distance between the lateral part of the foot and the medial"- how does this control pronation? Nevertheless, does a medial or lateral flange of a UCBL limit pronation in the absence of GRF, i.e external moment? The flange on the lateral aspect should need to cross the joint line of the STJ sufficiently to do this and limit motion of the calcaneus on the talus in open chain (swing) without an external moment acting upon the foot- does it, or does the orthosis create an ORF during swing by constricting the foot which I suspect is what you were trying to say? (what do we want the foot to do in swing anyway? pronate or supinate?). During contact phase, if the change in kinematic response that you envisage ("resisting pronation") is not due to external moments, i.e., GRF/ ORF, it must be due to a change in the internal moments; how might this be produced by the orthosis, if not through GRF/ ORF i.e. external moment?

    If you are still not happy, take Bowker's definition of potential modes of action for orthoses (take your pick): 1) by modifying the moments about the joint to restrict, partially or totally, the rotational motion at the joint; 2) by modifying the forces acting about the joint to limit the translational motion at the joint; 3) by reducing the axial forces across the joint through a “sharing” of the loads between the structural components of the joint and the orthosis; and, 4) by modifying the point of application and line of action of ground reaction force.


    It still doesn't change the moot point, how do the measurements of a Root protocol relate to this, Robert?
     
  34. Foot Doc

    Foot Doc Active Member

    Hi Kevin,

    I think this is the most reasonable post i have read in this thread. I couldn't agree with you more.

    All the points you make are valid and paramount to effective podiatric practice.

    Cheers,

    Sam (FD)
     
  35. Simon:

    Sometimes the prescription protocol is altered by the measurements, but most times they are not. However, when a patient asks me what I have found, they are always interested in how their measurements compare to the normal values for these measurements.

    My prescription for the amount of medial or lateral heel skive are determined mostly by STJ axis spatial location and by the location of the patient's symptoms, and not by the Root et al measurements. I came up with the 15 degrees on a medial heel skive since 10 degrees was too little of an angle of skive and 20 degrees was too much of an angle of skive when I first started using the technique 19 years ago.
     
  36. efuller

    efuller MVP

    When the STJ proates the talus adducts (internally rotates.) If it were to rotate far enough then it would hit the medial flange of the shell. When the talus hits the medial flange of the shell, the talus will push on the shell and shell will push on the talus. If the lateral clip is being pushed laterally by the lateral foot then the push from the talus on the medial side will not push the orthotic away from the foot and the internal rotation of the talus can be resisted.

    The preventing the increase in distance statement is fairly accuate, but in my opinion, can be better described as applying medial to lateral, and lateral to medial, forces in the transverse plane. Of course this only works if threre is a significant amount of adduction of the talus. Or another way of looking at it is, if there is a significant amount of forefoot abduction on the rearfoot. So it is not really ground reaction force, but it is transverse plane orthotic reactive force.

    Cheers,

    Eric
     
  37. efuller

    efuller MVP

    It's kind of like the F-scan. It makes it look like you are doing someting scientific. ;)

    I use calipers to measure the width of the fat pad. I make sure that the heel cup is that wide so I get less heel cup irritation. Used correctly, the calipers can scare little children. If that's the inetended goal. ;)

    Cheers,

    Eric
     
  38. BPod2

    BPod2 Welcome New Poster

    Great thread,

    I agree with Kevin and likewise perform and record measurements for the same reasons. I also find that without measurements as a point of reference for my orthotic precription it is difficult to know what to modify if the patient has a less than perfect response.
     
  39. efuller

    efuller MVP

    This is why I really like the tissue stress approach to prescription writing. Under the Root et al system, if the the orthotic didn't work you did the same thing over again and hoped to find your "mistake". There must have been a mistake because the patient didn't get better. Under tissue stress, if the orthotic did not improve symptoms you add more of the corrections in the direction that you think would help. For example, if a person with sinus tarsi pain symptoms did not resolve with a 2mm heel skive, I would add more material under the medial rearfoot post to effectively increase the skive.

    Regards,

    Eric
     

  40. I agree with Eric here. Even though I do Root et al measurements and take note of them in the patient's chart, when I treat patients I think more like an engineer using the tissue stress approach than using the Root type approach that I was trained on during podiatry school. The tissue stress approach should be taught at all podiatry schools. Maybe, someday, the chapter that Eric and I wrote on the tissue stress approach will soon be published...its only been 4+ years ago that we wrote the chapter along with the 40 drawings I did for the chapter!!
     
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