Do you take measurements during orthopaedic examination?

Thanks Eric. Elegantly put.

I think in a broader sense the same applies to orthotics with high medial flanges when put in a sturdy shoe and certainly in piedros and other kiddie boots. Its just one more place we can scrape together a few more supination moments to add to that side of the scales.

Regards
Robert

 

I disagree with this. You do not need to take measurements to ensure effective podiatric practice. Whilst I do agree Kevins post was excellent, (and already stated I do not find fault with any of his list), I also find Simon's point resonates with me most - how does this actually inform your orthoses prescriptions? i.e. does it change what you do??

It is interesting that I put the feelers out there back in post #14 with regard to anyone offering a rationale for why they took measurements and no-one did. Then Kevin posted his (albeit brilliant) response and people start having the confidence to publicly agree.

I wonder how many people take measurements but do so for no reason other than habit? Or when they really think about it would they have to admit they actually do not do anything with the measurements they take?

Ian

 

Ahaha. I think There are two different questions here.

1. Do biometric measurements inform your prescriptions?

2. Do you beleive biometric measurements have value (and therefor do you do them)?

I can well see an argument for 2 even if you disagree with 1. Effective use of orthotics is (sadly) about far more than just getting the right prescription. There are complex psychological and psychosocial interactions which go on during an examination also. Compliance must be gained, trust acheived, all those things which make the placebo effect work (don't knock it, its real!) If measurements place that veneer of "real science" and make these things happen then they have value.

How many times have you seen a patient with an absolute dog of an orthotic who was highly impressed with it because "the podiatrist used a computer to analyse my gait" or "a laser scanner". Granted they still came to you because it was not working but they were still happy with it weren't they?

And if you evolved such highly skilled assessment ability that you could glance at a patients foot and know instantly the prescription to use and could do the whole process in 9 minutes, how happy would the patients be?

Regards
Robert

 

Robert,

Nice post.

1. No

2. Yes (but still no)

I do take your point regarding patient perception, placebo etc but still feel that a thorough assessment, (well explained to the patient along the way) can gain this trust/compliance without drawing lines on the leg and calcaeum and reaching for the tractograph.

One of the things that fascinates me about this is how tetchy/defensive some people can get when asked if they do or don't take measurements. As I said already I don't believe there is a right or wrong, and if someone can explain what they do and why then job done. Even on here this thread has been viewed over 900 times, yet only 50 votes. Of these 50 voters, there are only about 10 of us who are actively discussing it. I just wonder why some people distance themselves from the entire subject?

Ian

 

Ian

I think we all agree with your points.

Perhaps, for the purposes of the debate, would you elaborate on the examination you conduct - particularly with reference to how each test changes the prescription?

L

 

Hi Lawrence,

I certainly don't set the world alight, nor do anything different to what I'm sure most posters here do, I just do what makes sense to me. Anyone who reads Podiatry Arena regularly or has been to a boot camp will probably do the same (as these two things have between them been primarily responsible for changing the way I think and practice).

To clarify, some of the kind of things I am talking about are:

(1) Considering STJ axis position to dictate the available 'area' in which the ORF can exert a supinatory or pronatory moment (deciding location of post/arch profile/plaster addition or 'type' of prefab issued)

(2) Supination resistance test to gauge how much force (i.e posting) the orthoses may require (rather than consider posture or degrees of calcaneal eversion for example)

(3) Lunge Test (this will decide if heel raises are a worthy addition)

etc etc

However I will hold my hands up and admit that with respect to point (2) that whether using the supination resistance test or whether using RCSP I suppose all we are curently doing is pretty much picking a number based on previous clinical experience rather than any evidence based research. However I think last time I spoke to Craig he mentioned he was doing some work in this area if my memory serves me right?

What is your preferred method of practice Lawrence? (What dictates your prescription variables?)

All the best

Ian

 

I thought that's what we were going to do in the sub-forum, but no discussion has been started there yet.

 

Simon

Are we being naughty?

Ian

I have been on a Biomech Boot Fair. I use the supination resistance test. However one critique oft put forward of measurement especially calcaneal/heel bisection based measurement is its lack of reliability. Just how reliable is the supination resistance? How specific is it? I have my doubts TBH. I have already had at least one individual wherein the resistance test suggested a medial wedge but in practice I had to modify the device to include a FF and RF valgus wedging.

Craig presents his flow chart of "tests that change the Rx" and he presents a case that foot morphological (shape) assessment is irrelevent. I dont see how it can not include morphology - for instance I believe that the identification of a large degree of forefoot valgus deformity will change my prescription. So my practice is one of using the tests like STJ axis spatial location, supination resistance, Hubsher (but I dont try to guage "early or late firing of the windlass" - a bit too spurious for me) and all those types of tests. I also examine range of motion of foot and leg joints and the relative morphology. The supination resistance may indicate that a medial rearfoot wedge may be appropriate but what if the STJ has no available motion?

I guess to assess RoM and morphology is to measure in some sense. Even if you use qualitative rather than quantitative descriptors.

L

 

In that case I too am a 'qualitative measurer'. (Perhaps the thread need to be renamed 'Who is a quantitative measurer?)

I also assess these things and do consider foot morphology (as you say FF Valgus deformities, or FF Supinatus for example). What I don't consider that much anymore is the weight-bearing foot 'posture', and although I don't mean to speak for Craig it was my understanding this was what he is referring to when he talks about shifting to the force paradigm, rather than stating that foot morphology 'irrelevant'.

Ian

 

As far as I'm aware it has been shown to be reliable in experienced clinicians -> Noakes and Payne (2003) JAPMA 93(3) 185-189.

Not sure about its validity though?

Ian

 

Yes the shift to the "force paradigm" is more his main point and granted I'm no doubt harsh on him to suggest he thinks morphological assessment as "irrelevent". But my impression was too great a de-emphasis on older assessment techniques for newer ones. Not to criticise Craig but its a timely issue. Again - the supination resistance test may suggest the use of a medial wedge but without assessing the rearfoot motion available and by one means or another assessing the relative range of pronation and supination how do you know there is the range of motion suitable for the wedge?

Its a bizarre situation. A FF valgus observation is relevent and changes our prescription. Yet we dont numerically measure it, yet to arrive at the conclusion our eyes and brains must have to some degree performed a mental bisection of the heel and compared it to the plantar plane of the forefoot. The brain also probabaly does a bit of maths and somewhere in the subconcious a number is cooked up. We then conciously then turn that into words like "small" "large" "significant".

Even RCSP posture - can we completely ignore this? Eric often points out the relevence of the finding of a an inverted heel and maximally pronated STJ - I believe in the dim and distant past this was referred to as "ye olde partially compensated rearfoot varus". Is there another way of assessing for this without at least mentally bisecting the heel and comparing its position in stance to the non-weightbearing assessment of the relative amounts of pronation and supination availbale at the STJ?

I guess Im a qualitative measurer too...

 

That paragraph is bloody brilliant.

 

Not sure I'm comfortable with "qualatative measure".

The concise OED defines measure as

And the observation of, for eg, a forefoot / rearfoot relationship in the way described above cannot really be said to do this.

If I observe somebody I might describe them as "tall" "short" or "gosh whats the weather like up there lanky". If I was measuring them I'd describe them in the standard units (cms or feet and inches).

All the things students are (quite rightly IMO) taught to measure with tape or goniometer are things I now observe.

I suppose as Lawrence says its a matter of translation. A true measurer might measure degrees on the foot and apply them as degrees on an orthotic. Ian, as a "qualatative measurer" might observe "quite a bit" on the foot, know from experiance that "quite a bit" of wedging comes from the Lab when he asks for X degrees posting and apply a number to the prescription based on that. In the NHS when I'm making my own insoles I can see "quite a bit" on the patient and make an insole with "quite a bit" of posting without ever attatching a number.

Here is a question. When you ask for 15 degrees skive or 5 degrees post is it significant that these are the same degrees as you mesure biometrically or might they as well be "arbitary units". I'm thinking of Kevins experiance that 15 degrees tends to be just right, 10, not enough and 20 too many. These are degree measurements but so far as I know they do not directly relate to degree measurements on the foot. Therefore he could describe this to the lab as "1AUskive" a low skive becomes "0.66AUskive" etc etc.

Regards
Robert

 

I started to write a post 3 times but could not word what I wanted to say.

I voted for measurements taken and wanted explain why but found that i was not expressiong myself well but I have seen the light.....

Im a qualitative measurer too... sounds a bit like an AA meeting

Michael Weber

 

Robert

By qualilative am I meaning a "standard unit" that is non-numerical? Dont know. Your OCD (sorry OED!!!) didnt say SI unit?

I was pointing out that many will claim not to measure but make observations about feet that at least imply at least some form of measurement such as forefoot deformity.They must go through a mental process of estimation that somewhere in the brain occurs in the form of "numbers" and this is translated in the conscious brain into a qualitative descriptor.

By the by, there's a game called subconscious counting. Get someone to arrange a number of objects on a desk out of sight then take the briefest of brief glances. Without counting them have a guess at how many objects there were.

 

There is a brain attached to the foot that you are applying the supination resistance test to. In feet that have laterally deviated STJ axes, an unopposed supination resistance test should be very easy. However, if the supination resistance test makes the patient feel like there ankle is going to roll into inversion, then they will use their peroneal muscles to resist supination and it will feel more difficult to supinate the foot.

What if you have a large degree of forefoot valgus and a high degree of rearfoot varus. The forefoot valgus wedge could be larger than the eversion range of motion of the foot. This is either uncomfortable under the lateral forefoot or in the sinus tarsi. I like to look at the foot standing and then try to evert the foot and see how much range of motion there is between the bottom of the fifth metatarsal and ground. This cannot be calculated with classic Root measurements.

You can still make decisions of whether or not to add wedging even if the STJ has no motion. It all depends on which structure you would like to reduce stress on. For example, a STJ fused in varus certainly should have a wedge under the forefoot to help even out the weight distribution across the forefoot in stance. Another alignment problem is genu varum or valgum. A wedge can help shift the center of pressure to a position closer to directly under the knee. This will reduce frontal plane moments on the knee.

Regards,

Eric Fuller

 

Hi Lawrence,

Have the patient stand and ask them to evert their foot (you will often have to demonstrate to get the patient to understand.) Then from behind watch what the heel does. A lot of the time the heel does not move. Rarely the calcaneus will evert. Some of the time the rearfoot (talus and calcaneus) will adduct without eversion (Classical oblique midtarsal joint motion). If the question is whether or not the STJ has range of motion available then you should look directly at the standing foot and not at measurements that have a couple of degrees of error. When I was teaching I would try and take the measurements and do the calculations and then in front of the students I would have to say well it would work if I changed a number a couple of degrees.

There was another comment on wanting to know range of motion before applying wedges. Yes, this is important for the forefoot, but not so important for the rearfoot. In the rearfoot, it's not about joint position, but how you want to change the center of pressure under the foot and hence the moment from ground reaction force.

Cheers,

Eric

 

Just my quick (and slightly cynical) thoughts on this topic.

As a new grad (only 5 yrs ago) I quickly found myself not using the great list of numbers I was taught i needed to aquire during my "biomechanical assesment". They just didn't really impact on what kind of thing i was going to stick in the shoe. So the natural progression was to eventually not bother doing it. I quickly realised what i thought i needed a foot to do and how to make something that i thought would make it do it.

However, my boss found out and I got into trouble. His reasoning was that if we are going to charge the item number for a "biomechanical assessment" then I should be doing a good old fashioned biomechanical assesment. Also, I was concerned that people felt like it was a lot more scientific walking out of the clinic with lines drawn on their legs after lots of ummming and ahhhing and frowning and seroius facial expressions. I think it improved their perception of my competancy.

I'm probably not the best podiatrist in the world, however, and I have taken the point by some that there can be valid reasons for taking these measurments routinely. I just know my reasons were entirely for patient perception.

 

Phil:

You have learned a valuable lesson here about patient care. Much of what we do as clinicians is to treat the patient mentally......as well as physically. How you dress in the clinic, how you speak to the patient, how you examine the patient, how your clinic looks to the patient, how your office staff speaks and relates to the patient, and how you handle your billing practices will all affect your patient outcomes probably much more than you would ever expect. All of these things are taken into serious consideration by the best clinicians. We, as clinicians, are not repairing machines: we are repairing people with brains, emotions, feelings and real lives.

 

I think that if we draw lines and measure for measurements sake we also tread a fine line with intentionally deceiving the patient/ billing company. Pretending that we are measuring accurately and validly when we know we are not, using time and billing for tasks that were unnecessary to provide appropriate treatment etc.. You can and will argue now that you use the measurements as Kevin described previously. But I suspect, if people are honest, many hadn't even thought of half of Kevin's list until he posted it here a couple of days ago and actually perform the measurements they were taught to do, log them, bill for them and forget about them as Phil intimated :morning: I can hear your protestations now "but Simon, I use them as a reference like Kevin said... blah blah" Yeah, right. Stop deceiving yourselves, it's not worth it.

If we attempt to manipulate the psychology of the clinical encounter as Kevin describes above, and we do, where is the line between the conscientious clinician and the snake oil salesman? Are both not attempting psychological manipulation (trickery)?:butcher:

Have fun- off to London today to see U2 tomorrow Breathe now... and don't buy just anyones cockatoo

 

Which begs the question: if we sell a patient a custom foot orthosis when the clinical evidence suggests that equally efficacious outcomes could be obtained using a much cheaper prefabricated device, are we not guilty of obtaing money by deception, unless the patient is given a fully informed choice?

 

Would this still work in open chain i.e., in the absence of GRF? Or would the orthosis just rotate with the foot without GRf beneath it?

 

I think it depends on the patient education and experience, too. Probably, for the first time, it will be preferred the practitioner who use a pressure map instead of goniometer or a foot scanner instead of plaster...
I believe that a possible answer is : "the one who can solve my problems " !

Daniel

 

What an interesting discussion.

I answered yes prior to reading as I interpreted the "orthopaedic" question a tad differently.

I don't bisect the calc as I know my reliability is shocking and I'm not sure what use it is though I was taught it long ago.

I take measures of things that I am trying to change to that I know whether I have or not. Primarily the 2 I do the most are the lunge test and popliteal angle, I use a digital inclinometer for both and I know my reliability is good. The other thing I put numbers on is manual muscle testing, while I know my personal reliability is good, the next person that grades strength will probably grade differently so if I was in a setting where it mattered a great deal I would use a dynamometer. There is something very cool about seeing a change in range or strength after a stretching/strengthening program. I do also if needed do the hip range.

As for the others, as I primarily work with children I predominantly use prefab's so measurement for prescription is something I don't have to think about a lot.

 

Hi just came across this thread

Eric you wrote

Now that's a good idea that I don't use at present, cheers for that.

As far as measuring goes, I like to measure and record those measurements for future reference. For example I might see several people for assessment but I don't write their prescription straight away, often I like to review data, (perhaps 2D video and pressure mat plus clinical notes and biometrics) and ponder the biomechanical variations and decide on the prescription I will make.

If measured biometrics have a wide variation in repeatability and reliability then I would suspect that some visual estimate of the same parameter would have a much greater variation. If you say that you use other measures other than direct measurement, like palpation of supination resistance, well I can do that too but how variable is the estimation intra clinician from patient to patient and day to day. These things will be extremely variable but they have not been researched and written about formally yet as some biometrics have.

I like and agree with Lawrence Bevans point about visual estimations of biomechanical / biometric variations and I like and agree with Kevin's reasons for taking measurements too.

Ian I can respect your methods and entirely believe that you get good results but I like the more formal method that to my mind has providence and provenance built in.

This is good for inter professional communication and these are things that customers will pay for, can respect and accept as proof of professionalism and I think as others have said, they are more willing to be compliant and see the value of the whole treatment plan.

Cheers Dave

 

Dave

Just a quick amendment to measuring the heel pad width. Its useful to do but measuring the heel width of the shoe the devices are going into ensures orthoses fitiing 1st time.
This method has reduced the amount of orthoses being returned for adjustment due to not fitting the shoe down to virtually zero.

Cheers

Phil

 

Simon:

Using measurements of an individual's joint range of motion and structural variability should not be considered to "deceiving the patient/insurance company" if the podiatrist is truly using that information to learn more about that patient's structure and function. In addition, whether we like it or not, "the psychology of the clinical encounter" is highly important when we all are treating patients and I would expect that every successful clinician knows how to relate to people so that they feel comfortable with them as physicians. This is not a matter of trying to deceive patients but rather a matter of trying to give patients more confidence in your treatment so that better therapeutic outcomes are more likely to occur. As I said earlier, we aren't treating machines, we are treating humans.

In addition, I wouldn't be so confident that taking measurements is never going to produce an association with gait kinematics and gait kinetics and that taking orthopedic measurements is useless or even "deceiving". About six months ago, I was a reader on a Master's thesis from the Biomechanics Lab at UC Davis which showed that there were quite a few biomechanical measurements that significantly correlated to biomechanical function. Maybe the right studies correlating structure to function just haven't been done yet.....I honestly think that this is the more close to the truth.:drinks

 

Hi Dave,

I suppose when it comes down to it whatever we do the main thing is that we get results and outcomes that are favourable. I said from the start 'each to their own'

I too often like to ponder over data and consider things for longer sometimes so will end up writing a prescription days or even weeks following an assessment. I suppose what I have been doing is attaching detailed written descriptions to my patients records rather than numbers; so that when I read my notes back I can immediately visualise the foot based on how I have described it, the same as I guess you visualising a foot based on numerical measurements.

Since this discussion started I have taken a look at the way I practice and realised that despite not owning a tractograph, not drawing on patients, and not assigning numerical values to measurements that I technically still 'measure' things (thanks for opening my eyes Lawrence)

Ian

 

Good point. Often all it takes is increasing the angle on the bevel. I just haven't gone to the hardware store and remembered to by the other kind of calipers.

Cheers,
Eric

 

When a STJ pronates and the forefoot abducts on the rearfoot, and the talus becomes promenent medially, the medial to lateral distance of the foot will increase weight bearing and non weight bearing. If an orthosis has a medial and lateral clip that is less than the maximum medial to lateral distance then it is possible for the orthotic to resist "pronation" with transverse plane forces. The problem is that you would have to attach the device to foot and practically it will fall off unless it is attached to an AFO or something.

Practically, it is very difficult to apply significant forces in the transverse plane becuase the location at which the forces are applied usually become uncomfortable. It might take a few tries to find the optimal stiffness of orthotic material and casting position.

Regards,

Eric Fuller

 

This thread has become a fascinating discussion. I do "Root measurements" on my patients that are getting custom foot orthoses even though I know they may not always give me much valuable information which may change my orthosis prescription. However, I have never believed that these measurements that I perform and record in the patient's chart is just about making better orthoses for my patients.

I have always felt that my job as a foot doctor and biomechanics specialist was to be able to tell the patient as much as possible about their foot and lower extremity structure, mechanics and function, when compared to normal, so that they could feel as if their money and time was being spent very well in seeing me. In other words, my goal has been over the past 24 years of practice, to provide my patients with more information regarding the structure and function of their foot and lower extremity than they have received from any other health professional. I feel that the measurements that I do are simply a part of what allows me to provide this service for my patients.

 

This is great Eric, thanks. Thats why you are where you are and I am where I am:drinks. Your discussion on the peroneal contracture is probably what was up with my patient and you have discussed this before - stupid me for forgetting. This is a good example of how trying to use but a handful of tests to pigeon hole patients ultimately leads to missing things.

In your example of large FF valgus and large RF varus I reckon you can get that info from the Root style examination but your way is more pragmatic.

L

 

Shhhhh Simon the patients and insurance companies will hear you!!
I think it is possible for an individual to train so that their own measurements are reasonably repeatable so it's not that reprehensible!

Also mental medicine is all part of the game, dog. You feelin me? Kevs being thorough and gaining the patients confidence, filling an appointment with waffle to bill more is different.
:drinks

L

 

Lawrence,

But if the measurments are still a waiste of time, as we all know they are, because they do not predict dynamic function, you are selling the proverbial snake oil!

regards

 

Graham:

Since the F-scan, or any in-shoe pressure analysis system for that matter, does not tell you anything about either joint kinematics or joint kinetics of the foot or lower extremity, as we all know, you are then selling the proverbial snake oil by performing such an exam on your patients!

 

So. To recap.

Those who "take measurements" are selling snake oil cos they're not predictive of dynamic function.

Those who use F scan are selling snake oil because its not predictive of joint kinematics and kinetics.

Those who do neither must by inference be selling snake oil because if we assume the above two have no useful data from their measurements they have exactly the same level of useful data (ie none).

But I bet all three methods can produce useful orthotics based on the paradigm of your choice. I'd further bet that if Kevin, Ian, Graham, Lawrence and me all saw the same patient we'd come up with similar end products and get the patient better.

I would venture to suggest that what defines snake oil is not how a prescription is arrived at, rather the claims made of the product to treat the condition.

Its a big accusation to level at someone and should not be done so lightly IMO.

Regards
Robert

 

Sorry for my stupid question but simply, I don't understand ! Why do you perform "Root measurements" if sometimes, these don't help you with the prescription ? It is not enough only to tell to the patient about these measurements ? Generally speaking, how much time it takes to perform all necessary measurements ?
Thank you !
Daniel

 

Robert:

You are right.....I was just giving Graham some of his own snake oil medicine so he could see how it tasted. :boxing:

Unless someone has much more knowledge about foot biomechanics or the available foot biomechanics research than I do and can prove me wrong, it seems very clear to me that there are currently many ways to properly evaluate the foot and lower extremity, both structurally and functionally, both with and without making measurements, to make proper foot orthoses for our patients. Until someone can show me that by my performing my measurements somehow prevents me from making therapeutic foot orthoses for my patients, then I will continue doing my measurements. Since I am regularly drawing patients from a 100 mile radius here in a densely populated area of northern California, and making 80 - 100 pairs of custom foot orthoses a month in my practice, then I probably am doing something right.

Once the research has been done that conclusively demonstrates that a single well-trained practitioner doing biomechanical measurements on a number of individuals can not ascertain certain structural characteristics of an individual's foot and lower extremity by performing these measurements, then I will start to pay attention to those who say that measurements are of no value or are "snake oil". However, contrary to the popular belief of many here on Podiatry Arena, that research has not been done yet.

Have a nice weekend....even you too, Graham.:drinks

 

Daniel:

Does every clinical test that your family physician does to test the proper function of your cranial nerves or your peripheral reflexes, or does every routine lab test that he does always test out positive for abnormality? When you answer that question, I will answer your first question.

As far as time required, about 10 minutes is required to perform a full biomechanical examination, including gait examination.

 

Kevin,

Apples and Oranges.

F-SCAN assissts in identifying what you are doing with an orthoses when looking at the force/time parameters. It is not used as the only tool in the prescription of the orthoses. Physical assessment of health, ROMs, assymetries and gait are also required

Structural Measurments, which have been shown to be both relatvely inaccurate and a poor predictor of dymanic function have no place in a profeesional examination. Especially when you know they are not useful.