Do you take measurements during orthopaedic examination?

PRO, Sir!

I'm Chris Gracey MPT, CPED. I've made all the shoe mods, braces and orthotics for the kids and adults at the NIH for over 10 years. I also see many of them clinically as a therapist so was very busy and either uninvited or uninterested in publishing until recently. I see folks on the outside too but they are mostly elite athletes for local pro teams. I own my workshop and have access to a motion analysis lab, Pedar, Stride Analyzer, etc. I've been an adjunct professor at multiple local universities. Doing a LE workshop for allied health professionals in Nov. I'm studying cycling FO's and an algorithm to predict orthotic parameters currently.

I do NOT write posts often so thanks for the abbreviation lesson.

Funny, It's just a mistake I said the "Fn" part...brain fart is all... but Man, you gotta have a thick skin around here, Huh? You guys are alright in my book.

Chris

 

Not just physio's. Pods too!

I refer anyone following to the hallux rigidus classification system Prof Payne published on this very forum.

1. Patient has Hallux rigidus

2. Patient does not have hallux rigidus

But as Dr Spooner says, thats a whole other thread.

Regards
Robert

 

It's 3am in DC. And my buzz is wearing off.:morning:

Limitus and Rigidus are NOT interchangeable in my book and denote different degrees of available (or lack there of) motion. Functionality is debatable but most agree in the presence of HRigidus, available range of motion at the 1st MTP cannot be considered functional.

 

Oh yeah. But its amazing how quickly it thickens. Its all good fun.

Seriously, I used to get deeply frustrated when I got picked up on every minor presumption, generalisation or unsupported statement. But there is a point to it. As Kevin has often pointed out clear unambiguous terminology is essential for the effective communication of concepts and ideas. As when Alex talks of supporting a triplanar axis and positioning a fulcrum on an orthotic. This may be a valid and important point but I don't know because it has not been clearly communicated.

But I digress.

Robert

 

Dead Milkmen, Black Flag, Minutemen, and Butthole Surfers Rule!!

Well, they did when I was a kid...:drinks

 

I don't play games with new posters, thanks for the offer. Bye.

 

Chris,

I asked how the measurements you take dictate your orthoses prescriptions. This was your first 'answer':

And this was your second 'answer':

Still not good enough Chris I'm afraid. HOW do certain measurements influence fabrication parameters? HOW do you refine your decisions in light of varying measurements?

Ian

 

Kevin,

It means I've got the balls to accept when something I have been using is shown to be untrustworthy and change accordingly.

 

I do. Its how we all learn. And I enjoy it (far too much!)

I promised Ian I'd stay out of this one but I can't! Sorry M8.

Whats missing is not a measurement but a diagnosis. Tissue stress theory is based around reducing tissue stress in damaged tissues. How then can an orthotic prescription be derived using tissue stress theory without knowing which tissue is pathological?

For example, lets take the measurements you offer and I'll suspend disbelief to assume they are accurate to within a degree. Lets give him a compressive medial knee arthopathy. What is the degree of rearfoot varus post I'd use? Well none actually, I'd be posting valgus instead. Lets give him a damn great neurovascular HD on his 5th met head. Again, I would'nt be inclined to post him medially! Give him a nasty bout of Tibialis Posterior tendon dysfunction and a medially deviated STJ axis and I'd be looking at a Medial heel skive rather than a wedge.

D'ya see my point? The orthotic prescription (IMO) is not based on X - Y * Z but on the pathology and the way the foot works. So I can't answer your question of how much rearfoot wedge to use because I lack the essential information of what is actually wrong with the patient!

So, having answered your question (quid pro quo clarice:butcher:) I have one for you. If your orthotic above has a rearfoot wedge of lets say 5 degrees what effect will this have on the actual foot?

Regards
Robert

Oh and PS

In the presence of Hrigidus there is NO available range of motion at the 1st MTP. Thats why its called rigidus. Its rigid.

 

Speak for yourself. Personally about the only thing I learn from this esoteric and callow bull****, is that my tolerance of such bull**** diminishes with each one of these individuals who come on here spouting that they are the light.

Your old mate the 4th dimension could be important; define rigid. If we have a point during gait when no motion occurs, is this rigid? Anyway, as I said, that's for another day.

In case anyone is interested, U2 were awesome.

 

De mellowing Simon? (that's my word, I made it up).

Fair enough. I'm guessing you are more a teacher than a student these days. But I'd sorely miss your wit if you did avoid these threads! I'm waiting for the next "I've had better laughs....... " line. Quote of the year 2009 is still open remember!

Re my dr who physics is it not true to say that at any point (instant) during gait no movement occurs? I would define rigid as the inability to move rather than the lack of movement under certain circumstances. But I sense the deep stirrings of a profound thought from you which will keep me up all night (again) so let's have it!

Cheers
Robert

 

"...my measurements are a validation of the visual assumptions I make and therefore influence the fabrication parameters by refining my final decision."

Welp, I guess it boils down to personal philosophy developed over time. If I observe HF Valgum, I can guesstimate the degree. If I measure it and the goni reads higher than my guesstimation, I've created a "Most likely" range that moves higher than I originally thought. I watch the arch fall and observe the Navicular Drop. I can be pretty confident of the minimal navicular height during gait but I perform the NDT just to be sure. If it's grossly different than my observed distance, I note it and make a decision to address it in my build or not. Now, when I go to fabricate the device, should it require a medial post, I may lean towards a degree higher. If I am concerned about the ND, I'll tailor the device to limit the distance during stance to a certain range through materials selection or shape dynamics, or % backfill on the positive mold. Or, If I measure the LLA and only backfill say 10%, to achieve alignment, I may include a plantarfascia relief groove for comfort.

Ian, I'm trying to put into words what I consider the "art" of my personal fabrication style. My measurements do not dictate the parameters, they influence them. Thanks for pushing me through the exercise.

Chris

 

oh and PS to you

Can you tell me what eval tool you use to derive your claim?
I use Coughlin and Shurnas, 1999 because it makes a distinction between live and film. Each is considered a level of rigidus but I only report G3-G4 because you really only use around 40deg on average (Nawoczenski, 1999) and there are so many things HR is not associated with.

C&P'd for your pleasure:

* Grade 0 - DF of 40-60° (20% loss of normal motion), normal radiographic results, and no pain
* Grade 1 - DF of 30-40°, dorsal osteophytes, and minimal to no other joint changes
* Grade 2 - DF of 10-30°, mild flattening of the MTP joint, mild to moderate joint narrowing or sclerosis, and dorsal, lateral, and/or medial osteophytes
* Grade 3 - DF of less than 10°, often less than 10° PF, severe radiographic changes with hypertrophied cysts or erosions or with irregular sesamoids, constant moderate to severe pain, and pain at the extremes of the ROM
* Grade 4 - Stiff joint, radiographs showing loose bodies or OCD, and pain throughout the entire ROM


Thank you for playing!!

 

For purists, "were" is absolutely correct. Gone is the angst and spit. They sold out for a well produced, Quincy Jones style of music and a more mainstream and global message, though and the results speak for themselves. What do you think of the new album? Was that a little Radiohead-esque sound I heard?

C

 

Oh wait! You answered that already!! My bad!

Peace and Props,

Chris

 

No Idea what "kiss my grits" means but I think I like you Chris!:drinks. I think we'll disagree lots but we'll have fun along the way! :drinks

Your post is long so I'll have to answer in stages, but on the HL / HR, I'll grant that those surgeons defined hallux rigidus as "Limited first MTP dorsiflexion and plantarflexion ". Touche. But I still don't think that if the definition for "rigidus" starts with the word "limit" that its a good definition!

More on the rest later.

Regards
Robert

 

It is certainly interesting to see what others are thinking and doing, I feel that there is no definitive answer to measurement taking, one does need to understand the need to identify if a STJ is compensated for or not and so the cast should reflect this.
As for the soft tissue influence within biomechanics then gentlemen good luck, how much oedema, how much muscle development how much splaying force(Lake 1950's) We just don't know because the dynamics of a patient changes just by the fact they are human and we do not have control, scientific, over their actions. Diagnosis is the key and if some of us require to take measurements and others do well as long as the diagnosis is accurate then that is all that matters. It's not theories or academic pride it's about helping the patient.
Newton wrote 3 laws, why, well maybe this discussion goes back to then and he covered all options.
I choose to support the foot at one point and others another point but there is no point balancing one section of the skeletal system if all it does is causes a compensatory overload somewhere else, shunting reflex as described in the CP lit. Just look at what the MBT shoes are doing to the thorasic spine.
So as long as we are trying to help, that is what matters isn't it.
Alex Adam

 

They knocked Dandelion Green down and Martin Hannett died. You can't play Shadows and tall trees forever, although they probably should. Time ticks on and the performance on Friday night was one of the best I've seen since War Tour, you can't jump off the speaker stack into the crowd when you're nearly 50 and someone would most likely sue you for landing on them, that's the difference from 1979 to 2009. I miss the heady days of of the small venues as much as the next fan (not those who go to a concert to watch it through the 1inch LCD monitor of their phone and complain when "it kicks-off" in front of the stage). Health and safety and booms around the stage killed the crush, there's nothing like the pressure of 50,000 people on your back, I haven't felt that since Joshua Tree, but hey that's evolution.

Radiohead- saw them at Walsall Town Hall around Creep time, they spent all their time on stage hiding behind their fringes. ~Each to their own.

 

Right O. So we got us a painful hallux limitus.

Sorry, abbreviation confusion. Whats ND?

Hmmm. Ok you lost me. Pathology is functional hallux limitus. With you so far. You want to reduce flexor tendon (and I would suggest plantar apeurneurosis) tension. Still with you. So you're using a 10 degree forefoot varus post.... no, lost me now. How will a ff varus post decrease tension in the flexor tendon? Surely that would exert dorsiflexion force on the 1st met and INCREASE tension.

Which would exert a planterflexion force on the 1st met and decrease tension. with you there.

What is Axis medial rotation?

Provided your increases planterflexion moments from the RF post and the arch height exceed the DF moments from the FFvarus extension....

.

Yep.

Yes! Know you of such a study?

Hmmm. Got to disagree there. Firstly there is a wee nuggett of data from Craig Payne in which a 6 degree high density EVA wedge showed an average change in the calc angle of 2.82 (+2.05). And a GRF alteration which as you say may or may not exist is very definitly the actual foot! A kinetic change is still a change and can derive a theraputic benefit.

And to you....


Regards
Robert

 

I agree with you so I go ahead and call it Fnlimitus up until a point of no return like 10deg or less. Then, in the presence of loose bodies, deformation, and disability, I call it rigidus.

 

Of course, I had just gotten done describing all this jazz on how I employ a RFPost and then I go and say it doesn't do anything?
I'm sorry for letting my jerk side out. I was trying to be funny but it just made me sound stoooopid. Although...you did say 5 degrees and the study was done with 6 and there was another more effective device out of the many examined if I recall correctly (but, I don't remember which one) I think it included an arch component. Woops, there I go again being a dumbAzz.

Peace and Props,

Chris

 

The rationale for measurement/recording as put forward here by Dr. Kirby seems solid. To extend the initial question a bit, I would like to ask which specific measurements are indispensable (irrespective of precision) and must be captured to inform the orthotic design process?

Furthermore, given that casting is the prevailing information capture tool out there, what unique information is believed to be stored in the cast that cannot otherwise be measured by examination of the patients foot and lower extremities directly? Indeed perhaps more information including the subset of Rootian measurements can be captured by comprehensive bio-mechanical examination of the patients lower extremities as a system.

So?? What measurements are the best to capture for fabrication of an orthotic and will any take umbrage if those measurements are not taken from a cast?

Thanks
Brahim Dagher
Podiatric Assistant
617.515.5992