EBM and Sacketts Empiricism

Found it

Just so we're clear, what exactly is a "flat rearfoot type"? Is this as in really flat, floppy, hypermobile feet? You're putting Valgus rearfoot posts in patients with flat feet? (!)

 

The Flat Rearfoot Type has a
SERM that is everted
and a
PERM that is everted

an example would be a Dwyer failed in valgus.
Dr Sha

PS: This is off subject and may be better held on another thread since I think we have developed the EBM topic to an advanced point at this juncture.

 

Robert,

10,9,8,7,6,5,4,3,2,1

 

Thankyou Dennis. Never fear, there is a big fat EBM point nestled within this little egg of a discussion point. Although I agree that the use of valgus rearfoot wedges for flat feet is worthy of its own thread!

And, to be perfectly clear, before we go any further, You use lateral valgus rearfoot posts in these flat feet right? And only these feet? Any other foot types you use them for?

 

I intend to remain civil in answering your queries but it is obvious to any reader that you are conducting this "interview" adversarially.
adversarial: 1. pertaining to or characterized by antagonism and conflict
2. (Law) Brit having or involving opposing parties or interests in a contest

Remember, you didn't like me when I interviewed your website adversarially.

You have a bias level that is beyond Robert and it always forces me to be adversarial in return. Then you complain that I am personalizing blah blah blah.
How do I get on your good side?

Please stop using the ambiguous term flat feet as it does not apply to FFT's.

You will find yourself alone on a site dedicated to valgus wedges for flat feet as it is your personal fantasy.

I use valgus rearfoot positing for the flat rearfoot type feet.
and none of the other rearfoot types (as a rule).
DrSha

 

In which the rearfoot range of motion occurs with the calcaneus remaining everted (valgus) throughout. Such that when the rearfoot is maximally pronated, the calcaneus is everted and when the rearfoot is maximally supinated the calcaneus is still everted. Don't you understand what an everted rearfoot PERM and an everted rearfoot SERM is yet, Robert? Please try and keep up.

Here are some other variants on the PERM..

 

Simon chimes ion adversarilly and you will be shocked when i am next.

Can't he focus on one of his low level Ph.D. projects that will produce no new level 1 evidence instead?

You guyz are such jerks.

Dr Sha

 

Sorry dennis, not being intentionally adversarial, I'm attempting to be precise, and to ensure that I have fully understood the neoteric use of lateral wedges before I critique it.

I don't use the term flat feet as a perojative, I was actually quoting you from your chapter in Principles of Diabetes mellitius in which you describe the flat RF flat rearfoot foot as

So I'm really just trying to use your terminology within your paradigm.


I'm a bit confuses about this point. Here

You describe the flat rearfoot flat forefoot type as

In the post below you say

And then

You understand my confusion?

However. As interesting an aside as that is, its not as you point out anything to do with EBM.

This, however, Is.

Medial Knee osteoarthrits. Occurs in all sorts of different foot types, I'm sure you agree. So lets say I rock up (ok, limp up) To your door with my stable rearfoot type and my medial knee OA.

There is a HUGE body of evidence to support treating medial knee OA with lateral wedges a selection of which I've posted below and which can be seen here. It is fair, I think, to say that the evidence for treating medial knee OA with lateral wedged insoles is solidly into level B, possibly even nudging A.

And yet neoteric biomechanics, unless you are lucky enough to have a flat reafoot type, will treat you with a neutral or medial rearfoot wedge.

How is this compliant or consistent with the preponderance of evidence?

Just asking

 

PLEASE don't be next. I'd love for you to stay on topic. Its relevant and everything!! And whilst it is adversarial in that I disagree with your contention that Neoteric biomechanics is EBM its not personal.

Or is this exit discussion enter ad hominem time?

 

Yawn. You wanted people to talk about your work in your language, I'm talking about your work in your language. It's still a pile of ****e in any language, Dennis. I'm sure my colleague is capable of pointing that out to you- I'll leave you two to it.

 

for every 100 flat feet, there are 1-2 FLATFOOTED (as you are calling them) rearfoot types that are flat rearFFT's. The most common FLATFOOTED rearfoot type is the flexible rearFFT and that is the one you are referring to in your evidence and like their findings, I would never use a valgus rearfoot post as stated in the FFT rules. I would generally recommend a 0 RF Post (vertical).

Robert:
I will stay on point with you allowing priorities and time deficits as always. You are ONE OF my EBM mentorS after all (seriously).

 

No, thats what you are calling them. I was quoting you. The flexible reafoot you describe as flat foot (don't know if thats different from flat footed)

No, the evidence I referred to had nothing whatsoever to do with flat feet.

Read some of it. All of it ADVOCATES the use of a valgus rearfoot post for medial knee OA. Which is obviously CONTRARY to the FFT rules. Which is why I want to know why the FFT rules are the opposite of the vast quantity of evidence we have for treating medial knee OA.

Read my post again, I think you misunderstood it.

 

Let me put it another way.

Good solid evidence advocates treating medial knee OA with a lateral wedge.

Fft advocates treating medial knee oa with medial, lateral or neutral wedges depending on foot type.

Therefore, since the neoteric approach differs significantly from a huge volume of evidence it cannot (in this regard) be considered evidence based. It advocates treatment contrary to what large and good quality studies have shown to be effective.

Does that make sense to anyone else? Chime in by all means!

 

It comes back to this problem Robert: while valgus rearfoot wedging has been demonstrated to be efficacious in the treatment of medial knee osteoarthritis and makes sense from first principles, has varus wedging, and neutral wedging been demonstrated to be less efficacious? OK, so neutral wedging has been shown to be less efficacious, which is what Dennis was advocating a couple of posts back, so his response there was not evidence based. But what about studies comparing varus with valgus rearfoot wedging?

It also comes down to how many studies does it take to change someone's mind, lets say the "best evidence" shows that medial knee osteoarthritis responds favourably to valgus rearfoot wedging, but practitioner X has found over the years that his patients with medial osteoarthritis have gained relief of symptoms in response to varus rearfoot wedging. Practitioner X has to overcome a number of psychological barriers in order to change their practice based on what the "best evidence' tells them. How much evidence is enough evidence to admit you were wrong? Depends on your ego.

 

In a brief review of these articles (I am familiar with one of them) I find it compelling evidence that a valgus heel wedge of 5 mm has positive effects on medial knee compartment OA. In that regards, I have never used a valgus wedge to treat medial knee pain(which I find more frequently than lateral.

I treat foot type-specific which for the common foot type without advanced PTTD would involve a verticle heel, sagital plane forefoot correction, prn, a vaulting of the arches of the foot and heel lifts, prn. I have had great success in treating OA of the knee and refer those that are not responsive to Rheumatology or Orthopedics.

I do not believe there is strong evidence to parallel my care with those that you presented but in my paradigm, I am using the best available evidence for my treatment which is very effective clinically.

Interesting to me would be the fact that a 5 degree valgus wedge would have a 2.5mm heel lift effect and secondly, I wonder (as I think back to the NIKE Waffle trainer and other valgus "stops" that I have tried and followed in the Literature), whether or not sinus tarsitis and lateral ankle problems may arise as a complication to the valgus posting in many feet.

Dr Sha

 

Depends on the length of the adjacent or hypotenuse. Basic Pythagoras .

Like I said Robert, it depends on the ego. I have seen the light, and I am the way.

So back to first principles Dr Sha, how does a heel lift influence the kinetics / kinematics of the medial knee in a way in such it should relieve the symptoms associated with medial knee osteoarthritis? If you could illustrate your response with references, that might be a bonus. In general, as the heel height of a shoe is increased the foot tends to supinate BTW, so increasing heel height should have a contrary effect to the valgus wedge effect i.e. increasing supination moment at the STJ as oppose to increasing pronation moment at the STJ. However, Daryl Philips demonstrated that the supination / pronation effect of heel lifting is dependent on the relation between the position of the net force exerted by the heel of the shoe and the position of the subtalar joint axis...

Question: what are the kinetic effects of a valgus wedge at the knee joint? What are the kinetic effects of a 2.5mm heel lift at the knee joint?

 

You say you are using the best available evidence for your treatment. The best available evidence (for medial knee oa) is the stuff I've given you and points clearly to valgus wedging. If you are using the best available evidence when a knee pain case appears you will be valgus wedging unless you know of BETTER evidence for varus wedging or neutral wedging.

So HOW are you using the best available evidence for your treatment? Are we talking about the same evidence but that you are using them differently or is the evidence you refer to different evidence. If so please cite.

Or do you consider the fact that you've had good results with neutral / varus wedging to be the BEST evidence and the cochrane database to be second best?

I'm not trying to be confrontational but you keep saying you use the best evidence but never show it. Here is a good example, one of the few area we do have solid evidence yet you maintain the contrary position and claim that your position is based on best evidence. So show this evidence.

 

I am talking about the best evidence for my paradigm.

Do you have evidence of the positive and negative effects of a valgus rearfoot wedge on the substructure over time?

Are these arthritics walking slower and taking smaller steps due to a reduction in stride or cadence from the valgus wedging rewducing theor arthritic pains?

I have never met a patient with arthritic knees that did not have concomittant pedal complaints or underlying biomechanical pathology and for me, the valgus wedge is contraindicated in many feet
that have fhl, pttd, neuromata, lesser met callus, ankle equinus deformity, etc. and so I have searched for treatments that avoid a laterla wedge. Again, do any of you remember the NIKE Waffle Trainer which is now avoided?

my evidence is the best available for my treatment paradigm until my treatment paradigm fails.

Robert: you say you have no treatment paradigm but for Medial Knee OA your paradigm is valgus heel wedging. Let's say, for arguments sake say that a future study shows another wedge or treatment as effective as the valgus wedge.
Are you saying we should aboandon existing treatment methods when positive evidence appears?
Celebrex, Thalidamide to that!!

DrSha

 

"I'll keep on chopping that 3rd toe off to get rid of that corn on the 3rd toe proximal IPJ, until someone proves me wrong." It'll get rid of the corn... but at what cost? -Right Dennis?

Robert, you won't win. Dennis is old and too stuck in his ways to admit that what he has been doing for the last X years might possibly not be the best approach to care for an individual with osteoarthritis of the medial knee joint. No matter how many studies you produce which show a valgus wedge is effective, until you produce one that shows any other variation of wedging is ineffective, he'll cling on to what he believes is right.. To admit that he was wrong and may not have provided appropriate care, this he'll never do.

In another persons "paradigm", everyone should walk around naked, that would rid them of all of their ills; clothing being the root of all pathology. Until someone carries out a randomised placebo controlled trial to prove otherwise they shall continue advising nakedness as a cure for cancer....

In my paradigm, Dennis is a cock and shall remain so until I have a randomised controlled trial which proves otherwise within my paradigm; even then I wouldn't believe it.

 

Robert,

One thing that I have learned over the years is that it is almost always of no use to try having a rational discussion on biomechanics with someone that has a financial interest in a certain product or a certain "pet theory". Maybe you will find, as I have, that time is much better spent on trying to educate those individuals that actually want to learn, rather than on those individuals that will only allow themselves to learn that which supports their beliefs.:drinks

 

This I know . But the debate still has value, to me at least. This is when I enjoy the arena when a stimulating opponent challenges me to justify WHY I think what I think. Its not about winning or losing, its about mental stimulation and learning to play the game. Mainly for me. Selfish I know but there we go.

Your time certainly is Kevin. :drinks And there are plenty of us (who do want to learn) who appreciate your efforts in that direction. My time is perhaps rather the less valuable. But its my time, and I'm having fun with it.

One of the things which hooked me onto the arena was the first full on stand up blarney between you (et al) and Brian. Before that biomechanics was my job. I enjoyed watching you at war so much, and learned so much in the process, that it became my hobby. You had no chance of "winning" against Brian, or of"educating" him. Lets face it, to do such he would have to find a new job! But you certainly educated me along the way and crucially entertained me while you were doing it! :drinks


Dennis

Wotcha my valued sparring buddy.

A simple point with something to say about the nature of evidence. You are talking about the best evidence FOR your paradigm. Evidence is all about trying to disprove your hypothesis (to prove the null).

Lets take an example to illustrate the point. I believe that Shaving your head cures the common cold. I shave 100 heads and 99 people get better (one went to hospital and got C Diff). This is evidence that shaving your head cures the cold. But its also rubbish because of confirmation bias. I had my hypothesis and I designed my study to prove it.

Lets say I still have that belief but that I want to Prove it the right way, by designing a study to DISprove it. So I sit and think, assuming I know it works (empirically) how would someone seek to disprove it. They might blame the improvement on placebo or regression to the mean (colds get better by themselves). So I set up a study to try to prove that shaving your head makes NO difference. To do this I must know, different to what? So I need my control group. And then I find that although all my patients got better, they did so in spite of me not because of me.

Confirmation bias. Its how we're wired and its reliable. Its also won me quite a bit of money in proposition bets in pubs.

So, you say you're talking about the best evidence for your paradigm. Well and good, I'm sure you could find some (although you've not showed me any yet). But I'm showing you evidence which supports the null. D'ya'see?

Irrelevant. Be happy to discuss this with you on the knee thread but that's not the point. It may be, as simon says, that a different wedge might work better. It may be that valgus wedging causes problems later on. But they are both suppositions. It may be, but the evidence in hand (EBM remember) shows neither. And as a by the by, since you value empiricism highly I can tell you that I've had no such complications with my patients.

Empirically, I started medial wedging most people with knee pain, and I've tried lateral wedging as well (for x ray confirmed medial knee OA). I've had better results with lateral. You've tried medial only and had good results with it. The preponderance of evidence says lateral. So empirically and Evidentially, I suggest that lateral wedging is favourite.

You're speaking in generalities AND using backward logic. Firstly, you keep referring to your evidence but you never show it to us. The only evidence you've offered is your own experience that it works, evidence shared by every homeopath, reiki healer, crystal healer and witch doctor from the dawn of time! And Brian Rothbart (don't like lumping him with the hippies, not fair on them).

You, I presume, Don't accept that Brian has "best evidence" based on his experience. Why then do you expect us to accept the same proposition from you? OR do you have externally generated evidence? If so, bring it out!

Secondly, there is a logical error in your statement. It implies that the quality of evidence is defined by outcome. The quality of evidence can be assessed objectively by such tools as we have both used. The outcomes do not affect it. The sun rising every day did not prove the sun revolved around the earth even though the paradigm did not fail. The evidence was poor.

Firstly, thats not MY paradigm. Its just a proposition which I believe based on evidence. I claim no ownership. Secondly, I'm not sure that qualifies as a paradigm.

Thats EXACTLY what I'm saying. If we did not abandon old methods when new onese are shown to be better then We would still be trepanning and sleeping with virgins to cure HIV (a horrible practice still common in africa). Yes, sometimes we try new things which are later shown to be less wholesome than the old. But that is the exception not the rule.

You mentioned Celebrex and Thalidamide. You could have mentioned any of these
http://en.wikipedia.org/wiki/List_of_withdrawn_drugs

All drugs which evidence supported but which were late withdrawn. A few dozen.

In counter, I will give you these
http://en.wikipedia.org/wiki/List_of_drugs_As-Az

26 pages, and tens of thousands of drugs which evidence showed to be better than the previous treatments... which actually ARE better than then the previous treatments.

And at the end of the day dennis, arn't you suggesting that we all abandon our treatments in favour of something more Effective? (FFT)

Or should everyone ignore FFT in case its another thalidomide? Can't have it both ways.

 

Robert:
I rarely use rearfoot varus or valgus wedges as I find that treating the rearfoot on the frontal plane is not applicable very often in practice (EBP). I don;t know why you are saying that I use varus wedges (or medial skives for that matter)?

In reading the evidence that you presented for medial knee OA, I believe that I will add knee bracing as described to treat the knee component beyond my current protocol in those foot types that do not require frontal plane rearfoot correction.

I will adjust my protocol in those cases where medial knee OA complaints continue in cases where FFT care warrents frontal plane care by adding valgus wedges in the rearfoot.
I actually have had cases like this and currently they are referred to my Orthopedic and Rhematologic colleagues for workups but now I have an additional treatment to render before making those referrals. Thank you once again for educating me and I will let you know the outcome.

Point of interest: If we were medial knee OA pain specialists, your evidence would trump mine (and you are right, I have none). Since that is a miniscual part of my (and I assume your) practice, extrapolating that to preclude that you are right (and lets be honest, that is really what we are both trying to prove right Kevin?) about the rest of biomechanics where your evidence is non existent just like mine. I'm sure there's some kind of circular reasoning you are using to justify this claim or am I being heureristic?

AS far as money interests, can Kevin let us know how much he has profited from lecturing, his lab work and how they have built his practice as he lays claim to being the leader of SALRE. I will continue to promote FFT because I believe that Podiatry will be able to offer better and expanded care, immediately, as they utilize The Centering Theory as those who have examined it and decided to utilize it to begin an EBP better than the one they are currently employing have found.

I am acknowledging your evidence but it goes against the core of my EBP and so I decide to incorporate it in its limited use as above.

There are those who have told me that debating on The Arena will get me nowhere because you guys are stuck in your ways.

In the future, I will reply as per Robert that "This I know . But the debate still has value, to me at least. This is when I enjoy the arena when a stimulating opponent challenges me to justify WHY I think what I think. Its not about winning or losing, its about mental stimulation and learning to play the game. Mainly for me. Selfish I know but there we go".
Dr Sha

You guyz are so rooted and biased that Spooner wants to discuss a sagital plane rearfoot treatment like a heel lift by examining its impact on the frontal plane as if it were a device designed to create a supinatory moment about the STJ Axis. NO IT IS A HEEL LIFT that does wonders for most feet more than wegding in my EBP.
:drinks

 

anyone seen my black kettle.

Dennis while your discussing things, what is you option on the use of the tissue stress approach to treatment. Ie if the item of tissue is indentified as having too much load, you design your treatment around reducing that load ?

Do you think this idea has merit ?

 

So now you think that a heel lift has a uniplanar effect at the triplanar subtalar joint. So in your world, Dennis: what is the effect of a 2.5mm heel lift on knee joint kinetics such that this should have a positive influence on the symptoms associated the osteoarthritis of the medial knee?

 

I'm only working off what you have written

From that I gather that you post if the rearfoot is flat or rigid. Still don't understand the logic in using a valgus rearfoot post for a foot type YOU describe as flat footed BTW.

I asked it before and it seems a logical point to move on to since you (rather gracefully) have taken on board the point on medial Knee OA.

Is your EBP anything more than what you have found works for you?

Lets focus in on that point because I think it is key to the debate about EBM. Is it? If so, what?

My God can it be... no... it IS!

We have something in common :

Regards
Robert

Good question!

 

Gents it appears Dennis has taken his bat and ball and moved on.....

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=48491

 

Dr Weber:
The only thing that could make me move on would be if all the postings were worthless commentary that do not justify the dignity of a response like yours.
Mr. Hyde

 

Very droll. Now, dennis,

 

So I know I´m jumping the question line a little but does the above question get an answer ?

 

Not Droll Robert, very pertinent and I'm sorry you all can't handle it. I assume that's why you guys are referring to the Walking on Hands thread in the third person.

Back to point.
My EBP has guided me from a position that begins and ends with Thou Shalt Not Harm.

In that sense, I would not want to utilize a treatment, even one proven by evidence as strong as yours, that has a potentially harmful impact on my patients.

In the case of medial knee OA, why would I want to universally introduce a potentially destructive rearfoot pronatory force into the shoes and lives of my patients in the form of a valgus rearfoot wedge as high as 5 degrees even if it meant 100% relief of medial knee OA especially if the entity can be handled in other ways?

I wonder if others feel the way I do with regards to valgus wedges to treat knees?

DrSha

 

Lovely. Thrilled for you. Now,

You wanna talk knees, we'll do it on the knees thread. You wanna talk your example, there's an App, sorry, thread for that too.

 

As I will not make this mistake in the future, I have never categorized or itemzed a list of the evidence that I have utilized to adjust my practice over the years.

I have been influenced by many.

Robert: I assume you have such a list at your fingertips (care to share?).

I am reviewing and catagorizing evidence from the following places which seem to have many titles that I am familiar with along with ones needing research.

Kirby's list on orthotics (on The Arena)
Larry Huppin DPM's list on his practic weebsite under evidence based medicine and
EBM Stuff http://www.sciencebasedmedicine.org/?p=558
I also enjoy and trust the EBM dictums and debates of
Michael Turlik, DPM going back to 2001

I'll answer to the stress theory on my next break.

To repeat:
In the case of medial knee OA, why would I want to universally introduce a potentially destructive rearfoot pronatory force into the shoes and lives of my patients in the form of a valgus rearfoot wedge as high as 5 degrees even if it meant 100% relief of medial knee OA especially if the entity can be handled in other ways?
answer where you like or others chime in.


DrSha

 

Yet, you would have us "universally" treat an individual based on their sperm's and perm's regardless of their presenting pathology; employing an orthosis prescription protocol which you have come up with based on your own personal experiences, without testing or scrutiny from scientific evaluation or peer review. This protocol doesn't appear to fit with first principles, valgus rearfoot =add a valgus rearfoot post. No need to state that by employing such a protocol we may end up introducing either potentially destructive forefoot or rearfoot, pronatory or supinatory forces in our patients. Yippee.

Just reviewed a couple of papers prior to publication in JAPMA, which make an excellent case against "foot-typing", I'll be recommending them for publication BTW.

 

Yes but:
In the case of medial knee OA, why would I want to universally introduce a potentially destructive rearfoot pronatory force into the shoes and lives of my patients in the form of a valgus rearfoot wedge as high as 5 degrees even if it meant 100% relief of medial knee OA especially if the entity can be handled in other ways?
answer where you like or others chime in.

Weber, I do believe the boys have taken their soccer, er I mean footballs and moved on.
DrSha

 

Shavelson, not really, I answered you up above. Rugby man myself: like to keep the ball (yours) tucked safely in my hands and not loose it in contact.

Back to my question, which came from your statement: what are the kinetic effects at the knee joint, induced by a 2.5mm heel lift that should result in an improvement of the symptoms associated with osteoarthritis at the medial knee joint?

Third time of asking...

"Yes, but": I would not "universally" apply anything, I would look at the clinical evidence and look at the options within that, and look at the INDIVIDUAL patient and their presenting pathology, provide them with the evidence and let them make an informed choice; while you would "foot type" all that came before you and regardless of their presenting pathology make your foot orthosis prescription based on that "foot typing"... which is why you advocate a valgus rearfoot post for an individual with a valgus rearfoot; despite the fact that the individual in question may have pathology that has an aetiology linked to excessive rearfoot pronation moment- you'd still increase that pathological force because that's what the "foot-type" recipe tells you to do. Like I said, a couple of interesting papers coming your way, Dennis. I look forward to reading your responses in JAPMA.

 

Dennis I´m still waiting for the answer of my question about tissue stress. I´m here watching and waiting.

Maybe answer mine or the 1000 that others have asked you may get an answer to your question.

Dennis the is some evidence that knee braces can help with treatment of medial O/A, but these knee brace may or maynot have a effect on foot mechancis, which may or may not be positive.

Do you know of a study which states that knee bracing for the treatment of medial knee O/A has a less detrimental effect than Valgus wedged orthosis on foot mechanics ?

or Knee bracing in the treatment of medial O/A causes a change in foot kinematics/kinetics A Biomechancial review.

or something along those lines

Remember that you use EBM in your practice. Where is the EBM I would love to read it if you can post up the paper.

 

Yeah, so you've READ some research. You've been INFLUENCED by research. That doesn't automatically make what you do evidence based any more than me listening to black sabbath makes me a guitar hero.

Evidence based is where you can reference what you can do (even if its only from bench data and first principles.) Having read some evidence then coming up with some ideas which are unconnected to it does not make it an evidence based model.

So If I ask you something about your recommendations you'll be able to quote me the reference / principles you based it on? I'll have a think of an interesting one.

Surprised you'd baulk at that, considering you are the man who's model treats SOME flat feet with a valgus wedge.

Let me refresh your memory on that, since you seemed uncomfortable with it when last I brought it up.

So whilst not ALL flat feet (your terminology) have the "flat rearfoot", the only foot type you treat with a valgus rearfoot wedge is characterized by being flat in sitting or standing. Your own words.


The foot type characterised by being flat in sitting and standing you treat with a "potentially destructive rearfoot pronatory force"

There is our example. Where is the evidence for THAT being a good idea? One or two studies will do. Bench Data or first principles would also be acceptable. I'm not fussy.

But we digress. And it would be rude of me to ask you questions and not answer yours. Lateral wedging for knee OA. Leave alone the fact that there are NO forces that are not "potentially destructive", why am I happy to do that?

1.
It obviously depends on what else is going on. If the person has an active pathology which I can see will be worsened by increasing pronation moment from GRF in the STJ, I won't use one.

Or if they have a flat foot in sitting or standing of course.

All treatments have contra-indications. Does'nt make them bad treatments.

2.
All treatments also have potential adverse effect. My stomach is wrecked from years of NSAIDs for example. However notwithstanding that we must make patients aware of the risks of ANY treatment we must also keep in mind what they are there for. And when I'm in pain I still reach for diclofenac.

And if they are limping around because of a screwed knee that won't do their gait pattern any favours will it? Their plantar fascia or deltoid ligaments might be able to survive a bit more tension better than their wrecked knee.

3.
And to answer your question directly,

Because if it is a choice of that, surgery, or continued pain you have a duty of care to offer it to your patients. If they decide to live with the certainty of pain from the knee rather than the POSSIBILITY of problems from the insole or the risks inherent to surgery that's up to them. But it IS a treatment option... and I can say with level 2 (at least) certainty that it works.

 

I love that third column in the table, can we explore that in this thread, or do we have to do it elsewhere?

 

Thought you'd like it.

we could certainly ask about the evidence for it

Like how a flat rearfoot / forefoot stops people doing daily tasks. Which tasks? And how does a rearfoot post improve the situation. And what the evidence is for THAT.

Good study for someone. Are flat feet a risk factor for not being able to brush your teeth.

 

Just like with EBM which was coined 15 years ago but has existed for many decades, I think we have always been influenced by the tissue stress theory even before Fuller coined the term more recently.

The thought that during closed chain and function over one’s lifetime, the foot and all of its osseous components, joint surfaces, muscles, tendons and insertional locations would each have a clinical load both micro and macroscopically that could lead to enough stress to cause eventual clinical events was entertained by the giants upon which we now stand.

I am not sure if our pads/straps/devices, etc know whether they are repositioning, decompensating forces or doing something else and in that sense, I have never thought much about the physics of my treatments.

I know that I must be working kinetically and kinematically but I have not micromanaged my EBP to that level.

In summary, the tissue stress theory is an approach to biomechanics that I feel is valid but from my position it has failed to produce many advances for me in the direction of treatment. It seems to explain my knowledge base in different language that as I have already admitted, I do not understand.

Can you point our any of Fuller's treatment advances using tissue stress (or yours?).