EBM and Sacketts Empiricism

and gentlemen/ladies:

we are talking about those who when profiled have a FLAT Rearfoot FFT, NOT those with FLAT FEET.

I retort, is there a difference between feet that are flat and feet that flatten?
That is a real Foot Centering Theoretical question.

and Simon, your childish questions to me about 2.5 mm wedges fit under the heading of not deserving the dignity of a response no matter how many times asked.

How many feet have you ever foot typed in your life would problably be a question having the same response if I repeatedly asked it of you.

Now I ask a reasonable one of you.

If you have a patient with a rearfoot that is in fixed varus of lets say 6 degrees, what type of post if any would you incorporate into your orthotic?
Dr Sha

 

Whew, I'm getting bombarded by all these queries.

Robert: I will answer your questions if they deserve answering on any thread if you stop saying that I divert threads.

 

I suspect that the tissue stress approach to the evaluation and managemet of foot pathology was actually introduced by Tom Mcpoil and Gary Hunt in their paper: Evaluation and management of foot and ankle disorders: Present problems and future directions.

http://sportspodiatryinfo.co.uk/Documents/McPoil and Cornwall - Tissue Stress Theory 1995.pdf

Note the word, "management" in their title.

Anyway, back to those questions, this one was mine, which came from one of your statements: 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?

Fourth time of asking.

 

:good:

but in the table you wrote, which is there for all to see you say that people with flat rearfoot / forefoot type HAVE FLAT FEET. It's in the table! First row second column! Features of the flat rearfoot and forefoot type, flat feet in sitting or standing.

Are you saying that what you wrote in the table was wrong?

 

Now that you have found our Chapter in Principles of Diabetes Mellitus (Shavelson, Steinberg, Bakotic) coauthored by some of the most prestigious M.D.'s in the world of diabetes, I wonder if you think that a physician, internist, endocrinologist or student reading the chapter would have a better understanding of biomechanics than if I discussed supinatory moments, tissue stress and dorsiflectory stiffness?
What about the preCharcot Syndrome?
What about ulcer prediction and prevention using foot typing that you are waiting for tissue stress to cause to exist?
What about the quality of life issues I discuss that you are waiting to happen that I suggest preventing?

 

if anyone know of any reason in law why this man and this other may not have argument joined they are to declare it now, or forever hold their piece.

C'mon. We know why. Dennis has never made a secret of the fact that his understanding of fizzics is shaky. He does not speak your language Simon. My resturant is full of eels etc.

 

What about that bit where you say flat rf/ff type is flat footed? And that you treat the flat rf type with a valgus wedge? Quit trying to change the subject.

 

Depends on the system of typing, using your system only a handful, using other systems thousands.

I've asked a multitude of reasonable questions of you, Dennis. As too have my peers. You never answer them. I'll answer your question above even though you are incapable of answering mine. To answer your question: it should depend on a number of variables, not least that of an accurate diagnosis of the presenting pathology of the patient. What I would never do, is attempt to treat a patient based on an angle measured at the rearfoot in isolation. Unlike your good self, apparently. So you tell me, Dennis: "a patient with a rearfoot that is in fixed varus of lets say 6 degrees, what type of post if any would you incorporate into your orthotic", if they presented with an osteosarcoma of the calcaneus? And moreover, how would this have an efficacious influence upon the patients pathology?

 

I stand by my statement the flat rearfoot type is flat in both open and closed chain as well as in SERM and PERM and it responds well to a valgus rearfoot post.

I do not think you understand or recognize this foot like I don;t recognize fizzzzzzics.
(we're getting mean again and I think Dr. Jeckyl is starting to shake and quiver)

 

Simon:

we have something in common, we are both cocks.

I feel the amdinistrator ready to castrate this site like he did the FFT.
I'm going for dinner.

PS: I still have never learned anything from Simon Robert.

 

So this type IS flat. And you DO treat it with a valgus wedge! Only at the top of the page you said that it wasn't.

Ok so what is your rationale / evidence for treating these flat feet with the valgus wedge?

 

Thats a pity because he has a lot to teach!

Perhaps one day, like me, you will recognise that what you take for meaness is actually the best education money can't buy!

Enjoy dinner. I'm going to bed.

 

What is better? Inaccurate biomechanics that the readership, in your view could understand, or accurate biomechanics which in your interpretation the readership couldn't understand? Arrogant beyond the point; your readership may have a PhD in biomechanics and have the ability to turn you inside out for all you know. Your co-authors may be well respected in the world of endocrinology, but what reputation do any of you have in the world of podiatric biomechanics? Zero.

Tissue stress answers the prediction of foot ulceration. We want to talk about the "quality of life" issues, believe me, we do. But lets get the answers to the previous questions first, before we move away from them, as is your aim. When we've done with that, then we can talk all you like about the evidence you have to suggest that your foot-typing system prevents and/ or treats diabetic ulceration.

 

No Dennis, we have nothing in common. The administrator won't get YOU out of this, Dennis. After dinner, the questions will still be here for all to read; the answers from you will still be non-existent. Answer the questions or forever, shut the **** up.

 

I don't know who Simon Robert is. But when I bump into him, I'll see what he might teach me. Perhaps something about punctuation, Dennis? That would be a bonus.

 

I do so passionately believe that inacurrate biomechanics that they can understand is the best for us to deliver to this marketplace or to most patients and sadly, to most podiatrists, PT's,Chiro's until they (like me) are at a level where they can benefit from your advanced (hopefully) biomechanical skills.

By the way:
have you recently produced any study or reviewed one, or even dreamed of one that would add to our Level 1 positive evidence on upgrading anything biomechanical?

have you recently produced any study or reviewed one, or even dreamed of one that would add to our Level 1 positive evidence on upgrading anything biomechanical?

have you recently produced any study or reviewed one, or even dreamed of one that would add to our Level 1 positive evidence on upgrading anything biomechanical?

have you recently produced any study or reviewed one, or even dreamed of one that would add to our Level 1 positive evidence on upgrading anything biomechanical?

have you recently produced any study or reviewed one, or even dreamed of one that would add to our Level 1 positive evidence on upgrading anything biomechanical?

We all know you haven't.
Mr. Hyde

 

Not gonna let this go. We agree that most of what we do is based on level 4 evidence, bench data and first principles. It's low level evidence but it IS evidence. So, I ask again, what is your rationale for this. Where is your bench data and what are the principles. And what is the basis for these patients being unable to complete daily tasks?

 

The answer is yes to your question, Dennis. Unlike you, I only need to be asked a question once in order for me to give a reply. Now, back to that question which you still haven't answered: how does a 2.5mm heel lift effect the kinetics at the knee in order to bring about a reduction in the symptoms associated with osteoarthritis at the medial knee joint?

 

how does a 2.5mm heel lift effect the kinetics at the knee in order to bring about a reduction in the symptoms associated with osteoarthritis at the medial knee joint?

I don't know

Please explain master

DrSha

 

Ladies and Gentlemen:
I think this thread has come to a significant moment.
EBM vs. Sackett's Empiricism

Robert (the prover) States:
We agree that most of what we do is based on level 4 evidence, bench data and first principles.

I (the carer) reply:
We disagree strongly!!!! When it comes to most of what I am doing clinically the evidence is Level V at best and rarely falls into Level IV.
Most of ot it falls under the heading of patient testimonials, case reports, and even expert opinion having little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, difficulties in ascertaining who is an expert, selecting the population and more which is basically worthless as applicable in practice.

The U.S. Preventive Services Task Force uses the following guidelines as to rating the value of incorprating evidence once gathered into practice:

* Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients.
* Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.
* Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.
* Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
* Level E Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

To the readership:
Can we use these guidelines to evaluate evidence in the future (or suggest an alternative).
PLEASE DON'T RUN AWAY FROM THIS or talk about my mutant parents.


FOR ME, this explains the debate over the value of evidence in practice vs. the delivery of care when functioning in an EBP. The disparity of how strongly or weakly we rely on evidence gathered on large groups of people to answer single patients questions that arise in practice.

I think your goal is to prove your biases and my goal is improving my ability to deliver patient care and outcomes.

DrSha

 

You are quite right. My mistake. I meant level D evidence

From the Uk system. My bad, I forgot which was letters and which was numbers.

Tthese are the catagories of recommendation from the evididence. The levels of evidence are a different animal.

Level D most closely fits with Level III. Descriptive studies, respected authorities and the like. I prefer the UK description because of the reference to bench data which IS important.

Sure we can. Just as soon as you answer the question I've been asking for half a page or so. Whilst I'm sure you'd like to "run away from it" it, its a pertinant point you've been avoiding for ages.

Just to refresh your memory.

--------------------------------------------------------------------------------------------------

So this type IS flat. And you DO treat it with a valgus wedge! Only at the top of the page you said that it wasn't.

Ok so what is your rationale / evidence for treating these flat feet with the valgus wedge?

I ask yet again, what is your rationale for this. Where is your bench data and what are the principles. And what is the basis for your statement that these patients are unable to complete daily tasks?


Regards
Robert

PS

I think your goal is to avoid having to explain why you advocate the use of valgus wedges for a flat foot, because there is NO evidence for it and NO logical explanation for it.

I think you are trying to send the thread off in a different direction by raising a new point getting shouty so that we all get distracted by inflammatory statements (like the one above).

I think that if a treatment within a paradigm cannot even be logically explained by bench data and core principles the paradigm cannot be said to operate at level D / III evidence and thus cannot be described as evidence based at all. I think this is highly relevant because it illustrates that not all biomechanical models are equal and while there is little above Level D in most of them, some of them fall short of even level D.
Prove me wrong. Answer the question. Deal with the issue before you try to jump ahead to the next one.

PPS
No mutant parents were mentioned in this post.

 

I will answer in between patients but the real problem I'm facing is that most "flat feet" are feet that flatten (open chain arched, closed cjhain flat. These feet The Centering Theory would never treat with a valgus wedge,
The flat rearfoot type on the other hand (the foot type missing from Scherer's classification that I upgraded) is rare, is flat in both open and closed chain and is treated with valgus wedges.

So as I don't understand your fizzics, you don't understand my Foottypingese.
We are discussing a flat foot type which is just one of the types that presents in closed chain as a "flat foot" (pointing out the value of a typing system as it subgroups flat feet so that they can be discussed, researched and treated differently.
Dr Sha

PS: I will once again become Dr. Jeckyl as I sense your calm. I'm so pleased.

 

Oh I'm the zen master me. Constant oasis of jedi like detachment.igs:

I do get what you're saying here. Personally I spend hours telling patients that just because they have feet which flattEN don't mean that they have flat feet, any more than an elbow which can flex is a flexed elbow.

The words of bruce lee come to mind. The water takes the shape of the glass, but is not the glass. The only reason that what I might call hypermobile feet are flat is because they are on flat ground. Put them on a high arch insole they become high arch feet. But thats just the shape they take not what they are.

So for me, the only foot worthy of the title of flat foot is what you call the flat RF flat FF foot.

So lets agree that we're both talking about feet which are flat in open or closed chain, weight bearing or not.

What is the rationale for a valgus wedge?

 

No idea which is why when you said:

I started asking you that question.

 

The Flat Rearfoot-Flat Forefoot Functional Foot Type

Rearfoot SERM Everted
Rearfoot PERM Everted
Forefoot SERM Dorsiflexed
Forefoot PERM Dorsiflexed

The flat rearfoot-flat forefoot foot type is not a good supporter or rigid lever, nor is it a good morpher or shock absorber. The bones of this foot type are tightly engaged in fixed (or relatively fixed) flatness. It does not assume an arch shape in open chain. The flat/flat foot type is the most unhealthy pure foot type because its engineering fails at all times as it does not leverage the pedal muscle engines to any great extent.

These patients invariable have had a lifetime of pedal and postural suffering due to their foot type related pathology. They have pain syndromes in many areas and a very poor quality of life. Biomechanically, they are very unhealthy.

This functional foot type is quite rare and since I have never seen it in children or young adults, I believe that it is a foot type with two methods of development.
1. Subjects that inherit an extreme variant of one of the more unstable foot types and whose lifestyle choices have allowed their feet to progress (like bunion development) into this end stage nightmare over time.
2. Traumatic Events and Surgical Failures such as a Dwyer Procedure that has left the rearfoot in fixed valgus (what else can you do here but employ a valgus rearfoot post?....Robert... question answered)

The non operative treatment of this foot type is palliative and involves lightly supportive orthotics shelled from forgiving thermoplastic with shock absorbing covers that are posted with a rearfoot valgus post the number of degrees that maximum inversion will allow (SERM)and a 1-5 forefoot varus post the number of degrees that maximum plantarflexion will allow (SERM). The posting materials should be of low durometer for shock absorption.

Comfortable shoe gear is very limited and must be carefull selected. Shoe have a 1+ positive heel and thick, shock absorbing soles. Today’s rocker bottom shoes are effective though not very business or socially friendly.

The Flat/Flat FFT is the non neuropathic equivalent of the Charcot Foot in that this foot has preventive sensation yet degenerates irreversibly short of heroic foot surgery and the best treatment for this functional foot type is preventing it from developing.

I have seen less than 25 patients that profiled and classified this FFT.

Below please find two illustrations of the Flat/Flat FFT in both open and closed chain.

(Illustrations)
DrSha

Discussion:
I am very interested to see the reaction of my Arena arguers (as per the graph, now I know who you are).

Because, like it or not, in my future postings, since I am being attacked by multiple sources on truly unimportant points of my postings for I’m not sure for what purpose other than meanness (what does it matter if the term EBM was initiated 15, 30 or 5 years ago? and who cares who deserves the credit for coining the term Tissue Stress Theory?), I will reply to queries that involve the central theme we are debating (i.e. the essence of the debate at hand)……
And CONTINUE TO CHOOSE to evade as you proclaim or in my terms, to not dignify other questions with a response.
(pleasingly, that means I never have to ackowledge Simon ever again! (misspelled on purpose so Simon will have something to comment on hahahaha)

I will from now on call these questions “Time Wasters” because for me, they are just that, since I have other work, family and social priorities of greater import.

From now on, if you want to debate my work, debate it from the position of me being a colleague as Robert has shown signs of when he stated:
“I do get what you're saying here. Personally I spend hours telling patients that just because they have feet which flattEN don't mean that they have flat feet, any more than an elbow which can flex is a flexed elbow.

So for me, the only foot worthy of the title of flat foot is what you call the flat RF flat FF foot”.
It took me 1.6 years to get to this point and I am still standing.

:drinks:drinks:drinks
DrSha

 

DrSha - I don't suppose you were Henry Crun in a previous life? Keep up the good work - it's wonderful (and don't be distracted from your task).

Best wishes

MR

 

Robert can you translate this into Podiatry for me I´ve read it 4 time it makes no sense.

It almost like reading another countries text like Japanese which then lead me to think of this song, which has nothing to do with being Japanese but something else....
The Vapours- turning Japanese

 

Yep. They're the foot type I had in mind when you said flat feet.

May I suggest also

3. Patients with a history of neurological disorders which have caused profound loss of muscle tone and subsequent stiffening of ligaments and joints into this position.

4. Paediatric cases with Cerebral palsy and extreme tightening in the triceps surae causing unremitting "escape pronation" in weight bearing can sometimes develop this over time.

Eh what?! Hardly a rationale!! "Why did you stab him", "what else could I do but stab him?" Not really an answer and certainly not a rationale!

We do NOT hold these truths to be self evident

Right. Sorry, perhaps I'm being slow today but you're going to have to help me out here. Why are you using a valgus post to the number of degrees that the rearfoot can INvert? That foot, in weight bearing will be maximally everted (pronated). The valgus wedge will cause it to evert * not invert so the number of degrees INversion available is irrelevant init.

Put in terms of physics, this foot will almost certainly have its sub talar joint at end range in weight bearing and I would venture to suggest that it will be compression at the sinus tarsi (bony stop) which will define it. By adding a VALGUS wedge you increase pronation moment and increase compression in the joint. They'll be no kinematic change (movement) but the residual moment (compression in the joint) will be increased.

Don't get it. Explain please. Why would you want to introduce a force to further pronate in a foot already suffering pathology from operating exclusively in a pathologically pronated range?

As an example of what I would consider a logical argument, here is why I would use a varus wedge in such a foot. With evidence based on bench data and first principles.

Summed up briefly

Pronated foot, probably suffering because its pronated, why would you try to pronate it more?!


Regards
Robert

*(well actually it won't because its at end range already but you get the gist. I'm trying not to spill moments all over that bit page)

 

Some of it I think.

The permed sperms and such is a way of saying that the sub talar joint is limited to a pronated range, unable to make it to neutral (calc vertical actually but we'll let it lie) and the forefoot is fixed in a range I would call inverted, such that it cannot correct even as far as neutral (perpendicular to the rearfoot.) Its a fixed or almost fixed, non correctable flat foot.

Because the STJ joint is pronated all the time it has lost the ability to pronate (act as a shock absorber) and because it can't supinate much either its lost the ability to act as an adaptor. Because of the position all the muscles are working inefficiently because their insertions have changes relative to the axes of the joints of the STJ and MTJ (the Tibialis anterior has probably become a pronator for eg)

[/QUOTE]

Nothing works. They screwed.

Beyond that I can't help mate. As per my last post I don't understand the rest.

 

Robert:

I so agree Re the muscles.
I purposely showed a high leg shot so the viewers can appreciate the muscle atrophy and tubular form of this patients legs. Their whole posture is lifeless

Most CP patiients I have seen have had high arched feet (like CMT, Firedrich;s, etc.
They would be more rigid/rigid FFTs. Fixed but more in open and closed arched positions than flat, although I have seen some that fit your description.

I am simply using a valgus wedge to conform the entire rearfoot plant surface to have the sense of GRF upon heel contact. As I have heard it said, "I am bringing the ground up to the foot". The same with the forefoot posting in varus.

There is not much range of total STJ motion in these feet 0-2 or 3 degrees so I am adding very little pronatory moment (I think). I would say that this would be analagous to a total contact arch conformity.

I certainly don't know if the valgus post is the best posting, only what I do that seems to give comfort (my only expectation here.) I am sure there may be better ways to skin this cat (as many others) and I would be interested in yours (and others) as you have worked with the flat/flat FFT as I am always eager to upgrade my work.

 

I see mainly Paeds. Perhaps thats why.

Oh I SEE. Bringing the ground up to meet the foot. That makes sense now. Now I see where you are coming from.

If you will permit me, I shall enlarge on what I meant. Its a light which only went on a few years ago for me so I do understand the difference in view.

You said

You are confusing moment with movement.

Consider it thus. We sit upon a seesaw, you and I. Now I am a well build man, big boned and well padded. You, I'm certain, are lean an wirey. So I sit upon the ground and you high in the air.

The force is our weights, the lever arm the arms of the seesaw. The moment the one multiplied by the other. Let us, for the sake of ease, say that the lever arms are the same.

Now I, being festively plump, weigh 14 stone. You, lets say, weigh 12. The seesaw has arms 1 meter long. My end of the seesaw presses on the ground with a force of 2 stone.

Now, up trips Mike. Pleased by the gay frollics upon which we are engaged and wishing to join in he sits on your lap increasing the moments on your end so the seesaw moves and i raise into the air. A visible (kinematic) change.

HOWEVER.

Lets say Mike sits on MY lap. Now the see saw won't move because my end is on the ground. BUT the moments have still changed. Mike, (I guess weighing about 12 stone) has exerted the same moment whichever end of the seesaw he sits. If he sits on you then there is a movement, if he sits on me there is not. So where have those 12 stone * 1 meter of moment gone?

Remember your newton. Every force has an equal and opposite reaction. So when I'm on my own, and the see saw is pushing down with a force of 2 stone, the ground is pushing up with a force of 2 as well.

This is called residual moment.

When Mike sits on my lap the force on the ground increases to 14 stone * (his 12 plus my 2). The residual moment has increased even though there is no movement.

Now extrapolate that to a foot in maximal pronation. The joint is bone on bone (bum on ground). When we add a force which will increase pronatory moment, the lateral wedge (mike), there is no movement, but the amount of force compression force in the lateral part of the joint (the seesaw resting on the ground) has still increased. The same moments, but instead of visible change, movement, kinematic, we have invisible change, kinetic.

A simpler example. You put a chair leg on your foot. It hurts. Someone sits on the chair, it REALLY hurts, although the chair leg has not actually moved.

Make sense?

 

I see mainly Paeds. Perhaps thats why.

Oh I SEE. Bringing the ground up to meet the foot. That makes sense now. Now I see where you are coming from.

If you will permit me, I shall enlarge on what I meant. Its a light which only went on a few years ago for me so I do understand the difference in view.

You said

You are confusing moment with movement.

Consider it thus. We sit upon a seesaw, you and I. Now I am a well build man, big boned and well padded. You, I'm certain, are lean an wirey. So I sit upon the ground and you high in the air.

The force is our weights, the lever arm the arms of the seesaw. The moment the one multiplied by the other. Let us, for the sake of ease, say that the lever arms are the same.

Now I, being festively plump, weigh 14 stone. You, lets say, weigh 12. The seesaw has arms 1 meter long. My end of the seesaw presses on the ground with a force of 2 stone.

Now, up trips Mike. Pleased by the gay frollics upon which we are engaged and wishing to join in he sits on your lap increasing the moments on your end so the seesaw moves and i raise into the air. A visible (kinematic) change.

HOWEVER.

Lets say Mike sits on MY lap. Now the see saw won't move because my end is on the ground. BUT the moments have still changed. Mike, (I guess weighing about 12 stone) has exerted the same moment whichever end of the seesaw he sits. If he sits on you then there is a movement, if he sits on me there is not. So where have those 12 stone multiplied by 1 meter of moment gone?

Remember your newton. Every force has an equal and opposite reaction. So when I'm on my own, and the see saw is pushing down with a force of 2 stone, the ground is pushing up with a force of 2 as well.

This is called residual moment.

When Mike sits on my lap the force on the ground increases to 14 stone * (his 12 plus my 2). The residual moment has increased even though there is no movement.

Now extrapolate that to a foot in maximal pronation. The joint is bone on bone (bum on ground). When we add a force which will increase pronatory moment, the lateral wedge (mike), there is no movement, but the amount of force compression force in the lateral part of the joint (the seesaw resting on the ground) has still increased. The same moments, but instead of visible change, movement, kinematic, we have invisible change, kinetic.

A simpler example. You put a chair leg on your foot. It hurts. Someone sits on the chair, it REALLY hurts, although the chair leg has not actually moved.

Make sense?

Regards
Robert


*And he feels strangely violated

 

Always thinking enterpeneurally, I see a major source of new income in your future.

Consult for us all as a professional biomechnanical interpertor working in The Tower of Biomechanics.

teach those of us in need kinetic and kinematics and those of us in need Architecture and FFT's.

DrSha
PS:
I like that so much better than your school of biomechanics (mean).

and

Where do I send my check.

 

Aye thank you.



You should see me translate heurism!

 

Robert

Re rearfoot valgus post

you wrote

I think what DrSha is saying (but using ambiguous terminology): From a reference position of maximum rearfoot eversion, let us say 16dgs everted, in some feet the STJ can only invert say 8dgs, therefore there is a maximum inverted position that is still everted with reference to the vertical position, where vertical would be where the calcaneal bisection is parallel to the centre line of the tibia (or posterior shank centre line). If the tibia has a 4 degree varum then you would end up with a 4dg valgus position of the heel bisection relative to the ground. Therefore it might make sense to post the heel 4dgs valgus to 'bring the ground up to the foot, for stability and pressure distribution..

This would have the effect of reducing internal forces, from whatever tissues stop any more inversion, that resist supination (inversion) moments and are replaced by external forces i.e. the valgus post.


Cheers Dave

 

Not with you dave. In a flat pronated foot type surely the pathology is far more likely to be in the structureswhich stop eversion rather than inversion.

And by distributing the pressure more evenly on the heel will we not move the cop more lateral to the axis? More stable yes but only by pressing the joint more firmly into end range of pronation?

 

Most of the feet I have seen of thisa type do not have ranges of motion in the direction of inversion as great as 8 degrees. I f they did, I would agree with Dr. Isaacs.

They are often frozen or 1-2 degrees.

In addiotn, and I hate to bring it up, I have to interject the relationship between the posterior tubercle of the calcaneus, the body of the calcaneus and the soft tissue that exists under the plantar bony surface of the calcaneus which plays a part in thisa discussion.

The tubercle is invcerted to the body and therefore a rectus tubercle would have a talus that is weverted to the floor.
Do you guys take that into account when posting?

 

Yes dennis. In fact I wrote about that in an article published a few months back. If you pm me your email I'll send it to you.

It was all about how pointless it was to try to base a treatment prescription on rearfoot positional measurements.

 

Robert

Remembering that this is a theoretical explanation of DrSha's proposition of a foot type and its mechanism and not an actual foot type that I have actually seen but:

Are you thinking that flat pronated foot always = external moments about the STJ that pronate the foot? What if the internal moments pronate the foot during open chain and the external moments from GRF tend to supinate the foot in closed chain. As per diagram:-



Now I don't think I have seen a foot like this bit that is not to say it does not exist and I think DrSha says he has only seen 25 in all his years of practice. Usually if a rearfoot is fixed in a valgus position then it is due to the effects of GRF over many years and so as you say adding a valgus rearfoot post to this foot would just aggravate the situation. I guess this foot type, should it exist (have you seen this Robert?) would tend to be congenital rather than acquired or perhaps the result of some osteophyte or some unusual shortening of soft tissue like the peroneals for instance.

Usually the foot that has an acquired flatfoot also has a medially deviated STJ axis and a CoP that is lateral to the STJ axis in closed chain and we often see the morphology of the ankle joint complex changed by the forces over time i.e. the joint position shifts laterally (Wolf's law)

Just exploring here

Cheers Dave

 

PS what's wrong with this site today? It doesn't recognise me login details automatically then when I log in manually every time I navigate somewhere else, like REPLY or EDIT, it tells me to re log in. Except on edit there is no facillity to relog in since the page is already logged in?????

See I had to re log in to post this