Evaluating Plantar Fascia Strain in Hyperpronating Cadaveric Feet Following an Extra-osseous Talotar

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Evaluating Plantar Fascia Strain in Hyperpronating Cadaveric Feet Following an Extra-osseous Talotarsal Stabilization Procedure
Michael E. Graham, Nikhil T. Jawrani, Vijay K. Goel
Journal of Foot and Ankle Surgery (corrected proof)

 

This coincides with why we use orthotics for plantar fasciitis. But of course with hyperpronation the foot has passed the "tipping point" and orthotics rarely help.

Good study.

Cheers

 

Whats Hyperpronation Fredrick ?

It is a rhetorical Question as it doesn´t exist.

 

Dear Mike

It always tickles me when I come across pretentiousness.

Cheers

Frederick

 

Funny you giving out personality statements.

I got a laugh

 

Dear Mike

No, really. It always makes me chuckle when I come across someone that has all the answers. Someone who really knows everything about something. Someone who knows the exact word to use, and the single meaning of the word.

Interestingly, this can be someone who doesn't have a practical/clinical knowledge of the subject at hand. Just an observer. A prurient pedant.

The paper is about an additional benefit of the sinus tarsi implant, presumably the one invented by Michael Graham. Many foot surgeons have helped many patients with this device.

So, I guess you don't like the "hyper."

hyper-,
prefix meaning "excessive, above, or beyond": hyperacidaminuria, hyperalkalinity, hyperechema.

hyper-
word element [Gr.], abnormally increased; excessive.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Presumably you have an idea of what pronation means, as in "overpronation."

So, if you take a Greek root prefix, and put it in front of the word "pronation," voila! you have a descriptor.

Or do you prefer "flat foot." How flat? Completely flat? And via what mechanism?

Cheers

Frederick

 

Maybe you might learn something if you reduced the worthier than thou approach

Hyperpronation is a useless term


- Discussing Kinematic change in relation to strain in the plantar Fascia is very interesting as it the internal moment which occur from a stent used in surgery- good luck with you further education on the subject Fredrick.

I use much of this knowledge treating patients 5 days a week and I might have learnt something in the discussion but we will never know.

 

Dear Mike

So, you decided to remove my response to your last blog?

I asked you why you didn't like the term hyperpronation.

Are you a coward?

Cheers

Frederick

 

What are you talking about ?

I have not removed anything.

When does normal pronation become hyperpronation ?

What are the ranges of normal pronation ?

As the above questions are unable to be answered or defined hyperpronation becomes a useless term.

Using mechanical terms to explain injuries or in this case changes in the plantar fascia strain levels is much more precise. Hyperpronation is not precise.

As for the coward question no funny thought

 

Although this is a commonly verbalized explanation for PF, wasn't there a study or studies recently posted that found that MLA height was not in fact a quality predictor of plantar fascial symptoms?

Frederick is there any chance that you would explain your assertion here further? What kinematic and identifiable etiological abnormalities are you referring to might I ask?

Irregardless of the back & forth between Mike & yourself over terminology, this is a very bold statement that is worthy of discussion I feel.

Best Regards,

 

I would agree that hyperpronation is not "precise." But it is certainly descriptive, just as is overpronation, metatarsalgia, flat foot, Mortons foot.

Over many years I have noticed that patients with hyperpronation, aka adult onset flat foot, aka peroneal spastic flat foot, aka posterior tibial dysfunction flat foot, aka non rigid or flexible flat foot were not amenable to significant reduction of symptoms with orthotics.

Because I wasn't generally satisfied with the various flat foot or subtalar joint arthroeresis surgeries, I persisted with conservative treatment of all sorts.

The primary problem seemed to be that the arch was so low that it could not tolerate the pressure of any significant correction in the orthotic. Patients did not like the Richie brace because it wouldn't fit in their shoes.

So, I have had really incredible results with the Graham implant over the last few years. It allows me to effectively treat patients I couldn't help before.

The fact that the implant may also decrease tension (cadaver) in the plantar fascia, is not only interesting, but consistent with why we use orthotics to treat plantar fasciitis.

That is what I said about the article. The hyperpronation pedantry and insults evolved from there.

Cheers

Frederick

Cheers

Frederick

 

Thank you Frederick, I understand much more clearly why you favor the term now. Personally I try to avoid using prefixes such as 'hyper' in relation to describing pronation as it is merely a finding or observation and not an etiology or diagnosis, or would you disagree? The other examples that you provided are true diagnoses are they not (aka peroneal spastic flat foot, aka posterior tibial dysfunction flat foot, aka non rigid or flexible flat foot)?

An example supporting this is PTTD, one of the disorders I would imagine that you seek to remedy with the Graham implant. PTTD is more likely caused by frank injury and/or progressive attenuation of the PT tendon and the result is diminution of the MLA, pain dysfunction etc follow and are the sequelae, not the primary cause.

If you consider joint play in the other joints of the body we do not say "shoulder hyperabduction or hyperflexion" to describe subluxation or dislocation, it is imprecise. Pronation is obviously a normal feature of static & dynamic loaded gait and we've all seen a number of patients with greater than normal pronation range of motion (some in several foot joints) and no symptoms. When they do have symptoms, "hyperpronation" is often a finding but is it the cause? Perhaps in a flexible pediatric flatfoot deformity where there is notable ligamentous laxity throughout the foot, the lack of developed constraint mechanisms leads to pathology and thus symptoms.

In any case, I feel that we should use the more correct terminology pediatric flatfoot to describe the condition. I am unaware of any ICD-9 code for "overpronation". I think these are the points that Mike was trying to make? Otherwise the distinction and separation between licensed health professionals who diagnose and treat conditions with CFO's and the retail stores, shopping kiosks and internet sites proffering their "orthotics" to the public.

I'm trying to think of diagnoses that describe the kinetics rather than the kinematics that result in foot pathology; the forces and not the structure and drawing a blank. We do treat the kinetics and not the structure with foot orthoses I hope we agree. Some very intelligent person said on PA "you can have a kinetic change without an observable kinematic change, but you cannot have a kinematic change without a kinetic change". Brilliant. With an implant you can do the latter as you well know.

I've seen a number of arthroeresis implant that still required CFO's and vice-versa. I was taken back by your comments about CFO's where the foot has passed a "tipping point" but I am mindful that there are later stages of PTTD for example where I agree that CFO's have limitations, as do implants etc. You are correct that some patients cannot tolerate any correction but I find them rare and non compliant to begin with often. You know the type "will that work in my sandals, they very soft and the ONLY thing that I can wear"?

PA is invaluable for those of us who are not surgeons to learn from those that are and to interact with them, with colleagues and with other disciplines.

Interesting thoughts, good discussion and topic Frederick. Thank you.

Regards,

 

Dear David

I certainly agree with your post, and the evolving knowledge of the foot. Medical terms or diagnoses aren't perfect, but we need to classify symptomatology. ie. Metatarsalgia is vague, more a symptom than anything else. Flat foot isn't very descriptive. How flat? Where? Calcaneal inclination angle? Three dimensional?

Even though diagnosis is only a classification, we often think of it as etiology. In PTTD we assume that the tendon failed first, but we don't know that. If the tendon loses it's mechanical advantage, and can't supinate the foot, it atrophies, and so can be a sequela of the flat foot. Peroneal tendon spasms can result from the muscle splinting of a painful flat foot, rather than a primary neurological disease causing the flat foot.

ICD-9 follows the profession, it doesn't set the standard. Once a term becomes useful, and generally used, it may become standard. Hyperpronation is a relatively new term, but certainly didn't originate with laymen.

What makes hyperpronation useful is that it describes the 3 planar movement of pronation, but in excess. It implies that this is of primary importance, although not necessarily causative. It also means that if reducible, it can be treated by an intrasinus/canalis implant to prevent the talus shifting forward, occluding the sinus/canalis tarsi. It doesn't work as a doorstop, like the earlier StaPeg.

We routinely use overpronation to describe what the average foot does in stance and gait. I would guess hyperpronation was coined because it was just more excessive.

By the way, although hyperpronation can be associated with ligamentous laxity, most of the time it isn't. Children usually are bilateral, adults are often unilateral, with no known precipitating event.

Cheers

Frederick

 

Do we now? I don't. It's a tautological and well nigh useless term and I'm surprised to still see it used in this research. We should be better than that.

Pronation tends to load the medial column and increase the dorsiflexion moment of the 1st met. Increasing the external dorsiflexion moment of the 1st met will increase the internal plantarflexion moment exterted by the Plantar fascia. Conversely if the probation is limited (by a stent) then the external dorsiflexion moment will also be reduced and the corresponding internal plantarflexion moment from the 1st met will also reduce.

That's well and good. So why introduce such a weak and inaccurate term as "hyperpronation". I can only think of one reason and it disturbs me somewhat.

 

And co-incidentally Fred, Mike Weber is one of the most open minded and knowledgable biomechanists you are ever likely to meet. He is rather well respected around these parts. Your ad hominem earlier in the thread is unlikely to win you any friends OR move the debate forward. And apology would not be out of order.

 

Dear Robert

Thank you for your review of pronation. The subtalar joint stent doesn't stop pronation, it just restricts it to a more normal range. The talus just can't shift forward.

Patients return to sports pain free. They can balance. Their knees even stop hurting!

I'm sure I don't know how you are disturbed.

But, one shouldn't be pompous, pedantic, and insulting, and not expect something in return. Quibbling about words doesn't help any patients.

And what is a biomechanist? I know what a podiatrist is. I know what a podiatric surgeon is. Is this a new English degree?

Cheers

Frederick

 

Oooo, you're a charmer arn't you. Ok, if we're not going to be civil about it. That works too.

The language you are using, and the language of the piece, are somewhat below what is considered acceptable terminology on this Board. Bluntly, its a bit Janet and John.

That was not a review of Pronation. That was a mechanical description of a mechanism which would explain the findings of the study. My point being that it can, and should be described in more precise and definable terms than "hyperpronation". We are not writing here for students or lay people, we're writing for professionals and academics. As such it is fitting to use proper terminology.

You don't say.

Fair enough. Perhaps you could furnish us with details of what a "normal" range of pronation is? Because without that definition its a meaningless statement. "Normal" as in the Rootian "ideal" concept of normal? Normal as in within 1 SD of mean? And if so, for which ethnic group? Is the "normal" range common for Afro carribean feet and european feet for example?

With respect, you're wrong. Accurate terminology is absolutley necessary for the accurate communication of ideas and concepts. This is true in general debate and goes double for research. Sloppy terminology is important for communication and also shapes our thinking.

Phrases like hyperpronation, Overpronation, correction, normal (unless normal is defined, stabilization (likewise) Flat Feet (in my opinion), hypermobility (in Kevins) and such like are actively harmful to the development of the science of biomechanics because they are perojative and infer negative or posative connatations to things which should be nothing more or less than accurate descriptions of mechanical concepts. This, on a long enough timescale IS harmful to patients.

Then let me enlighten you. The hyprocure stent can, In my opinion, be a useful clinical tool like any arthroesis. As you accurately say it limits pronatory end range of pronation, which can be very clinically useful. If, for example, the range of pronation is such that the sub talar axis is medially deviated to a substantial degree it can be very difficult to acheive sufficient supination moment from ORF to reduce the residual pronation moment to a sufficient degree to bring tissue stress in pathological tissues within pathological thresholds.

Thats all well and good, and I don't doubt that the authors of this paper were fully cognicent of the precise mechanical effect of their device. That being the case, I rack my brains to try to come up with a reason they would use such lame and imprecise terminology as "hyperpronation", a word with no agreed definition and only the vaguest of descriptions.

The only thing I can come up with is that to a substantial proportion of our colleagues, the concepts of tissue stress, internal kinetics and the rest of the last 20 years worth of advancement in understanding are a closed book which they lack either the wit, or more likely the motivation to open. There are a lot of podiatrists and indeed even podiatric surgeons who are still stuck on the idea that pronation is always bad and supination is always good. Terms like "hyperpronation" and "normal range" pander to this mindset.

Bluntly, I don't want to see patients who pronate beyond an arbitary point considered as surgical candidates simply because they do. I have first hand experience of seeing this implant considered inappropriately based on somebodies skewed interpretation of "hyper pronation".

If we define the action of the Hyprocure as what it is, limiting the end range of pronation, probably limiting the medial excursion of the sub talar axis thusly reducing the lever arm of the GRF which creates the pronation moment in WB then we can expect to use it responsibly and appropriately. If we frame it in such crude conceptual terms as "hyperpronation causes plantar fasciitis and hyprocure eliminates hyperpronation" then I can see problems ahead when people revert to this rather than actually thinking it through properly.

Claiming to "eliminate hyperpronation" begs the question of what exactly IS hyperpronation. Without that it just sounds like marketing.

 

Frederick I feel that classifying symptomatolgy and reporting it along with the appropriate diagnosis in the medical record and on claim forms is good practice. In truth insurers will sometimes reject claims with ICD-9 codes that only note symptoms. In my office we often use mechanism (If known), symptoms and diagnoses to support claims submissions.

The issue that we are discussing though is a finding and one that does not correlate well to symptoms in the literature or in clinical practice for that matter. You're correct, flatfoot is not very descriptive but neither is overpronation. I wont belabor the point with you as I can grasp your position. I respect it but I disagree with you, enough said.

Robert makes an excellent point; hyperpronation is arbitrary. This one word sums up a good deal of the marketing that I encounter aimed at my colleagues to induce them to use "this lab", "this insole" etc. With regard to the feet and podiatry I expect much more than that to justify the need for custom foot orthoses and even more so surgery.

This reminds me of a local pod who performs a lot of these procedures. He advertises using this terminology, runs a boutique practice and almost always performs bilateral implant surgeries. Not difficult when "everybody overpronates" right? This is a part of my aversion to this terminology.

 

Dear Gentlemen

I think we are perhaps being a little precious about this. When I shifted to New Zealand from California, I suddenly couldn't spell "correctly" not to mention my pronunciation.

Because some schlock down the block doesn't practice the way we do, and advertises, doesn't mean we can keep him from using any word we dream up.

Insurance companies are a different issue. Certainly they should not determine how we communicate. Render to Caesar . . .

Bunion is an example. The word will not go away. We all know it means nothing, or everything (or turnip).

Given a choice, many patients in pain don't want a brace if they can be cured.

I think we can be a bit more inclusive in this blog, rather than leaving it to nattering about teminology. As knowledge changes, the words will change, and they will never be exactly correct. I read this blog to learn something I can use in practice (and to debate/play about global warming). Not to debate terminology. How many angels . . . ?

Cheers

Frederick

 

I'm limited here by time, and a phone sized keypad.

No, but it does mean we can critique it. That's what we do here. And before you think it's a local thing we do it to each other with equal or more rigour.

You don't get it. This is not about terminology. It's deeper than that. It's about how we consider, diagnose and treat patients. Pronation is not a disease to be cured! It's a movement. When we describe it in those terms it becomes something different!

You gave a perfect example :-

A small selection of the conditions people describe with the blanket hyper pronation. But all very different conditions which may require different types of care.

To take the grossest example, consider a flat foot with massive fixed forefoot inversion. A "hyperpronated" foot by most people's reckoning. Abnormal tall tarsal biomechanics? Hell yeah! But will the hypeocure alter the plantar fascism tension? Of course not because the medial column is fixed!

Hyperpronation lumps that in with all the others. And the observations made of that foot would not fit the findings of the study. That's why we don't use that terminology!


That's just one example. And t

 

Its also not just gentlemen btw ;-). I just got schooled on another thread about callus by a very knowledgable young lady for using the word "abnormal".

Good terminology is not gender specific ;-).

 

Dear Gentlemen - I was really just replying to Robert and David, but let's use it in the generic sense, like "mankind"

For someone who doesn't know what hyperpronation means, you seem to know what it means. The foot I think you described is not what I would describe as hyperpronated.

No, I think I do get what you are on about. But, it's not of much interest to me. I am all about patient care.

Cheers

Frederick

 

Exactly the point which Mike, David and I have been trying to communicate! If there is no coherent and agreed definition, and there isn't, then it's all a matter of opinion. You say a foot with a heavy forefoot inversion, which requires the Sub talar joint to pronate to the point that the navicular weight bears to get the forefoot plantarfrade is NOT hyperpronated? Why not? It seems to satisfy both the hyper and the pronated bit.

Ah, so sloppy terminology is acceptable when we're "all about patient care" then. And what do you think everyone else is talking about?

How can I make this clearer?

Using loose, ill defined terminology like "hyperpronated" will adversely affect patient care by lumping complex and disparate pathologies which should receive separate consideration and different management under a crude catchall umberella and inappropriately advocating a single treatment for all of them.

If people take this paper at face value, it could result in using the hyprocure inappropriately which will lead to negative outcomes. Simply because people can't be bothered to consider feet in more depth and detail than hyper-pronation. Whatever that means exactly.

 

Ah, well there we go. Now we can agree on something.

Not even the Pope can keep people from thinking for themselves.

Welcome to the real world.

Cheers

Frederick

 

Simon & Frederick

Without really wanting to get emboiled in your tit for tat, your conversation reminds me of the continuing feud between 'academics' and 'clinicians' about the nature and usefulness of podiatric research at the clinical level.

One side sees technical engineering and high brow knowledge of biomechanical function as key to delivering repeatable interventions for mechanical problems. The other camp appears to shrug their collective shoulders and appreciate that's all well and good, but generally sticking anything in the shoe that tilts the foot in the opposite direction to where is goes at the moment, generally fixes a lot of stuff.

It just appears to me that when all you have to use to fix things is a hammer, everything looks like a nail - and finding a better way to swing and design the hammer is what its all about.

I look forward to the day when all podiatrists in all countries can prescribe whatever drug they want, and deliver any surgical solution they need. Then the bigger picture will be a much more interesting conversation.

...

LL

 

I get blamed for everything! Nothing to do with me Lucky.

 

Either freud is picking you up off the floor or you made quite a subtle joke there.

Of course it is. I'm mostly your fault. And a lot of Kevin's, but mostly yours.

We should be better than that. Nothing wrong with opinions, but using terms in research papers (much less everyday conversation) with meanings which depend so much on interpretation is not going to help the profession to be taken seriously or advance the science.

 

Apologies to Simon, Freudian slip.

Sometimes difficult to tell who is taking part in the conversation from Team UK when you skim over the avatars....

No excuse.

LL

 

"Throw a rock in the air, you'll hit someone who's guilty"- Bukowski

 

Speaking of Charles Bukowski, a friend and myself met his widow Linda some years ago in San Pedro, California at a sushi bar. She smokes Beedies and has numerous cats, which tends to freak me out. Got to sit in the chair where he penned some of his work, Linda gave me one of his copies of Pulp, his last novel. Interesting evening to say the least, not really on topic but I thought it was quite serendipitous and cool.

“Great art is horse****, buy tacos.”
― Charles Bukowski

 

33% reduction sounds impressive, but is 0.27mm group mean difference as impressive??
N=6 feet x 2 measures (before and after), so where did the N=18 come from?
Im no stats man, but those variances seem large relative to the claimed significant difference, ?
How much force was applied to generate strain?
I think Erdemir claimed strain rates in excess of 5% with 'cadaveric walking' (not specifically 'hyperpronating' feet at that).

I understood that foot posture and foot motion were not significant predictors of PF?
We seem to speculate that tension is the/(a) cause of PF- do we know this? Is compression relevant (as may be the case with other degen enthesopathies)?
Perhaps this paper should be considered a pilot study warranting further investigation.