Foot orthotics and postural stability

Sorry if my posting disturbed you, Robert. I did not say that all Sole Support orthoses cause problems for all patients. I'm sure that many of them work well for some patients. It's just I haven't seen any patients that are happy with Sole Support orthoses, only those that are unhappy or are not being helped by them. Of course, we all see other podiatrist's failures more than we see their successes. That is true in all medical professional offices.

There seems to be only one podiatrist in my area who is using Sole Support orthoses. From the few I have seen, they are basically a higher arched, non-rearfoot posted, semi-flexible plastic-shelled orthosis with a topcover that has had its heel contact point ground flat to about 1-2 mm thickness. Contrary to the pitch given, Sole Support orthoses do not seem to be revolutionary at all in any way. From what I have seen of these orthoses, they look very similar to orthoses that I and other podiatry students in my class were experimenting with back at CCPM nearly a quarter century ago in the MO lab. In other words, I have not been very impressed so far with Sole Support orthoses.

The whole point of anyone or any company who uses Podiatry Arena or the web to sell their product by using testimonials http://www.solesupports.com/testimonials.htm and other advertisement techniques to proclaim the benefits of their orthoses is that they will never tell you about the patients who are not helped or are harmed by their orthoses. They only tell you about the wonderful benefits of their orthoses and why their orthoses are the only true "biomechanically correct" orthoses.

Therefore, one of the purposes of my last posting was to provide a little anecdotal evidence from a different perspective for those readers of Podiatry Arena who have not seen Sole Suport orthoses or who have not seen patients who have worn Sole Support orthoses. I believe my posting is necessary to provide a more balanced viewpoint of this company's orthoses contrary to what the company's president has been providing us with. Wouldn't you agree, Robert? Or should we let people post here on Podiatry Arena with unsubstantiated and unreferenced claims regarding their products without challenging their claims? What do you believe is the most balanced approach for contributors of Podiatry Arena?

 

Balanced view

Kevin

Well that's the rub isn't it. As you say some people have been relying on filtered information to give a uniquely positive spin to their apparant outcomes and i agree that this is irresponsible. It is also to be expected. I forget where but somewhere i saw a piece on "identifying snake oil" and one of the prime things was that the company reported universal success.

If i am buying a used car i will not expect the salesman to tell me about the family who bought their's back after a month because the wheels fell off half way down the Moterway! ANY posting from anyone trying to sell something should be treated with a degree of suspicion! Sad but true.

NEW PRODUCT IN NOT-THAT-DIS-SIMILAR-TO-OLD-PRODUCT
SHOCK!

Thats quite interesting to those of us who have yet to have the pleasure of seeing one of these things. Sounds like the wheel has been re invented yet again. In the interests of balance there's nothing better than a report on a device by an independant person!

I would absolutely not presume to know the most balanced approach for contributors. One of the joys of this forum is the variety of people and styles of post and to discourage ANY approach would be a tragedy! Even the unsubstantiated, unreferenced and arguably self serving and cynical posts we have seen have sparked some really dynamic and entertaining debate. I for one have learned a great deal from peoples rebuttals to such posts, especially yours.

I merely and very humbly opine that i have found the posts in which people rise above the "they work because i've seen them work" and "they don't because i've seen them not" most convincing. Even coming from one as respected as yourself anecdotal evidence is, for me, unconvincing an unhelpful. Your rational and well thought through arguments and reports on what these devices actually look like in the flesh carry infinitly more weight!

It has been said that there is nothing more said than a beatiful idea killed by an ugly fact. For me there is nothing more heartening than an ugly idea killed by a beatiful fact.

That was all.

With extreme respect

Robert

 

Sole orthoses

I also have samples of SSO. I was not surprised by the appearance of the device and it is pretty much what I expected after watching Ed Glaser's presentation. Sure, it has an arch that follows the foot profile to provide a greater contact area to exert the corrective force. That's pretty much what we are told in the DVD. If we can accept the ideology, what makes the device different is the concept of maximally supporting the arch together with the combination of orthotic material matched as closely as possible to the patient’s requirements i.e. body mass, foot flexibility, shoe wear, activity level etc.

Ed does not, it seems to me, claim that the appearance of his orthoses is revolutionary. Amidst the spin he freely admits 'this is nothing new'. His specific claim, I think, is made on the strength of his interpretation of foot mechanics, and what it is that is required to achieve optimum mechanical correction, specifically that based on the observation of sub-talar architecture, the facets, and subsequent joint motion and how and when this should be controlled in the gait cycle.

Sure I accept the presentation has a heavy marketing spin. Is Ed universally wrong in levelling those criticisms against the 'traditional' concepts taught in podiatry schools ? Does a re-evaluation of those concepts from an engineer’s perspective hold no value at all? Is he right about measuring errors, the unreliability of neutral suspension casting, the problems with STJ 'neutral' etc.

Ed caught my imagination when he states that 'theory should match observation' and many of his own observations, are a mix of physics and engineering principles, which do not rely on discredited tenets, explained succinctly and with a refreshing clarity, and this makes for a compelling and seductive discourse..

Although Ed Glaser identifies 36 or so diagnoses which could be related to the injurious effects of abnormal foot pronation I do not see where he claims that ALL foot pain is caused by pronation.

Treatment failures are a fact of life and will affect all no matter what the intervention. If poor outcomes can be traced to one practitioner perhaps there is a training issue? Unfamiliarity with the technology, casting methods, prescription variables? Was there an opportunity for the patient to have the orthosis adjusted?

If it is the case that ‘many of them work well for some patients’ is Ed Glaser wrong?
Sole Support orthoses have been the subject of evaluation by PhD’s in biomechanics at Georgia State University. Assuming there is no financial interest, the findings suggest the orthosis have a positive effect on the gait cycle.

Sure the idea the hallux should receive ~60% of loading pressure at toe off is also a ‘Rooted’ concept but are we now saying the basic principle is wrong and this is not how weight moves across a ‘normal’ foot?

 

Kevin,

I would like to make a general comment before I answer your post.

I think the logic behind your argument here is a good example of where these kinds of discussions tend to lead when we begin to scrutinize the topics as we do.

I’ve seen it in other threads, in other health professional debates, and now in this thread. What I mean is that when we have a debate like this one, the conclusions inevitably circle back to the debaters underlying (and sometimes unchangeable) position, regardless of the content of the dialogue.

We refute, we argue and we micro analyze, to the point where we are discussing the minutiae of our positions which can be of questionable clinical relevance. At some point our arguments are limited and we hit a point where the research is not available, or technology limits our understanding, and the argument bounces back to the big picture. “Well, I saw one of these that didn’t work”.

Not meant as a criticism, just an observation of how many of these debates tend to go. Everyone does it, and we will continue to do it, because it’s what we do.

Since you have returned the debate to the big picture, I will try to address some of your concerns with the product.

There are a few points here that should be clarified. So everyone knows where I am coming from: I work with Sole Supports, I have researched/investigated the product, and I have used them in practice for 5 years.

First, Sole Supports does not claim to be a cure-all. Second, Sole Supports is an aggressive FO that attempts to place the foot in the most corrected position that the patient’s anatomy will allow and tolerate. This is how they are different, but inherent in this process is some change and tissue stress. If there is no change in tissue stress (which could result in some transient pain) then what good are we doing with a foot orthosis????

Sole Supports providers are told that this is not an orthosis that is dispensed and then forgotten about. They require a break in, pathology specific stretching and even sports specific break in. Re-exams are required to ensure that the orthosis has been properly calibrated to the patient’s weight and activity level. Providers are given countless avenues for technical support on topics such as: proper shoe fit with the FO’s, troubleshooting patient complaints (distal arch pain, first mpj pain, etc), and what type of foot conditions may not be appropriate for SS. The implication that Sole Supports claims to be a panacea is erroneous.

You are correct in your description. I would ask if you feel a physical description of orthoses truly captures the differences. I guess I made a similar generalization when I implied that Foot Levelers all look the same – someone from that company would probably argue that.

You are right that the MASS position is much higher than the cast corrected neutral position of most orthoses. The device is designed to precisely match the patient’s foot in the maximally supinated position during the swing phase. No arch fill at the lab. Speaking of arch fill and low arches, I am having a hard time understanding the reason behind a modification in the lab that would decrease the arch height and alter the cast that the provider sent in. I would think that the main reason is so that the device is more comfortable and that there are fewer warranty issues. I have had a hard time finding any information on this lab process. One recommendation I saw was that athletes should have a greater amount of arch fill? Some insight into this concept from a different perspective is welcome.

The devices are non-rearfoot posted for reasons that are adequately debated in the “skives and posts” thread. I also notice that Smith and Spooner (in JAPMA 94(6) 2004) showed a decrease in first ray dorsiflexion with varus posts. Not a goal of orthosis correction as I see it.

Semi flexible is incomplete. You could add calibrated digitally to deliver the appropriate force and flexibility.

Before making a general statement about any orthosis, I would have more questions for this patient. For what reason were they prescribed? Any history of peroneal injury? When were they fitted? Is he in the break-in period and if so was he advised on stretches and a reduction in wear to allow for compensation? The studies we are discussing in this thread showed an adaptation period of about 6 weeks before the orthosis had the desired effect. Has the patient changed activity levels that could be altering the orthosis?

Your comment about seeing other practitioners failures is an appropriate one. We’ve all got the answer to someone else’s problems.

With reference to the peroneal tendonitis you mention. The peroneus complex decreases the supination moment during the end phase of midstance. If you are saying that the increased supination moment caused by a high arched orthosis would increase the peroneal muscle activity, I would agree, but only transiently and not pathologically. I would point out that whenever you are changing the function of the foot, some muscle activity is changed, but I think it is a big leap to assume that it is to the detriment of the patient. The peroneus complex also functions to plantar flex the first ray at toe off. The argument could be made that an orthosis designed to assist in plantar flexion of the first ray (by way of this “excessive” supination) might only assist the peroneals in this activity.

Respectfully,
Stu

 

Stu,

Since you're back posting again could you answer the question I asked a while back and tell me whether you think it is desirable to increase sub 1st MPJ loading in a foot with forefoot supinatus?

 

So, Stu, what is your point? Do you think that our form of academic discussion is any different from debates that have occurred within any branch of the medical profession for the last few centuries? Or are we doing something dramatically different here on Podiatry Arena that I am not aware of?

When you say "I work with Sole Supports", does that then mean that you receive monetary compensation from Sole Supports for your services? Or does that mean that you work with Sole Supports for free? (I would be very impressed if this were indeed the case.) In addition, do you receive a discount from Sole Supports for using Sole Support orthoses for your patients, or are you charged the same price that any other clinician would be charged for Sole Support orthoses?

When Ed Glaser first came aboard Podiatry Arena to tell us about his many pet theories on foot and lower extremity biomechanics, he stated that there was only one orthosis that could perform what he says the Sole Supports orthosis can perform. Isn't this sort of marketing hype from the President of the company, along with the testimonial pages on Sole Supports webpages (with no attempts anywhere on your webpages to explain that not all patients may be cured by Sole Supports orthoses), intended to make a layperson or unsophisticated clinician assume that Sole Supports orthoses could possibly cure nearly any type of foot and/or lower extremity pain? Wouldn't you think that if you wanted to be truly academically honest with your Sole Supports affiliation that you would insist that the "testimonial" section of the Sole Supports webpage be removed unless the company you work for also had a disclaimer that not all patients may benefit from Sole Supports orthoses??

Stu, please describe to me anywhere that Ed Glaser makes a statement that "Sole Supports are not a panacea" anywhere in his DVD or on your Sole Supports website. From what I have seen on these two readily available resources, none of these other factors that you have listed above and that I, and many other podiatric biomechanics educators, have been teaching to podiatry students and podiatrists over the past three decades are mentioned. Do you actually think that Sole Supports is the first orthosis company or biomechanics resource that has suggested to clinicians the following:

1) They require a break in, pathology specific stretching and even sports specific break in.

2) Re-exams are required to ensure that the orthosis has been properly calibrated to the patient’s weight and activity level.

3)Providers are given countless avenues for technical support on topics such as: proper shoe fit with the FO’s, troubleshooting patient complaints (distal arch pain, first mpj pain, etc), and what type of foot conditions may not be appropriate for SS..................?????????

I think that Dr; Mert Root was teaching these concepts back forty years ago at CCPM and I have also previously published these concepts in my two books (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997; Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002). Sole Supports labs is not the only lab that gives their clients academic lessons on orthoses. The orthosis lab I work for has been paying me to write a monthly newsletter for them for the past 20 years and I have now written a total of 232 monthly newsletters, all for the cause of increasing the academic knowledge of our, and countless other orthosis lab's clinicians.

By the way, I don't think the provider using Sole Supports here in Sacramento is taking advantage of all of the resources that you claim Sole Supports provides to their clients.

This is obvious by scrutinizing about four pairs of Sole Supports orthoses. Do you think, Stu, that all patients with pronated feet need to be functioning in the subtalar neutral position or the supinated subtalar joint position??

This is probably the reason that Sole Support orthoses are so different from other orthoses. Because Sole Support orthoses are very high-arched they have a high likelihood of leading to medial arch irritation problems or to STJ supination instability problems in many individuals and, therefore, many orthosis labs would rather not deal with these types of headaches. That is probably why most orthosis labs use quite a bit of medial arch fill in their orthoses....more arch fill means fewer returns and fewer complaints from their clients.

This is an interesting opinion that you and Ed have regarding orthosis therapy. Unfortunately, few podiatrists that I respect share your opinion that non-rearfoot posted orthoses are always the best orthoses for their patients. I use rearfoot posts in about 80% of my patients' orthoses and routinely get good to excellent results with these rearfoot posted orthoses. How do you explain my clinical observation that rearfoot posted orthoses have worked extremely well in the 10,000+ pairs of orthoses that I have dispensed to patients over a 21 year history of practice??

How do you "digitally calibrate" the "force and flexibility" of an orthosis? How does the prescribing clinician accomplish this measurement in their practice to know how much "force and flexibility" their patient needs in their orthoses?

Peroneal tendinitis and/or peroneal fatique can be a common complaint in any orthosis that has excessive varus correction or excessive medial longitudinal arch height due to the increased external subtalar joint (STJ) supination moment that is caused by these varus/high arched corrections (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989; Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992; Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992; Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001.) Both the peroneus brevis and peroneus longus muscles are the only extrinsic muscles of the foot that can add significant internal STJ pronation moment to counterbalance any excessive STJ supination moments from over-varus-corrected foot orthoses (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997; Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002). I would think that you would agree that it is not a big leap to say that any patient that receives an orthosis for their asymptomatic foot and says that this pain (in his peroneal tendons) is so bad that he is having a hard time walking and he says that in the 2-3 times his prescribing podiatrist has adjusted their Sole Support orthoses that he has not been able to make his previously asymptomatic foot feel any better with those orthoses, that this is a detriment to the patient. Maybe this is why other orthosis labs quit making orthoses that look just like Sole Support orthoses....too much peroneal tendinitis and medial arch irritation???

 

Stu,
I suggest you read the paper since we showed (as other authors have too) the varus rearfoot wedges decreased peak hallux dorsiflexion in our paper, not first ray dorsiflexion as you stated. If you read our discussion of these results you will realise why this observation was made.

If you increase sub 1st MPJ loading with a Sole Support what effect do you think this will have on MPJ dorsiflexion?

 

Sorry Simon, it's easy to get sidetracked in these discussions, I'll get to your other questions as well.

My answer is yes, I do. The authors in the plantar pressures study found that with the supinatus deformity plantar pressures were increased over the lateral metatarsal heads at midstance and toeoff. As you know, the thinking is that the 1st met head that is hypermobile or unstable or “decreased in first ray dorsiflexion stiffness” (thanks Kevin) cannot sufficiently bear weight and it is transferred to the lesser met heads.

In a previous threads parts of this topic have been covered nicely by yourself and others:

supinatus thread

In theory, an orthotic device that supports the MLA and plantarflexes the head of the first, can control for the lateral weight shift properties of the supinatus deformity. I would also suggest that one of the main goals of an orthotic is not only to shift plantar pressures away from the lesser met heads, but to more evenly distribute pressure through the midfoot and medial forefoot at midstance.”

Any concern that the added plantar pressure under the first MPJ would only add to the varus moment of the supinatus deformity is alleviated by preventing the midfoot from collapse.

Would you say that plantar pressures should be greater over the 3rd, 4th and 5th met heads at toe off?”

Stu

 

Simon, I did read your paper. Sorry terminology error. To be clear, you studied "rearfoot wedging on peak dorsiflexion at the first metatarsophalangeal joint".

And concluded that.....

"Within the limitations of the study, the results suggest that both forms of wedging had a statistically significant effect on peak first metatarsophalangeal joint dorsiflexion, with reductions occurring with both types of wedging."

To me, any explanations which would be "necessarily speculative" as you state in your paper, do not convince me that reducing hallux dorsiflexion by way of a varus wedge, is something that I want to do with an orthosis.

Stu

 

Here is a classic example of foot position, versus foot pathology. While forefoot supinatus may be a positional factor, it is not in my view a pathology. Indeed in Valmassy (chapter two or three I think), there is a nice list of pathologies associated with forefoot supinatus which seem to fit with my clinical/ research observations over the past 15 years or so. These are generally disorders of the 1st MPJ- hallux limitus, hallux valgus etc., I don't think that increasing the loading beneath the 1st MPJ in these conditions is a good idea in the majority of patients as it is likely to further inhibit normal function of the joint and exacerbate the pathology.

Is it? This is evidenced by?

I think it depends on the propulsive strategy adopted for that given step, which is dependent upon the velocity, direction and terrain.

 

When you understand the paper, you will realise that the results were necessarily speculative because the sample size of just 30 individuals means that the power is somewhat lower than desired. You see how we put these great big warning signs in for readers, go re-read: just how many times did we warn about small numbers in that paper? Still haven't found similar caveats in papers funded by Sole Supports.

This statement above tells me a lot about you Stu. You see on the one hand you are saying that our speculative explanation does not convince you and yet in the next touch of your keyboard you are believing and taking the results of the study as read. Love this kind of manipulation.

When you really read and understand the paper, you will realise that the effect observed in association with varus wedging was probably more to do with the methodological weaknesses and/ or heel lift effects as was clearly stated in the study. If you prefer to just look at the pictures see figure 8.

When you really really read and understand the study you will realise that there is a world of difference between statistical significance and clinical significance. How much dorsiflexion is "normal"? Answer, depends on the shoes you're wearing, how fast you going, and in what environment.

Would I ever want to jam up a painful 1st MPJ? Yes in certain circumstances I would, have done, got rid of the patients pain, got thanked and paid for it and would do it again. Perhaps that's just one more happy difference between me and you Stu. In my experience patients don't present with forefoot supinatus, they usually present with pain. All they want is the pain to be gone. Jamming up a 1st MPJ in painful end stage hallux limitus/ rigidus in an elderly patient does get rid of the pain. I don't know of any orthotic which can remove osteophytes and for some people surgery is not an option so using a Morton's extension and combined with footwear modification will provide the patient with the outcome they are looking for over a very short time scale. Tell me why this is wrong?

 

Mechanoreceptors and balance

Krome,

I could not agree with you more. I have long thought that one of the reasons that we saw a significant increase in postural stability with the Sole Supports orthoses is that the increased area of contact and specifically the full contact of the Sole Support causes more intimate skin contact evenly dispersed across the orthotic. I think that changes in angulations of the terrain are more clearly sensed due to shearing stresses placed on the skin. This is much like the mechanism of action of athletic taping. Certainly a piece of tape will not hold an athlete capable of leg pressing 1300lbs., but it will pull on the skin making him more aware of proprioception. Automatic and trained balance mechanisms are employed that will then reduce or prevent injury. Just one of the many benefits of full contact support.

Excellent Concept,
Ed
www.solesupports.com

 

Stu works from his home over 1000 miles from the lab. We started out hiring Stu for research 10 hrs/wk. This has gradually grown to 30hrs/wk. For this he receives a salary.

You have stated that there are hundreds of labs doing exactly what we are. Could you please name one central fabrication lab that offers all of the following:

1. MASS position casting certification.
2. Requires MASS position Gait Referenced Casting.
3. Goes FULL CONTACT with the shape of the foot achieved from the above.
4. Digitally Calibrates each orthotic to the proper force curve for that patient’s body weight, forefoot flexibility and momentum.

I am having a hard time locating one. Is there a single article other than those using Sole Supports that specifically tests an orthotic that has all of the above characteristics? NO not one. All of you suppositions and anecdotal observations are without substantiation. I certainly can’t see any bias on the part of the observer, HA HA ….. The correct answer is that those tests are being done as we speak at several universities and soon to be more. Very exciting results are coming out. That is exciting for us, maybe depressing for you, I don’t know. I forgot how much laughter I had doing this.

Stu said it but you obviously want to hear it from me. Sole Supports are not a panacea. Unless the doctors that I have been talking to on the phone every day and those that show up at my seminars over and over even though they have been using my product for years are lying, they are working on the vast majority of their cases. In fact the comments I receive quite often is that they work far far better than the standard technologies that they were taught in school or whatever lab they were using before. Certainly not a scientific study just feedback. One reason that I have not had time to post here is that our >25% growth rate this year has demanded considerable attention from me. Additionally, we have been testing new research tools, fabricating and testing our new nine pin calibration unit. Playing with our new 3-D and high speed cameras. Fun, Fun, Fun. And more Fun. Life is good.

See above

That is a very good point. Much of that material is covered in the workshop portion of the course which is in the certification CD. This can be purchased via email for $150.00 + S&H USD by contacting mshelby@solesupports.com

You will not find those four concepts above in any of the writings you describe, least of all your stuff which you so shamelessly promote here. Shame, shame, shame. At least my DVD is free including shipping by just emailing Misty at the above address.

Never said we were. In fact the Oregon Brace company has been doing it for years. We might be the only Foot Orthotic Lab in the USA that REQUIRES EVERY SINGLE PRACTITIONER TO BE CERTIFIED. If there is another, I am unaware. Does the lab you work for do that? Seems like it would limit growth, but it hasn’t.

And this should be considered a serious body of work that is peer reviewed and held to the highest research standards that even the great and powerful Simon would approve of.

Stu can easily answer this from mere clinical experience. My answer is that the foot moves through positions it does not function in one unless you are making a brace. This is a calibrated, functional device so it flexes with the foot.

Here lies a major misunderstanding of our technology. This is why I require people to be educated before using our product.
Firstly arch irritation problems usually occur when the arch is too low or the shell material is calibrated too rigid, not too high. In a flat hard insert, like the ones you make, the foot drops to a relatively sudden stop with each step. When you first get a Birkenstock, they are painful in many cases because the foot is not used to that impact. The vast, vast, vast, majority of all adjustments are in the up direction. When an orthotic is full contact, and flexes with the patient it feels as though the ground is molded to the foot with each step. Unlike sand however, the orthotic applies the correct force and flexibility to control the excessive pronation.
Secondly, the foot is more stable in supination. The orthotic, according to the raw data from the GSU subjects I looked at and later confirmed with our f-scan, is dramatically and visibly transferring the weight bearing medially, decreasing the likelihood of ankle sprains.

Here you hit the nail on the head. The reason why you, your professors and other labs divorce the shape of the foot from the shape of the orthoses (with “cast correction” … a real oxymoron) is because they get too many warrantees. Calibration is the key here, obviously and is easily seen in our steadily decreasing warrantee statistics which are already dramatically lower than the industry standard. Over the last 10 years, as we researched calibration, we saw our warranties drop and drop and drop to where today, warranties that are related to mis-calibration (Such as collapsing or too rigid orthotics) is a fraction of one percent.

You are right, it is a pity that we have not reached more doctors but we are doing our best.

Your are right, you are every bit as good and maybe slightly better than a good pre-fab. You can relieve symptoms in some patients.

I believe I went into a long explanation of calibration in the thread Skives and posts. The answer for the clinician is simple. The clinician is required ONLY to measure the body weight and flexibility of the foot. From that data we can calculate a first approximation of the average force applied to the foot and adjustments are made for activity level and the calibration device (patent pending) helps our skilled master grinders “tune” the orthotic until the measurement matches the calculated value.

I love this. This is a completely unsubstantiated statement followed by a list of your own publications that are totally irrelevant. Nothing you referenced here makes that point.

Again, the same from such an authoritative source, your non-peer reviewed newsletters.
The peroneus brevis applies a supination moment but the p. longus changes functions as the position of the foot changes. Great 3D animation of this in the DVD.

I once had a patient say that their orthotic caused diarrhea. I think my anecdote is funnier than yours.

When an orthotic actually does make a dramatic change in the gait cycle and the patient often experiences transient muscular changes and even pains. Stretching is recommended, slower break in, possibly this pair was mis-calibrated (no one is perfect…even you). At this point I would prefer to refer this patient for a PT evaluation rather than abandon my attempts to modify function. There may be many other contributing factors that will come out in a thorough PT eval. Very often the transient muscle pain is from a muscle actually being used efficiently and increasing its tonus. I recently changed my exercise routine from recumbent tricycling (Greenspeed GTO from Australia)
http://www.greenspeed.com.au/gto.htm#The GTO Touring Trike
to a Velotechnic Grasshopper recumbent short wheelbase two wheeler.

http://www.hpvelotechnik.com/produkte/ghp/index_e.html.

The change in mechanics and the need for balance caused nagging back pain for the first 150 miles as I began using back muscles that I had previously neglected. I also noted that I was standing straighter, better posture and felt stronger, just had a lot of pain. I got through it. Changing things can hurt sometimes. What you have seen is relatively rare however and may just relate to the bias of the observer. If my customers routinely were seeing what you seem to be, I would most certainly be out of business….instead I am growing at a fantastic rate and mostly through word of mouth.

You are right again, if you don’t know calibration (as your previous question indicates that you do not) warranties will eat you alive and most labs just gave up. We took a different path and just invented calibration. Without it ….well, good luck.

Every time I introduce a NEW aspect of our technology that makes us unique in the foot orthotic field, it is seen as self promotion. If you want to look at it that way OK. If you open your eyes, as many have done and continue to do, you will see that behind this thinly veiled “sales pitch” is a revolutionary approach to foot biomechanics that has never before been proposed, tested, manufactured, marketed of even conceived. If you had discovered full contact, mass position, and dynamically caster, calibrated othotics 10 years ago, why did you do nothing with those discoveries. You could not make them work, so like other labs, you went back into the box and locked the door. Your lab certainly does not offer any product with any of these characteristics and certainly never has made even one orthosis with all of them.

Life is good,
Ed
www.solesupports.com

 

Observe the obvious

Lowering the head of the first metatarsal will absolutely increase 1st MTP DF. It is very easy to demonstrate this. Press up on your own first met head and DF ROM decreases, press down on the head and it increases.

Ed

 

Ed, I thought that Stu was a big enough boy now that you would let him answer for himself. Stu was doing quite nicely answering my questions, and in a very civil manner, until you stepped in and ruined it for him.

Unfortunately, such is what often happens in these types of business relationships within the medical profession...the person with the real brains and the ability to objectively analyze information often has to answer to the big boss that has less scientific ability but has more aggressive marketing/business skills so that they can constantly focus on always improving the "bottom line of the bottom block".

By the way, Ed, I love this part of your website:

Published Research demonstrates Sole Supports superiority!
Click Here

Read our user testimonials!

http://www.solesupports.com/index.htm

 

Simon,

I was only able to find two studies that you had published so far. The first had two subjects and now you admit that your other study was too small to be meaningful. Actually, I like your wedging or posting study. It showed that posting can be harmful.
We did NOT write the GSU paper, never even read it before publication, found out about it six months later that it was even in print. We certainly did not control or even influence what was said so ask the authors about caveats. The study was only partially funded by us.

Methodological weakness. If we can’t trust your research, what have you contributed with it and what meaning is it? Why did you publish it?

As I stated previously, the lab is not always directly applicable to the field.

This is actually right. I would NOT recommend a Sole Support for the elderly patient with painful traumatic arthritis with osteophytes because the increased function in this elderly patient might cause more pain. Good point. A brace of some sort that limits motion is better for this patient. Increasing function is for those who both desire and are capable of improving function. There are lots of ways to cover up pain without improving function: Cortisone, NSAIDS, Anesthetics, Pain Killers, Neurectomy and bracing to name a few. Choose the therapeutic modality that most suits that patient. Always aiming just to cover up pain however would be setting the bar too low and a cop out. There is an appropriate time to utilize an orthoses as aggressive like Sole Support: one that takes the patient much further. We have different goals...which is OK…I like to fix things, not just cover them up most of the time.

Sincerely,
Ed
www.solesupports.com

 

Great link....thanks!!! The last two are especially good. I like where Dr. Barrett writes: "As I lecture all over the country, this will undoubtedly increase professional awareness of what I consider the most important biomechanical work in the last couple of decades."

Stu, BTW, is doing a fantastic job, I agree. I am sorry that you have difficulty fathoming the internal structure of a company that is based solely on "We Make People Better". As usual your baseless assumptions miss the boat completely....they are not even at the right peer and really have no place in an academic discussion like this. Stop worrying so much about how I structured such a successful enterprise and stick to the biomechanics please. Civility is not your strong suit either, Kevin.

If you don't like testimonials...don't read them.

Ed

 

sole supports

Dear Ed Kevin et al

Civility seems to be an increasing tricky thing for everyone. Its all been getting a bit personal lately!

Dragging back to the Science and biomechanics of the whole thing i have a few questions regarding the published research mentioned in the above link.

I preface this by saying i am a clinician not a researcher and concepts like Statistical power tend to cause me to froth at the mouth and throw myself on the ground thrashing until somebody throws water at me.

There are three pieces of research on the SS website which are claimed to "demonstrate sole supports seniority"

One is a japma study on the variability of Bog standard casting techniques. I don't see how this is particularly relevant or indeed proves one type of insole is better than another.

Another is a rather interesting study which seems to indicate that sole supports improve postural stability. This is relevant and interesting but does not compare SS insoles to any others and therefore cannot be said to show "superiority" to anything else

The last is a study with 17 participants (calm down Mr Spooner,) which apparently shows that SS insoles work better than others.

However the main criteria for measuring effectiveness seems to be that it shifts weight off the medial side of the PMA, specifically

"The SOLE orthotic appeared to be more effective in achieving the goals of custom-molded orthotic intervention, which include decreased pressure on the lateral metatarsal heads and increased pressure under the fi rst metatarsal head at toe-off."

Given what the SS actually is, an orthotic which casts the foot in an extremely supinated position, the study appears to show that supinating the foot more appears to unload the medial side of the forefoot. (duh)

IMHO there is a big difference between the concept that more supination shifts more grf to the medial side of the foot and the claim that this makes them "superior". Putting a thumbtack under the first met head will shift even more weight laterally but that hardly makes it a good idea. Surely an orthotic needs to do more than this.

As i say the statistical power of the study may also be suspect, i defer to my infinitly more intelligent colleagues on that, it is the direct relevance of the study outcomes to the publisher claims which troubles me.

comments?

Regards
Robert

 

Ed you are extrapolating beyond the limits of the findings of the study that you funded. What the study demonstrated was increased loading sub 1st MPJ, it did not show anything with regard to 1st ray position, nor 1st MPJ dorsiflexion. A varus forefoot wedge will increase sub 1st loading, but doesn't increase first MPJ dorsiflexion. Moreover, since you are a fan of our paper on rearfoot wedging and 1st MPJ dorsiflexion, you wil realise that while the varus rearfoot wedge increased the declination angle of the 1st met, it didn't appear to have a positive effect on 1st MPJ dorsiflexion.

 

Actually I've published 5 papers so far, a further one has been accepted and will be published soon. Two more have been submitted and are under review. All have relatively small sample sizes. My PhD thesis, which you can get from the British Library used 579 subjects- power >98%. Not the greatest academic track record, but certainly not the worst.

Now enough about me, lets talk about you. I looked for something you had published- but couldn't find anything. So I guess I'm 5-0 up on you plus a PhD so I'd appreciate it if you didn't try to slate my publication record, since it appears to be somewhat superior to yours.

Now before you do publish, you've got to take a course in reading and interpreting research. The study sample size was small and hence conclusions drawn from the study should be treated with caution. Does this equate to meaningless? This study of 30 subjects was still somewhat larger than the sample of the two papers which you funded using 17 subjects. The difference is, while I as a researcher am cautious in presenting results, and like to draw readers with lesser knowledge to the weaknesses and statistical limits of the study, other workers state their findings as if they are facts. In essence the power of our study as I recall was probably greater than the studies of 17 subjects reported by your employee, but I'm just more scientific in my approach to reporting.

The study did not show that posting can be harmful. See there you go again Ed- extrapolating beyond the data. Please, read up on research processes. You can't just "conslude" what you want to "conslude", you have to stick to what the data says.

Ed see my comments above, all studies have methodological weaknesses. I review for JAPMA and the British Journal and read countless articles every week- I haven't seen a paper yet that didn't have methodological weakness. We have contributed within the statistical limits of the study. I guess I publish for a lot of reasons, but mainly so I don't end up as a snake oil salesman talking out of my butt. Ultimately, I guess you should ask the editor of JAPMA why they felt it was worthy of publication.

What does this mean?

I think the potential side-effects and risks are lower using an orthotic than through the other modalities you list. Where did I say that I "always" do this?

 

Simon,

I love the orthotics you used for your study. They are the definition of tilted pancakes. They hardly increased the declination angle signigicantly. If you consider that these non-arched thin orthoses increased the declination angle significantly then there is your perception problem. The increase is so miniscule that it is insignificant unless you are comparing it to cast corrected flat hard pancakes that are usually passed off as "custom". Yes, I am extrapolating beyond the limits of what was published because I saw some of the raw data. Once again we only partially funded this study. PAL also funded it along with other grants. You are implying that the researchers caved in and sacrificed their integrity to please the sponsors and that just is NOT the case....Lori Tis and Beth Higby (both with PhD's like yours) have such a high integrity level, knowledge of research methodology, a university statistics department. Their integrity is beyond reproach and they did not even share the paper with us prior to publication. We had zero input so please cease you baseless jabs....they make you look bad.

Sincerely,
Ed

 

Words of advice for you, Ed: allow Stu to come back into the ring!! You are getting beat up, and will get beat up, beyond your capabilities and you need to send in a more noble opponent, like your paid consultant, Stu, in for the debate who knows how to interpret research and understands scientific method. It is probably best that you stay in the background, paying your way to lecture at seminars across the country on the "superiority" of Sole Support orthoses.

 

Could you please provide the other three article references?

I was just surprised. The way you attack everyone else’s research, I thought yours would just dominate the podiatric literature in both quantity and quality and every paper would be done in a manner that is statistically beyond criticism. That is just not the case. I have to say, that I have delivered over 600 lectures and the best biomechanists I have met have no papers published. Publication does not make you right. Credentials do not make you right. You seem to reduce every argument to: I must be right because I have more prestigious publications and a PhD BUT then on even cursory examination, and even by the same standards that you hold everyone else to, your publications thus far are weak.

So your paper, the GSU paper and the vast majority of papers published are just rubbish and should be thrown out with the possible exception of your thesis. Papers have limitations; they at GSU did not hide the fact that there were 17 subjects. Every reader knows that study size is relevant and will take that into account. Just horse sense will tell you that, we don’t need an advanced statistics course to read articles or write them. You can hire experts to do the statistics for your publication. Then the astute practitioner will compare what he is reading with his own clinical experience and give it a relative value (evaluate it). We all do this. You enjoy playing with the numbers. I like understanding the concepts and theorizing about how to gain better function. If study size has a direct correlation to accuracy, and I believe it does, what is the mathematical correlation between study size and accuracy? What is the graph? What size is believable? And will you not still have to compare it to the data you observe?

I see patients complain of decreased DF of the 1st MTP (Hallux limitus or rigidus). It is not a great leap to claim that a device that limits the motion further would be harmful unless your orthotic is really just a splint or brace.

Respectfully,
Ed

 

Oh boy, you turn your head for one minute on this podiatry forum and you miss a lot of excitement.

Welcome back Ed, your posts sure do liven thing up!

For those of you who don't know Ed personally, please don't confuse his boundless enthusiasm for his product with a ruthless financial pursuit. His desire to cover the world in Sole Supports is only surpassed by his true desire to help people with their foot pain.

Back to the debate……..

So I think we agree here that forefoot supinatus is a position that is associated with a few pathologies. The most important thing I see here is that supinatus seems to be associated with lateral weight bearing at toe off. I would think reversing that trend would be of benefit.

I had said:

“that any concern that the added plantar pressure under the first MPJ would only add to the varus moment of the supinatus deformity is alleviated by preventing the midfoot from collapse.”

You asked:

I don’t know, isn’t it? Let’s discuss. Forefoot varus is relative to the rearfoot. So, if you are maximally supinating the rearfoot, wouldn’t it be very difficult to have a relative forefoot varus force? Unless, I suppose if the forefoot was perpendicular to the ground. A Super Supinatus!

I should start by saying that I do agree with KROME that published researchers should be first and foremost congratulated for their work, and their willingness to disseminate their findings to the public applauded. So Simon, I sincerely congratulate you on your work.

I have read your conclusions over a few times and maybe I am a bit confused by your interpretation of the results above. Perhaps it is as you say and I just don’t really really understand the study, but in your explanation above I can’t help but get the feeling that you are saying “Well my results didn’t show it, but here’s what really happened.”

I couldn’t agree more with you more that there is a huge difference between statistical significance and clinical significance, in fact that point has underscored many of my posts in our earlier stats discussion.

Oh sure, I get it. Manipulation……chiro jokes. Funny

Regards,
Stu

 

You’re right, it doesn’t prove one orthotic is better than another. It is only relevant to the fact that there is an extreme amount of variability in standard casting techniques. SS is doing investigations now on the reliability of their casting technique.

Agreed. Just interesting and worthy of discussion in this thread.

I would point out that the study showed a statistically significant decrease in plantar pressures for the lateral forefoot, and insignificant changes in the medial forefoot. I don’t think it showed that the medial side of the forefoot was unloaded.

This is a concept that we have had trouble getting clinicians to come to terms with for years, specifically that increased supination with this device could actually unload the lateral forefoot. Which is can often times be what we are after.

Assuming you are referring to the following…..

"The SOLE orthotic appeared to be more effective in achieving the goals of custom-molded orthotic intervention, which include decreased pressure on the lateral metatarsal heads and increased pressure under the fi rst metatarsal head at toe-off."

Robert, I will be the first to say that I was surprised that the authors made this jump as well. Since I am not the author I can't comment further, but I would like to state some facts about the funding of this study so this leap is not misinterpreted.

The study does contain the caveat that it was partially funded by Sole Supports.

In this case, partially funded meant providing orthotics for the study. PAL provided a discount on their orthotics for this study as well.

That was a few years ago. No other contact was had between the researchers and the company. Years went by and then voila….publication. In fact, SS only found out about the study after it was published.

Regards,
Stu

 

Kevers,
One of your classmates, who attended one of my recent lectures told me that it was your nickname in school.

For the record, Stu does not need my permission to post here. He is his own person. I believe it is you that are getting beat up even though you rarely post anything of substance.

You still, even though it has been asked of you now half a dozen times have NOT answered my question: What position do you cast the foot in? I am expecting some vague answer that gives no concrete parameters at all and teaches us nothing, as usual. Surprise me.

No one ever said Stu was a "consultant". Do you just make this crap up?

I have already gone over my financial arrangements with those for whom I lecture. For years I was paid handsomely, now I donate my honorariums back and sometimes I make additional donations to research funds etc. That is my option and I often choose to give back to the profession in terms of research grants, donations to foundations etc. That is no business of yours, has no relevance to any biomechanical discussion and is totally useless to the readers of this forum. It is merely a lame attempt to attack my character. Your blatant attempts to mislead the participants of this forum is unappreciated, irrelevant, and makes you look petty.
When will you grow up, stop the personal attacks, and limit your comments to what is relevant...biomechanics. Until that time, every time you dissemminate lies or spread malicious rumors, I will be there to correct you even though I would much prefer to discuss patient care.

Life is Good,
Ed
www.solesupports.com

 

By the way, Stu, good to have you back. I enjoy your ability to debate these topics objectively and with good intellectual reasoning.

Forefoot supinatus had been previously defined by Root, Weed and Orien as a positional supination deformity of the longitudinal midtarsal joint (MTJ) axis. Since we now know that there is probably no such thing as a longitudinal MTJ (thanks Dr. Nester), then I don't know how a forefoot supinatus can even exist.

Now if you want to say that there is a difference between a forefoot varus and forefoot supinatus, the former being structural and the latter being positional, then I could partially agree with this. However, there is no way to tell between one or the other "deformity" and there is no such thing as a forefoot to rearfoot relationship that is not affected by temporary changes in the capsular structure of the MTJ/midfoot joints caused by the prolonged effects of ground reaction force (GRF), muscle forces and/or external manual manipulative forces. In other words, I think the term "forefoot supinatus" is so ill-defined and difficult to objectively determine that it should probably be replaced or discarded.

Any forefoot that has increased GRF medially and decreased GRF laterally will tend to, over time, develop either an increase in inverted forefoot deformity or a decrease in everted forefoot deformity due to ligamentous creep and stress-relaxation phenomena of ligaments. This would mean that a patient with a "natural" or "structural" 7 degree everted forefoot deformity could have enough subtalar joint (STJ) pronation moment acting on their foot during weightbearing activities to cause sufficient medial shift in GRF at the forefoot over time to eventually develop a 2 degree everted forefoot deformity and still should be considered to have a "forefoot supinatus". In other words, a forefoot supinatus theoretically does not need to have an inverted forefoot deformity but may indeed be an everted forefoot deformity.

Forefoot supinatus, using classic Root terminology, does not cause any pathology but is a result of excessive calcaneal eversion. Root proposed that forefoot varus was the cause of STJ pronation that forced the STJ to pronate just to bring the forefoot plantigrade to the ground. However, the more likely truth is that forefoot to rearfoot relationship should be regarded as a dynamic intersegmental relationship of the foot that is affected not only by congenital foot structure but also by dynamic positional changes at the STJ, MTJ and midfoot joints of the foot over time. Understanding the foot in this fashion would then explain how the term "forefoot supinatus" may be very difficult to determine and therefore may represent a hopeless dichotomizing of inverted forefoot deformities with no possible way to determine the relative structural vs positional contributions to the forefoot to rearfoot deformity.

 

Say hi to Paul for me since this was his nickname for me (we called Paul "Vagus"). We ran together with Rich Blake (inventor of the Blake Inverted Orthosis) and 9 other of my classmates in the summer of 1980 on a "Border to Border Run" from the California-Oregon border to the California-Mexico border. I personally ran about 110 miles that week and I was part of the relay with my classmates to act as a form of advertisement for the California Podiatric Medical Association. Five of us had run the Boston Marathon the year before. The CCPM Class of 1983 was also known by our teachers as the "Motley Crew" due to our behavior during school. I can assure you that I had nothing to do with that name.

Here are a few of my other more "famous" classmates from the CCPM Class of 1983:

Alan Catanzariti, Ross Taubman, Steve Palladino, John Giurini, Jeff Christensen, Jim Clough, Robert Eckles, Kirk Koepsel, Charles Southerland, and James Stavosky.

It is amazing for me to think that these young lads of over two decades ago (that I worked through four years at CCPM with) are now considered some of the leaders in the Podiatric Profession within the US.

 

You are right, Ed. This site has had too much personal stuff on it lately. However, I must confess, I have had a good time with it all. I'll try to be a good boy and keep it academic. I'll give you credit..... I don't often have someone who will go toe to toe with me like you have here on Podiatry Arena.

We just seem to do things quite differently but I think we do share the common goal of wanting to make the patient better at the end of the day.

I have spent the last 21 years of my life educating podiatrists on how to make their patients better, fighting the traditional biomechanical teachings at podiatric medical colleges, and trying to develop better theory and techniques for the profession.

I am interested in any research that you and your company can do to accelerate the intellectual growth of the profession and am interested in any contributions you and your company can make toward improving foot orthosis design techniques for all podiatrists that use all foot orthosis labs.

 

Kevin,
Thank you. I agree, so lets both drop our defensive and offensive postures, get on the same side and take foot biomechanics to the next level together with all the other brilliant minds that are on this site, both reading and contributing.
I agree that we have approached biomechanics from a different angle and that is always good. I invite others to do the same.... think critically and creatively about how we affect this amazing machine that we are all so priveledged to study and treat.

Respectfully,
Ed
www.solesupports.com

 

I would like to echo this particular sentiment. All to easily discussions can degenerate into bickering and academic point scoring. Patronising responses and intellectual muscle flexing only serve to stifle contributions. Adopting the "I am mightier than you because ..... etc etc" approach is not conducive to a respectful and professional exchange of ideas.

 

You may wish to tell that to the reviewer of the paper, as it was their opinion. But see fig. 8

 

Think of it as a literature search.

Ed, I critically engage with the literature. I don't "attack everyone elses research" nor do I blindly accept it. I have never suggested that my research is superior to anyone elses research, rather I have critiqued my own research for all to see on this site.

I have to say, I have delivered several thousand lectures and the best biomechanists, in my opinion, have been the ones who are published. Does this mean I agree with them all and they are always right? Of course not. This is juvenile argument deflecting from the real issues.

I'd like you to point to where you think I have done this. This from the man who came here and proclaimed that everyone else was wrong and he was right. Take a long hard look in the mirror.

These are your words not mine- please re-read what I actually said.

Ed, you're so right. I'm getting bored of this so I'm just going to believe everything you say from now on, no questions from me because you must be right. Stay Asleep, Watch More TV and Enjoy the Surface. Have a nice Day.