Forefoot Varus Predicts Subtalar Hyperpronation

Kevin,

I absolutely know that. I was practicing a little satire in an effort to make my point.

Jeff

 

Kevin, I'm like a lightening rod on the Podiatry Arena. When I discuss my own opinions inevitably it turns into an attack Merton Root (his personality) and his work.

If you go back and review this thread from the start, you will see I discussed a number of things including heel bisection technique and differentiating forefoot varus and forefoot valgus using heel bisection. I made no mention of Merton Root. The reason I don't normally participate on the Podiatry Arena any more, which is a shame because I do find it enlightening and enjoyable for the most part, is because every time I do we eventually end up right where we are at today, discussing and debating the importance of Merton Root's contribution and his personality rather than the content of his contribution and how it relates to modern day biomechanics. As Daryl mentioned, much of his work is misunderstood so I guess this is just an inevitability.

My youngest son is a junior at UC Davis and is majoring in biomedical engineering. When he was considering career paths one of the reasons I steered him away from podiatry is so that he doesn't have to deal with the kind of hostility and personal attacks that I have had to deal with, especially on this forum. The only reason I got involved in this thread is because Dr. Sciaroni brought it to my attention. And for the record, he is not a customer of Root Lab. We met a couple years ago at a conference and he has been sharing this theories about growing pains with me. Although you may not necessarily agree with him on a number of issues, I hope you will respect his interest in biomechanics which is lacking in so many U.S. podiatrists today.

I realize that I'm certainly not the only one here who periodically feels insulted or offended. I can't change the fact that Merton Root was my father and that I chose the career I did. But I am human and I do have my limits. For a variety of personal reason, I tend to focus on thing in my life that enhance my quality and enjoyment of life. The podiatry arena doesn't always fulfill that goal which is why I will probably drop out once this thread has run its course.

Jeff

 

I know that Jack Morris, DPM, was aware of the windlass mechanism of Hicks since we discussed it in the biomechanics clinic when I was a Biomechanics Fellow from 1984-85. Bill Sanner, DPM, who also had been a Biomechanics Fellow before Rich Blake first taught us about the Windlass Effect of Hicks in our 1st or 2nd year biomechanics class in about 1980-1981.

However, I'm pretty sure John Weed, DPM, did not understood the concept of the Windlass and Reverse Windlass since, even during my Biomechanics Fellowship, when I told him of some of Jack Morris' ideas and observations on seeing the hallux plantarflex and the STJ simultaneously pronate when a student stood with their hallux/digits off an orthoposer (which we knew as the Reverse Windlass Effect), Dr. Weed said something like "The plantar fascia can't supinate the foot since it isn't a muscle".

It was at this point that I realized, in about 1984-1985 during my Biomechanics Fellowship, that even the great John Weed had some problems with his understanding of foot biomechanics and that, if I wanted to move forward in my understanding of foot and lower extremity biomechanics, I would need to get out of the CCPM Biomechanics Department and do my own research and thinking. Thank God that was the decision I made 30 years ago.

Therefore, since John Weed was the one that referenced "Normal and Abnormal" for Mert Root and Bill Orien, then it is likely that none of these three men were aware of Hicks' classic research papers, or didn't think they were worthy of including within their book. That is the only logical explanation that I have and certainly explains some of the problems that I had while I was a student and Fellow at CCPM that I often was better read in biomechanics research and alternative biomechanics theories during my Biomechanics Fellowship than many of my Biomechanics Professors were.

I'm afraid that this type of behavior still goes on since most podiatry schools in the USA only teach Root biomechanics, and the students have never been taught or have heard of any alternative biomechanics theories. Lab Guy (Steven Gaynor) can certainly provide us with a little recent experience he had in this regard into how biomechanics is being taught in the US podiatric medical colleges.

 

Jeff:

What's wrong, you don't like beating your head against the wall???? :bang: You're a good guy, Jeff, and I hope you stick around because I do consider your opinions very valuable, as do many others here on Podiatry Arena.:drinks

 

1995 and I can´t remember discussing windlass then, but did mention it alot when I taught Biomechanics to undergrads for 3 years a few years ago

 

Nice picture, though Simon could have bent his knees a little.

I will agree that each of us brings our own personal biases into any discussion, based on our personal experiences. We are much more lenient with those whom we personally know. I will say, that my personal experiences with my father, with Mert Root and with Milt Wille will make me much less critical of them. On the other hand I tend to be more critical of those whom I knew less well and you knew better, e.g. Chris Smith, Ron Valmassey, etc. [Please don't misrepresent that I think they are bad people or clinicians nor that they haven't been valuable to our profession] So I will just chalk these characterizations we each have based on personal interactions, be it positive or negative, to human nature, and I can accept such, be it mine or others frailties. Having lived in Australia for 2 years, I also try to be sensitive to the bombastic American image of trying to overpower the world, e.g. if it comes from America, it must be good, and if it's good for America, it must be good for everyone. It's nice to see some of our accomplished British professionals invited to lecture in America these days. Hope to see more.

What's really important is not who's name is attached to any idea. Biomechanics is biomechanics. I agree we need to discuss ideas, not names. Unfortunately names pervade every arena. For example if I say, "Euler's identity" you know exactly the equation I'm talking about. Without it, we'd never have wave mathematics. If I say "Newton's 2nd law" you know what I'm talking about. If I say "Keller Procedure" we all know what we're talking about, even if there could be a previous procedure published that could be considered similar. That's why I tried to get people to adopt the term, "Root Postulate", not to praise Root, but to put a term that would be identifiable with an idea, whether it is a correct or incorrect idea. I still maintain that it is the one truly unique idea he had. I think I try to give people their due respect in developing ideas. I try to give you, Kevin, due credit for the ideas you originated. I have no problems in introducing the term, "Kirby Plot" or maybe you'd prefer "Kirby Method" to denote the way that you introduced to the profession the technique of identifying the location of the STJ axis. And I don't have any problems with the term, "Kirby Skive" even if someone may question that there was an earlier idea published that was similar -- it never caught on. Kirby skive is much easier to say than any other moniker. I question whether history will find me to have had any original ideas, and I confess that I try to build on the ideas of others. I have mentioned the names of many others who have had a postive influence on me in developing biomechanical knowledge and skill. One person that I don't give enough credit to is Bill Olson, and if I end up publishing a paper on my current research, I will put a little note of acknowledgement at the end, in tribute to him. I do believe that it is important that we also quit attributing ideas to Root that weren't his, but which he adopted. For example the 2-axis model of the MTJ was never Root's, it was Manter's, through and through. So instead of everyone saying "Root was wrong" when it comes to discussing the 2-axes of the MTJ, let's start saying, "Manter was wrong."

Summary: It doesn't matter who's name is attached to anything, in the end, it's still just biomechanics.

With best wishes,
Daryl

 

While I am surprised to hear of your experience and am one of the first to disagree with John Weed that the plantar fascia can't supinate the foot, I do find Hicks is referenced in his book(e.g. references #23, 24 page 93, #20 page 107, #28, 29, 30, page 292, #36, page 347) (BTW -- I was a great admirer of Jack Morris.) I realize that there was a tremendous amount of politics being played at CCPM, so it probably was best you got out early in order to spread your wings. You would have been crushed by a lot of egos there (not just in the biomechanics dept). :boxing: I'll hash over with you sometime the politics at DMU, and so it goes for every institution. I think that NYCPM has been least influenced by the Root camp (not Root himself, but his evangelists). Steve Levitz is still there. I consider Dave Skliar to be a great source of thoughts and ideas to ponder, and he did have an influence for many years at Barry. As you know, when I was at DSM, I invited a wide variety of people to lecture, including yourself, Jack Morris, Dave Skliar, etc., as I felt the students needed as wide a variety of views and needed to be able to evaluate ideas in terms of their adherence to proven mechanical principles.

Looking forward to seeing you in Vancouver,
Daryl

 

Interesting thoughts. Those same egos that you suggest were at play at CCPM back in the day, I find here at PA in this one link alone. Egocentric thought does not have timelines, and, IMO, attempts to silence free thought and advancement from within and outside one's frame of reference. My suggestion that those that don't perform, or never have performed surgery, as being more egocentric, still stands as a possible basis for that behavior...at least here.

 

I told Dr. Leonard Levy when he went to CCPM to be president that he or XXX (I won't name the leader of the ego group) was going to have to leave. Sure enough, it was Levy who left, and today he is one of the heads at NOVA - one of the largest health training institutions in the U.S. It is unfortunate the podiatry lost to general medicine one of the real forward thinkers in podiatric education.

Daryl

 

Almost nobody seems to know about Root's work in East Europe or at least in my country ! Is this good or bad ?

Clinicians wants some devices, making nice colorful pressure graphs, to think/decide instead their place. Patients wants to see technology even they don't know that technology without theoretical background is nothing. Sometimes I feel a lot of passion implied on PA in discussions about important people from the "evolutionary chain of foot orthoses development" [to quote Simon] and, as an outsider, I'm asking my self why : because of a much more easy to understand, practice and teaching system as what seems to be the Root's one or because the new paradigms are not enough clear and ask for more effort to be managed in practice ? From where is better to start where nothing there is ?

Anyway, to quote Louis Armstrong: "what a wonderful world" ... the podiatry is !

Sincerely,

Daniel

 

Daniel:

Simon, Eric and I had a good time finally meeting you at the conference in Zaragoza, Spain last year. You have a good understanding of this material. How do I know this? Because you ask great questions!

One of my favorite things about Podiatry Arena is that I get to "speak" to people from around the world on a subject I love (i.e. foot and lower extremity biomechanics). Every now and then, I will get to then meet these Podiatry Arena "names" in person at one of the conferences I am lecturing at. For example, last year I finally got to meet you after all these years of you being on Podiatry Arena, along with many of my other Spanish, Portuguese and Italian podiatric friends and colleagues.

What is important for you at this point in your career is to try to read as much as you can and then ask questions when things don't make sense to you here on Podiatry Arena. The regulars here on Podiatry Arena are always more than willing to help individuals like you who are trying to improve the level of foot health care in their own respective countries. Don't feel like you are being a problem when you ask us questions since I greatly enjoy teaching intelligent individuals as yourself.

Let me tell you a little story about myself that occurred over three decades ago. When I was a podiatry student, I don't think that anyone asked more questions of my biomechanics professors than I did. Most of the time, I did this in private either before or after class, or in our 3rd and 4th year biomechanics rotations. One of my biomechanics professors became so annoyed with me asking so many questions of him that, after a while, when he saw me approaching him with my questions in the biomechanics clinic, he would turn and rush away from me to avoid me. In other words, I was very annoying to many of my professors, but I think that a few of them appreciated my thirst for knowledge, even though it did mean more work for them.

With this in mind, here is the process I recommend:

1. Read.
2. Ask questions.
3. Attend educational seminars.
4. Develop new clinical skills.
5. Experiment with different clinical techniques.
6. Force yourself to write and/or lecture on a regular basis for your local, national, or international podiatric community.

6. Repeat 1-6 over repeatedly for the remainder of your practice career.

The result of this process is that you will become a leader in your community (or your nation) in foot and lower extremity biomechanics.

In other words, keep asking those questions Daniel!!:drinks

 

Speaking about Europe here: http://www.ivo2015.com/index.php?pg=program you can see the program od IVO Congres [19-20 March, Paris]. Looking at speakers name it seems to be a different world than PA

Daniel

 

Jeff-realize this...there are a few individuals in our profession that appear, to this observer, to be more interested in creating a legacy for themselves than advancing lower extremity biomechanics. Your fathers' work is just that...a legacy. Don't ever shy away from what he created...it is his legacy and yours as well. Be proud of the efforts he made in writing that book that is still the benchmark by which all else derives in our field. I understand why you steered your son into a different direction...our profession is "hurting" in this country and much of that is due to the lack of salient and prudent research that results in affirmative changes to patient care. My article on GPs, and its relationship to RLS will help change that, IMO. Perhaps I discovered the root, (pardon the pun), cause of GP and the connection to RLS because I wasn't bogged down with force vectors, axes of motion, etc., while assessing a patient's needs. I had to go through my own "process" of discovery because none of today's pundits were of any help. I introduced myself to you by your connection to the co-author of the article, and I'm glad I did. You've been a wealth of information and a very good sounding board for my thoughts. I appreciate your input more than you know.

To have a Podiatrist finally determine the cause of growing pains in children and make the connection to RLS in adults is great for our profession. To have the author use Root biomechanic techniques in discussing it, is even more so.

 

Hello Daniel,

I tried to access the site from my US government computer, but the site is being blocked. I will try from home later.

However I did read a small blurb from the foot-and-shoe.com site that said, "Announced thematics are „Neurologic lesions and polyhandicap“, „Diabetic foot: Prevention and treatement“ and „Rhumatoid foot in every states“. "

Unfortunately, most of the people that contribute in the biomechanics arena at P-A (I don't like the abbreviation PA because I lived in Pennsylvania for quite some time), do not specialize in these particular areas, and I haven't seen many of the big diabetic foot specialists contribute to P-A. Approximately 50% of my biomechanics cases are diabetic foot issues (all diabetic feet have biomechanical issues). More important than understanding the joint kinematics in the diabetic foot is understanding the soft tissue biomechanics issues. Likewise, one will never expect to achieve a normal gait cycle in the neurological patient. The rheumatoid foot also has to have special considerations that your typical sports medicine patient does not have. So in today's world, I'm finding that being a biomechanics expert with one particular population does not make you a biomechanics expert with all populations.

Anyway, good luck at the seminar.
Daryl

 

Hello Dr. Phillips,

I've tried to attach versions of IVO Program in English and French.
Sincerely,
Daniel

 

Daryl, I have to disagree with your last sentence. Biomechanics is biomechanics, unless you are talking about podiatric biomechanics. The goal of biomechanics is not to create a "normal" gait. Practitioners of biomechanics use mechanical principles to solve patient's problems. Say, you have a neurolgic patient with a drop foot gait. The problem is insufficient dorsiflexion moment at the ankle and the treatment is to figure a way to add dorsiflexion moment. A lot of the biomechanical problems of diabetic insensate foot is caused by high plantar pressures. The treatment is to reduce the force in one location and move it somewhere else. To be a biomechanics expert, one needs to understand how changing the environment of the foot will change the pressures, forces and moments acting on the foot. These principles will apply to all feet.

Eric

 

Eric,

I think Daryl is saying that the biomechanical considerations when treating an insensate foot are different than when treating a sensate foot. For one thing, the patient may not be able to provide the same feedback as a patient with sensation so there is increased potential for harm. Also, there is a difference between simply offloading (accommodating) and transferring force from one part to another and using a device that provides more of a functional change. I call these types of devices hybrids since they combine elements of functional and accommodative orthoses. The material composition and Rx (pouring position, filler, etc.) for these devices is different and is based on different biomechanical criteria like whether or not there is an open ulcer.

Jeff

 

I think you're nit-picking a little bit at me. I can probably hold my own on any basic biomechanics Jeopardy show. What I'm trying to say is that the field of biomechanics is so broad these days, no clinician can truly be an expert in all clinical biomechanics populations. Just attend an ASB meeting to find out how much is going on at so many institutions. As an example, in my trying to study the latest literature on the biomechanical abnormalities in the diabetic foot, I have to almost totally ignore the literature on running. I prefer to send my runners to you or Kevin. I really don't care if their knee pain starts at 5 miles or 10 miles. There is no way I'm up to date on the latest running shoes, nor on the pros and cons of barefoot or minimalist running. It sounds easy in a diabetic to just transfer weight from one part to another, but when you actually put that patient on a pedobarograph it suddenly shows that you don't know everything. Can you tell me what the difference in reponse is to plastazote vs. poron? Can you tell me the best way to measure the resilience of the metatarsal fat pad? How do you know if an ulcer is being caused by excess pressure or excess shear force? Sure I can figure a lot of things out, but each specific population has their own particular nuances that experience can only teach you. I learned, for example, in the 1990s, that treating figure skaters involves not only an understanding of basic foot kinesiology and anatomy but also a knowledge of the demands of the sport itself and the sport equipment they interact with. If you don't understand how the radius of hollow of a skate works, you may miss something that could be important for that particular person. In diabetic biomechanics, soft tissue biomechanics is more important than any axis theory (not saying that axis theory isn't important). And you've got to pay attention to what the characteristics are of the various materials you put against the foot, and you've got to constantly monitor them as the characteristics change over time. If you're a diabetic you perfer to have your shoe insert made by someone who is doing it several times/day, not a few times/month. And of course, you've got to add in that never ending battle of understanding the psychic of your patient and how to best communicate with them. Communication pattern is totally different between the 20 year college student who runs 5 miles/day vs. a 65 y.o. poorly controlled diabetic, battling chronic ulcerations. You develop different communication patterns for various groups of people.

So I've come to the conculsion 1) clinical biomechanics is still the art of applying basic principles to a unique sencient biologic system, 2) there's nothing wrong in admitting that I don't have to know everything about everything.

Best wishes,
Daryl

 

I think we all need to be careful with terminology here since I can see both Eric's and Daryl's point. When we say "biomechanics" as podiatrists we are generally talking about foot and lower extremity biomechanics which, in actuality, is a very small subset of the many fields of interest within the international biomechanics community.

Here is what Wikipedia lists as the subfields of biomechanics:

Certainly, none of us are experts in all of these fields. Rather, we are all podiatrists who specialize in a few of the subfields of biomechanics. Not all biomechanists treat patients. Many biomechanists are researchers who have never treated a patient in their lives.

For example, when I worked with Steve Piazza and Greg Lewis (both PhD engineers specializing in biomechanics) on our cadaver research on subtalar joint axis location at Penn State Biomechanics Lab in 2004, these two were very happy to have me there speeding up their cadaver dissections. I did each of the cadaver dissections in 30 minutes that took them 2 hours to do. They were engineers, not surgeons. However, when it came to the 3D motion analysis, computer software and advanced calculations, I had very little idea what they were doing. Were we all biomechanists? I believe so. But we were biomechanists that each possessed a specialized subset of skills that helped us complete a research project that each of us separately could not have done alone.

Therefore, if we are using biomechanics as a general term, please remember that not all biomechanists are clinicians that treat patients, just as not all podiatrists are experts in biomechanics and not all "biomechanics experts" are experts in foot and lower extremity biomechanics. We need to realize that what we do is not necessarily at the center of the biomechanics world with the other subfields of biomechanics orbiting around our sphere of interest. We, as podiatrists who specialize in biomechanics, are just one small piece of the international biomechanics community that is very broad and diversified.

 

Agreed. However the uniting factor should be the application of mechanical principles to biological systems. I liked Daryl's quote that he'd "been taught all the bio, without much mechanics", I certainly recognise this in reflection upon my own undergraduate education. Too often the "biomechanics" elements of pre-registration programmes have shied away from, well frankly, biomechanics.

Forgive my recent hiatus, I have been rather unwell for a few days. Daryl, to return to your earlier point, I criticise Root as I would criticise anyone elses published works, his work certainly does not receive any more or less attention from my scientific approach to further my understadning of the intricacies of foot and lower limb biomechanics than any other published author. I really do not care whether you think this makes me look bigger nor smaller in your nor anyone else's eyes. I also pride myself on reading as widely as I possibly can on the subject which has been my passion for the last 25 years, devoting as much as my free time to it as my family will allow me to, to better my own education. So, when someone claims that Root invented foot orthoses and invented non-weightbearing casting, I'll be among the first to point out that neither of these contentions are true, whether the person making such statements is Root's son or my own mother. When the person making the claims then goes back and changes them after I've refuted them, I'll get annoyed that they changed them, but I won't loose sleep over it, I'll just keep on reading and evaluating the literature to the best of my ability and I'll continue to point out the flaws in other's contentions and re-evaluate my own, on the basis of others criticisms of mine.

Julian Cope wrote something along the lines of: "you can stand upon the bible, but it won't make you taller", I suspect that standing upon the complete works of Merton Root without applying a critical eye might result in a similar outcome. I'd never be satisifed with that, I want to grow. This isn't 1977 and to me, Root's books, despite their titles, shied away from biomechanics. Worse still, biomechanics has come to be seen by some to = foot orthoses. Cope went on to write: "it diminishes you with every lie it speaks", interesting.

 

Kevin,

Biomechanics is an area of study that falls under biomedical engineering. Many, perhaps the vast majority of people who practice biomechanics are not biomedical engineers and it is not necessary for them to be. For example, in podiatry school you were taught biomechanics but more in terms of the basic principles and practical application of biomechanics. When I look at how much physics my son has had to take and continues to take as a Biomedical Engineering major, most of it would be totally unnecessary to the practice of podiatry. In fact, it wasn't until his junior year that they stated to study anatomy and physiology because they have been required to take nothing but physics, math, chemistry, circuits, etc.

In the U.S. we have seen a decline in the amount of hours of biomechanics that is required at the podiatry schools. Do you see this trend changing in the future and if so, why?

Jeff

 

Glad you're feeling a little better. The "wog" has certainly been making its rounds in my neighborhood too.

Sometimes in reading the posts on this email I think that it's like listening first to CNN report the world news, vs. FoxNews, vs. BBC." Everyone seems to have their own spin on the same world events, and they effect us all differently. But I can appreciate what you've said here. I do agree totally with your last sentence. Several years ago I wrote a small op-ed for one of the podiatry magazines, the title of it was biomechanics [does not equal sign]orthotics. Every day I'm faced with those diabetic ulcers, pre-ulcers and post-ulcers, and I'm trying to figure out the fluid mechanics, the Newtonion mechanics and the neuromuscular mechanics, and put them all together with the metabolic factors to come up with a solution to healing and prevention. One of the best talks I ever heard was Peter Cavanaugh at the Perth 1991 ISB meeting, which he later published in 1992 in J.Biomechanics on Ulceration, Unsteadiness and Uncertainty. I think it is a such a classical article, it should be compulsory reading in podiatry school.

I think you know that I defend the principles I think Root was right about, but I'm not stuck only on the "Root Bible". Actually I'm very much against those who would cry, "We have a Bible and don't need any more Bible." (BTW - Root's Bible doesn't have the word 'biomechanics' in the title.) I mentioned other texts previously that I value every bit as Root's work, and I couldn't function without those additional texts. One interesting analogy would be to ask how Sir Isaac Newton solved a differential equation that had as it's solution a natural exponent. (You'll remember that "e" was invented by Euler). I'll try to find out a little more on that one. I do appreciate your reading of the literature. One of the things I think is important in reading the literature is to make sure we don't allow authors to get away with misquoting other people. I find a lot of that with Root (I'm reviewing a paper right now that is miquoting Root and then proving that the misquote is wrong. Duhh!) I confess my personal biases. I'm also much easier on my critique of my parents than my spouse is -- we all are.

OK - so putting the name of he, whose name we shall not say, aside - let us turn our attention to a basic biomechanical principle that really is a big question rather than what looks like an obvious answer: How do we define the EROM of any joint? How do we know that we are at the EROM of a joint? Anyone who has to clinically document an examination is faced with this question, and will be unless we can eliminate the need to ever document a joint ROM. So instead of arguing about who said what about EROM, I would be interested in seeing what the various opinions are, how you handle this clinically. Here in the VA, any disability report has to include joint ROM information. Will be interested to seeing the responses.

Best wishes,
Daryl

I have attached what I think should be considered a real ROM curve for any joint. Can we agree where on the curve we should label the two clinical EROM points?

 

VOL. 1 does, despite it not containing any biomechanics as I recall.

On your load/deformation curve there are no vertical points at the extremes of the line where the deformation does not change in response to an increased load, viz. there is no end of range of motion, Daryl. The problem we have is a complete lack of scale on either axis; the relatively flat area in the centre of your curve could just represent the toe-regions in the net stress/ strain curve of the restraining ligaments, the areas where your curve increase their verticality being the beginnings of their linear portions- we cannot make assumptions regarding, end of range from your graph other than that there isn't one, in my opinion Daryl. Edit, actually there are an infinite end range of motion positions, one for every magnitude of load on the graph- yeah baby, there's my mojo returning.

There in the VA has the reliability and validity of joint ROM information obtained via the tests being employed been established? That it is required in your hospital, doesn't make it either in the real world.

 

I think it should be vertical or horizontal points in response to an increased load !
Daniel

 

Daniel-welcome, and let me give you my two cents on the topic. Yes, patients would dearly love to see technology work in their favor, and I believe we should provide that to them...that, and solving their problem(s). I strongly suggest you purchase Root's "Normal and Abnormal Function of the Foot, Vol. 2". This will give you a basis, a foundation from which to evolve yourself in your clinical work. While the book is not an end-all to any discussion of biomechanics of the lower extremity, it will provide you a "launch pad" from which you can take your own experiences as a clinician to a different level. It may also open doors to other books written on the topic that can enhance your work.

Patient complaints can provide us with a wealth of information, not just on the particular musculo-skeletal problem, but digging a little deeper to determine cause. Patients will also provide you with overlapping symptoms with other patients...to the point that you will begin to see "patterns" in the pathologies...consistent and reproducible complaints that are common within your patient groups and will allow you to begin to form predictions and conclusions. While many pundits may espouse theories in an attempt to teach us what to think, I encourage you to explore those common patients complaints and teach yourself HOW to think. I believe your results will improve as your patients do, as well.

That being written, technology is moving forward at such an incredible pace, it's hard to keep up. The marriage of analog and digital is still occurring, in ways that make me believe it very likely that this symbiotic relationship will transform medical/podiatric education. First, in case you missed it, here's a video I had produced for a project that I've been working on. A simple animated video that was targeting primary care physicians, but I have since found very useful in my practice to educate my patients.

https://www.youtube.com/watch?v=7BSetRI_UH4&feature=youtu.be

Now, as simple as that is, think of the possibilities for student education with much more sophisticated animation. Then, think of the possibilities for future technology becoming a reality as I type:

https://www.youtube.com/watch?v=aThCr0PsyuA

MS HoloLens is nearly upon us, and creates MANY possibilities for education, of our patients and for medical/podiatric students.

http://www.forbes.com/sites/insertcoin/2015/01/25/could-microsofts-hololens-be-the-real-deal/

"As a Google Glass owner, I can immediately see how it will be incredibly useful for so many kinds of people. Doctors, mechanical engineers, any sort of field worker….But for us lay folk, the device only serves to make us look awfully nerdy, to make us economic targets, to make us less aware of the world around us, and to leave us more disconnected than ever from the real people we encounter every day.”


They call it the practice of medicine for a reason...because we "practice" our craft every day. The speed in the dissemination of information will be greatly increased by those that are willing to embrace the digital age and find the common ground with analog. This, in turn should speed up the learning process for those that follow us. My patients are impressed with the work I did up to this point; they appreciate the audio/visual education...it makes sense to them. Hopefully soon, there will be other technologists that will combine their talents with ours and produce meaningful material.

 

I've tried many times to buy Root's books through Internet but it was impossible to make the online payment ! To buy Mr. Raymond Anthony's book I've waited 1 year till, at the end, I've written directly to him, he found 1 book in his office and sent it to me! Reading a lot of articles where Root was mentioned I've tried to understand this paradigm from small pieces taken from different articles... When I started to have an image of this paradigm I've understood that already some professionals is challenging it proposing new thinking models. Very confusing moment ! What was interesting is that in my country , generally, only big deformation of the feet are treated with orthotics so my first question was how a foot with a congenital deformity [for example] should be casted because for sure the neutral position method is not applicable. Was the moment when I've understood there are, for sure, many theories which should be considered when prescribe an foot orthotics for a pathology. I think the biomechanics should be the "binding agent" for all these paradigms.
Sincerely,
Daniel

 

Daniel,

I can't agree with your generalization that feet with congenital deformities shouldn't be casted in the neutral position. You have to consider both the type and severity of the congenital deformity to determine how to cast the foot. Clubfoot is a good example. In some cases a clubfoot may be too great to try to use a foot orthotic casted in the neutral position and in other cases it will do just fine. Another example is a rocker bottom foot type. In some cases you may want to use a pronated cast (pronated a little in some cases and pronated completely in other cases) or a neutral position cast. It really depends on the nature of the deformity, your mechanical or treatment objectives and what type of orthotic device you plan to use (accommodative, functional, hybrid, etc.).

My advice is to start simple with your prescriptions and pathology and build on that foundation by adding more complex prescriptions to treat more complex pathology only after you have had experience and success in treating the less severe pathology. If you start out trying to treat the most sever pathology and have failures, you may become frustrated. But if you start simple and see success and build on your success, you will find the path to greater success as time goes on.

Jeff

 

Yes, the volume I did contain the word, Biomechanics in the title. However I don't see that you made the same criticism of Donatelli, "The Biomechanics of the Foot and Ankle" 1990 FA Davis Co. I'm not sure why you believe that range of motion, either qualitative or quantitative isn't part of the world of biomechanics. YES, it is only a small fraction of that total world, nevertheless, it is still a part. I have many criticisms of the volume I myself. Many particulars of doing an examination are not in it. I consider that volume more of a concept than a technique book. It was an important addition to the literature in 1971, the same way that Morton's books in the 1920s were important additions. The examination Root described should never be considered to be a full exam. The entire volume needs redoing, in which a full examination technique (similar to the Barbara Bates book on physical examination) is described. One thing that the book does briefly mention, which most people don't include in their examinations of feet, is the muscle testing exam.

Sorry the diagram I put up didn't meet your precision criteria. It was intended to make a point, not be a research paper. The idea was that at the ends, there is a failure point of the ligaments. Yes, the slope technically would reach infinity at the ends. It was a concept to get some discussion going. The graph is only in one plane of motion, we would need a three dimensional surface to represent all planes of motion, which is what I think you were meaning by your "infinite EROM" statement.

The discussion was to bring us down from some ethereal academic tower, to the real world. I'm sure that you have government and private institutions that ask for documentation of ROM of joints. And I'm sure that you don't have to submit to them any documentation of the validity of the any instrument you're using. I'm not referring to my individual hospital, the VA is one of the really big health organizations in the U.S., but it is used to be representative of what we, as health care providers, are being asked to do.

With that said, I'm really interested in your day-to-day practice of podiatric medicine. If you never do a ROM exam, then just say it -- tell me that you refuse to do quantitative exams on patients, even if their insurance (be it health, disability, or lawyer) asks for the documentation. Tell me that you tell those people who look at the books and rate disabilities by the range of motion in certain joints, that their disability ratings are not valid. If that is the case, that the Simon Spooners of the world have risen in revolt and challenged the health care systems, thereby rendering a result that ROM exams will never be asked for again by any agency :boxing: -- then maybe our children will be talking more about how Spooner, not Root, changed the world.

Take care,
Daryl

 

Today I had another post disappear from the podiatry arena. What is going on???????????

 

Because we weren't talking about Donatelli...

Ok, maybe I was being a bit facetious. I concede, it's got a tiny bit of biomechanics in it.

I answered your question to the best of my ability given the information provided. By infinite number of end of range of motions I meant that a given displacement will occur for a given load. Hence, for each given load there is a specific end of range of motion. Therein lies the problem of clinical range of motion studies, without quantifying the load applied we can never be sure which end of range has been achieved. Do I apply the same force to a foot as you when I perform my studies? If I don't, discussion of range of motion between us is pretty meaningless, don't you think?

Obviously the load/deformation characteristics of a joint will be influenced by factors such as hysteresis, so cyclical loading/ unloading prior to measurment may influence the data too.

Suffice to say, I am more interested these days in "joint stiffness" than "range of motion".

See my last sentance above. Moreover, the problem is that in the "real world", graphs like the one you put up aren't being generated.

I very rarely quantify range of motion, but there are other quantifications beside range of motion, Daryl. To reiterate my point from yesterday, that an agency may request / require certain information does not mean that such data is valid nor reliable, Daryl. Or do you think that if an insurance company requires that you submit a range of motion study in order to get paid, your range of motion study is now automatically valid and repeatable?

Out of interest, where were you hoping people would say the end of range of motion was on your graph?

 

Actually, Simon, I don't know if I have a great answer, I wasn't trying to put an answer out there or say I have some type of secret to share. I have pondered this question for 35 years, and I still am pondering it. That's why I was looking for input from people as to what their opinions were. It really was an honest inquiry to see if there is some type of majority opinion already, or whether we really need to do some serious inquest. This is a problem for almost every joint. If you think goniometry of the forefoot to rearfoot is a mess, I would maintain that ankle joint measurements are even a bigger mess, and I have much less faith in those than in midfoot measurements. The flat part of the line could represent the passive tension in the tendons that pass on each side of the joint, but even passive tension increases exponentially. Is there a way to tell when the ligaments stretch beyond the toe region of their passive length-tension curve?

Like, I said, this is a generalize question that maybe we should pose to some physical therapists as well. Without a consensus, we will be forever arguing about reliability studies of ROM of finger joints, wrist joints, shoulder joints, spinal joints, hip joints, knee joints, and even foot joints. Are there tools that we could develop that would be goniometers with pressure points so we could develop force vs. angular deformation curves for the ROM of any joint? I throw this out for all to consider.

Best wishes,
Daryl

PS - I paid for my runScribe this week. I'll be interested to see what it can do. Might try to hook it up to some goniometers and see what can be measured.

 

I believe the key lies in measuring the load/ deformation curves.

 

Simon Spooner wrote:

My post had value! I used satire to suggest that Simon would bring the field of physical therapy to a screeching halt because he suggested that quantitative and qualitative ROM assessment was not useful at the VA Hospital where Daryl practices unless it has been validated. Clinicians in many fields assess ROM and it is an extremely valuable clinical tool. It is part of the art of the practice and is taught in medical schools and in fields like PT and podiatry to name a few. One can feel spasm, crepitus, laxity, stiffness, etc. and can appreciate extremes of motion, be they measured or not. Simon likes to play the devils advocate role and when I try to challenge his stance, my posts get deleted. If my objection to his argument to Daryl adds no value, then Simon's comments to Daryl adds no value and should be deleted. I think his comment is central to our debate about the practical application of biomechanics and demonstrate that he practices in a manner that is well outside the norm, at least when compared to podiatrists and other specialists here in the U.S.

Jeff

 

Jeff, you miss the point, I suspect intentionally in order that you may attempt a cheap shot.


Here is what I said:

Now, can you point to exactly where I said:

No you can't because that wasn't what I said, was it?

Let me re-iterate for you Jeff: just because an agency requires certain data does not mean that the data is valid nor reliable. The lab you inherited from your father requires that a clinician submits certain data, right? That doesn't mean that the data they are submitting to you is valid nor reliable, it's just that your lab asks for it.

I seldom quantify range of motion, so how can you then translate that to me "practicing in a manner that is well outside the norm" and then make an assumption that I do not not assess joints at all? Your wishful thinking straw-man is just that, Jeffery. I really don't think you know what you are talking about, but then you are not a clinician at all, are you? Drawing lines on the back of peoples legs and taking the measurements that your dad advocated in Vol. 1; my guess is that really would be perceived as "practicing outside of the norm" in the UK and Europe in 2015. We established earlier in this thread that I practice in a pretty similar fashion to Kevin when it comes to foot orthoses therapy, are you suggesting that he "is practicing way outside the norm" too?

BTW, when you write here, you don't get to decide who's contributions are valuable to the wider audience- get over it, you are not in control here, well only as far as the "ignore" button. If you don't like what I have to say, or you don't think my posts are valuable, add me to your ignore list, Jeff.

 

Simon,

First off Simon Spooner, I did not inherit the lab. I took control of the lab while my father was still alive via ownership interest (stock) in lieu of compensation. After achieving sole ownership and control of the company I invested far, far, far more of my own money in the company than my father ever did in order to grow the company, move the company and invest in CAD/CAM manufacturing. You speak out of complete ignorance when you pretend to know things about my company that you cannot possibly know. It makes you look foolish, petty and childish.

And it was you who missed the point about data. Even if a technique has been validated, it doesn't mean that the individual clinician is performing the technique properly so their individual data might be questionable. What good is validation if the technique is subject to individual variability? Does that mean that the data is useless? For example, should we no longer accept the results of the subtalar joint axis spatial location technique from anyone who isn't certified in it and isn't periodically re-certified, since we can't really know if the individual practitioner is performing the technique properly or not? Is that the world you live in?

In the real world where those of us who don't live in ivory towers must function, we recognize that no technique is perfect and that there can be variability between clinicians who perform tests. But we also realize that the information gained gives us a far better appreciation for human variability, function and pathology than we would have without these imperfect techniques.


Jeff

 

No, I don't miss any of that, Jeff. And I recognise you for what you are too. SO an invalid, unreliable measurement is worth performing- is that the world you inhabit? Pseudoscience for the sake of pseudoscience.

 

One major difference between STJ axis palpation and some of the goniometric measurements is this.

For forefoot to rearfoot relationship I don't think there will ever be a good inter tester reliability. There will certainly be some intra tester reliability issues because of the heel bisection variability, the variability in joint loading, the variability in the finding of neutral position and the day to day variation in the position of the medial column.

I will say that having performed the numerical measurements of heel to leg motion I have learned to feel quantitative measurements. I can feel the difference between a foot I think has a coalition and one that does not. I don't have to use a goniometer to qualitatively know the difference between a low and an average amount of motion. Because of the variability of the lines the actual numbers don't mean much. Yes, performing the measurements will teach a student to feel what an average amount of motion is. Performing calculations with the numbers can teach the concept of a partially compensated varus. Knowing that there are some feet that run out of eversion range of motion before there is significant weight on the medial forefoot is important. However, the numbers that are produced in the exam are not good enough to predict whether someone in fact has a partially compensated varus. John Weed used to teach a standing exam where the examiner would attempt to slide their fingers under the medial and lateral sides of the foot. I would trust this finger slide more than I would trust the numbers from the goniometric exam. One can perform a biomechanical exam equally well with and without the measurement umbers from a goniometer when figuring out how to make an orthotic. (Unfortunately disability raters like numbers and when rating disability you will have to use numbers.)

Eric

 

Eric,

We weren't necessarily talking about heel bisection or forefoot to rearfoot measurement. We were discussing evaluating ROM of joints in general and whether quantitative and qualitative assessments are beneficial or not.

By the way, why did they use cadavers in the study? It is a non invasive technique and I would think it would much be better to try to validate reliability with living subjects in a clinical environment with actual practitioners.

Jeff

 

Jeff:

These researchers first used a foot model made of wood to see if palpation could predict the wooden model "STJ axis" and then used cadaver feet.

Joris De Schepper, Ken Van Alsenoy, Johan Rijckaert, Sophie De Mits, Tom Lootens, and Philip Roosen (2012) Intratest Reliability in Determining the Subtalar Joint Axis Using the Palpation Technique Described by K. Kirby. Journal of the American Podiatric Medical Association: March 2012, Vol. 102, No. 2, pp. 122-129.

Ken K. Van Alsenoy, Joris De Schepper, Derek Santos, Evie E. Vereecke, and Kristiaan D'Août (2014) The Subtalar Joint Axis Palpation Technique—Part 1. Journal of the American Podiatric Medical Association: May 2014, Vol. 104, No. 3, pp. 238-246.

Ken K. Van Alsenoy, Kristiaan D'Août, Evie E. Vereecke, Joris De Schepper, and Derek Santos (2014) The Subtalar Joint Axis Palpation Technique. Journal of the American Podiatric Medical Association: July 2014, Vol. 104, No. 4, pp. 365-374.

The benefit of using a cadaver foot, versus a live foot, is that a cadaver foot can't work against the examiner with unwanted muscle activity and you can drill bone pins into cadaver feet without getting consent and without being in Sweden.

In the research studies I did with Greg Lewis and Steve Piazza, PhD, from Penn State Biomechanics Lab on STJ axis location, we used both cadaver feet and live feet.

Lewis GS, Kirby KA, Piazza SJ: A motion-based method for location of the subtalar joint axis assessed in cadaver specimens. Presented at 10th Anniversary Meeting of Gait and Clinical Movement Analysis Society in Portland, Oregon. April 7, 2005.

Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007.

Lewis GS, Cohen TL, Seisler AR, Kirby KA, Sheehan FT, Piazza SJ: In vivo tests of an improved method for functional location of the subtalar joint axis. J Biomechanics, 42:146-151, 2009.