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Have Biomechanics Become An Afterthought In Podiatry?

Discussion in 'USA' started by NewsBot, Oct 20, 2019.

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  1. Both Paul Rasmussen (rest in peace) and his daughter, Jennifer, have sponsored seminars in the past. They were attended by a handful of our lab clients, about 30 at most, which is not very many and doesn't pay for the costs of such a seminar. PFOLA had seminars for years and they were excellent when they were run by Paul Scherer (rest in peace), but US podiatrists showed very little interest in the seminars, with most of the interest coming from international podiatrists and researchers.

    The question then becomes whether a good biomechanics seminar, geared toward podiatrists, like PFOLA used to be, could get over 100-200 US podiatrists to attend to make it a healthy and successful seminar, so that it could be held on an annual basis. From what I have seen with the previous PFOLA seminars, US podiatrists are more interested in foot and ankle surgery, diabetic wound care, and learning more about billing codes that increase their income than they are in learning how the human foot and lower extremity functions during weightbearing activities and the science and art of custom foot orthosis therapy.

    We have led the horses to the waters of knowledge many times, but they need to want to drink. US podiatrists, for the most part, are simply not thirsty for biomechanics and foot orthosis therapy knowledge. For me, for the past decade, I have gained much more pleasure speaking internationally to those podiatrists, physiotherapists, pedorthists and orthotists who are eager to learn more about how the foot and lower extremity functions and about the intricacies of custom foot orthosis therapy, than I have had speaking here in the US to podiatrists who have little interest in these subjects. My guess, is that within the next 20 years, pedorthists, orthotists and physical therapists in the USA will be competing on an equal level with podiatrists in custom foot orthosis therapy, simply because US podiatrists have lost interest in these subjects.
     
  2. Jeff Root

    Jeff Root Well-Known Member

    Kevin, it has been my observation that DPM's become more conservative as they get older. I know a lot of DPM's who essentially gave up doing most surgery in the latter aspect of their careers. So I wonder if the pendulum will eventually swing back in the direction of conservative care as today's foot and ankle surgeons age? If so, the demand for biomechanical education may increase at some point in the future. In addition, some DPM's tell me they make as much if not more money with conservative care and foot orthotic therapy because the reimbursements for surgery are low. I have been told they can make more money with a pair of custom orthotics than doing bunion surgery. Typically theses are providers who charge cash for their foot orthotic services.
     
  3. So go where the evidence takes us and train podiatrist to utilise and modify OTC devices more. 20 years ago 80% of the devices I dispensed were custom made foot orthoses and 20% OTC devices. Now given the advances in available OTC devices, I’d say that those stats are reversed with about 80% modified OTC being dispensed. I’ve not seen any obvious differences in patient outcomes.

    The reality is for the vast number of patients I see, they simply do not need full custom devices because there are so many great OTC devices available here in the UK. I use my knowledge and expertise to pick a good starting point OTC which has the design features I’m looking for (those that I would have included in a custom device) and simply modify chair side. It’s a win, win. Patient gets an effective device at a reasonable cost there and then; I get a profit from the sale of the device.

    The biggest commercial labs over here have diversified away from just custom foot orthoses with most selling their own ranges of OTC devices and hybrid OTC footwear- seems to be working out well for them.
     
  4. Jeff Root

    Jeff Root Well-Known Member

    One additional factor driving this trend away from DPM provided foot orthotic therapy is institutional medicine. Fewer DPM's are in private practice, especially the younger ones and the decisions about the nature and scope of service are made above their heads. As an example, one facility where we had three podiatrists as clients had their lab and equipment taken away because the administration didn't like the mess. About six months later they were told they could no longer provide OTC or custom foot orthotics to their patients and that they had to refer out to an O&P for that service, thereby taking treatment control away from the practitioner.
     
  5. Great opportunity there. Set up an OandP company and tender to provide services- staff and devices. Certainly within the orthotists groups in the UK this is what the big commercial labs do- tender for local NHS contracts. Show that you can provide a cost-effective service and you’ll win contracts.
     
  6. Jeff Root

    Jeff Root Well-Known Member

    We do work for the O&P's. The Rx's we get from the O&P's tend to be much simpler than that of many of our podiatrists because the biomechanical evaluation and prescription writing process tends to be much different between these two groups. As for PT's, we attend a state PT conference and the overwhelming majority of PT's wanted to refer out because they did not want to or were not accustomed to biomechanical evaluation and prescription writing process. Didn't pick up a single client from that conference but I learned a lot about the PT's perspective on foot orthotic therapy.
     
  7. Dr Rich Blake

    Dr Rich Blake Active Member

    Simon, I also take that approach on the majority of my athletes. I advise them we can customize an OTC (my preferences are Sole or Power Step) now to get the biomechanics more sound instantaneously, and perhaps someday go to a custom more durable device. This is well over 50% of my patients. If they have very complicated biomechanics or very chronic pain that mechanical support should help, I tend to go to custom devices by the 4th or 5th visit, even if they are having complete success with the temporaries. Rich
     
  8. Dr Rich Blake

    Dr Rich Blake Active Member

    Kevin, you have a more solid feel than I do on this subject. I will let you know what I sense back in New York and they are expecting 100 podiatrists to a biomechanics seminar. On the humorous side, I talk on the Inverted Orthosis right away Dananberg talks about the fallacy of heel corrections. I will try to stay in the moment. Rich
     
  9. Jeff Root

    Jeff Root Well-Known Member

    I ran across this quote today by my father Merton Root in an interview in the October 1989 issue of Podiatry Today:
    “For years people have thought that I was against surgery. I'm a strong advocate of surgery but only surgery that is well indicated. I believe that research in surgery has a long way to go and its basis is biomechanics”.
     
  10. Dr Rich Blake

    Dr Rich Blake Active Member

    Jeff, I am so amazed in this day and age that pre op evaluations will not look at crucial biomechanics before surgery! Like doing bunion surgery on a patient with 19 degrees heel valgus resting stance. Rich
     
  11. Dennis Kiper

    Dennis Kiper Well-Known Member

    I believe a better answer as to why bio-mechanics is not flourishing is because traditional orthotic technology cannot achieve the calibrated scientific precision that the planes of motion of the MTJ (not the STJ) require for mechanical efficiency of the functional mechanics and reduction of biomechanical inflammation. And growing a Rx is very difficult if not impossible to a pt who has outgrown a Rx that works for the first couple years--then what?
    A properly fitting orthosis is a health benefit to ones biomechanical health over a lifetime. It isn't just for an injury. It's like brushing your teeth is to your oral and systemic health. It reduces and minimizes the degradation to joints and muscles.
    It's you who is behind in clinical biomechanics, - maybe you could swallow your pride and start importing knowledge?
     
  12. Jeff Root

    Jeff Root Well-Known Member

  13. scotfoot

    scotfoot Well-Known Member

    Dennis ,
    Re your orthotics , can I ask what effects wearing them has on postural stability in single leg stance ?

    Gerry
     
  14. Jeff Root

    Jeff Root Well-Known Member

    I was posting in good faith so that those who are interested to read the study.
     
  15. Dr Rich Blake

    Dr Rich Blake Active Member

    I know from my Inverted orthotic that people would say remarks about the technique that I had abandoned 25 years ago as I have learned. This is one of the reasons I wrote my 2019 thoughts about the technique and I want to hear from the profession about how they interpret it and the pros and cons. My feeling is that Jeff has now 20 years of experience since his dad passed and I wish he would share his thoughts. This is not a static process. Dennis, thanx for your comments. Jeff, what do you think? Root Lab Newsletters? You could cover a subject each month of current beliefs. Rich
     
  16. The trouble with these ‘Merican magazine articles is that there doesn’t seem to be much in the way of peer review. Let’s take a quick quote from the article cited:
    ”Studies that actually attempted to measure motion of the first MPJ in patients with hallux limitus showed no improvement in dorsiflexion range with custom foot orthotic intervention.11-13”

    Reference 11 is the bone pin study by Kilmartin, Kilmartin was one of my PhD supervisors so I was around as a research assistant when this study was performed. First off, the subjects didn’t have hallux limits; secondly the Root orthoses employed in the study reduced hallux dorsiflexion. Good or bad thing? That depends on the context. Irrespective the author here has misrepresented the research in an attempt to build argument in favour of their opinion, despite this research showing the opposite. If he’s done it here, where else has he done it. Can’t be bothered to review the entire article as it’s not of interest/ my job.

    Like I said, biased opinion piece with misrepresentation of what the literature actually says to meet the author’s agenda.
     
    Last edited: Nov 6, 2019
  17. Jeff Root

    Jeff Root Well-Known Member

    Rich, newsletter like Kevin's are a valuable resource but they are not peer reviewed so we must take that into consideration.
     
  18. and there’s fun, while Jeff didn’t seem too enamoured with Kevin’s suggestion that pedorthotists might hold a future for biomechanics in the USA, we are now putting our faith in a fireman who inherited his dads business...
     
  19. And by the way, it’s not a study.
     
  20. Jeff Root

    Jeff Root Well-Known Member

    Simon, this will be my last reply to you ever. As I told you before, I didn't inherit the lab and I invested hundreds of thousands of dollars of my own money in it to make it what it is today. My father started the lab for an invest of about $1000 and I worked for many years at near minimum wage, like every other employee and like that of many other labs. I have intentionally tried to avoid engaging or even acknowledging you on this thread and I regret having replied to your post. I will not tolerate your continued personal attacks on me and I will have nothing further to say to you ever. Your true colors always show through. I can't tell you how many people have asked me "what your problem is" but they are many. Have a great life!
     
  21. Good, bye Jeff. Yet I shall continue to point out your inherent bias at every opportunity. Sleep tight.
     
  22. Dr Rich Blake

    Dr Rich Blake Active Member

    I really do not know your history, but I have to say that Jeff Root is an incredible person, and totally dedicated to the profession of podiatry. He is one of the good guys, no great guys. His dad was alive long enough to see some of his rules broken, and I watched him as scientist attempt to understand why instead of less refined responses. Even though many of these rules are 60 years old, they can still be applied in many instances and they have been vital to the health of my patients. I can only say from a distance, you both are incredible individuals, and lets try to find common grounds and go forward. Rich
     
  23. People have tried to tell you Rich, too late into here. Ten trenches deep. I cannot abide Jeff Root, nor he me. But it does make sense he took over twenty years ago having been a fireman with no educational background in Podiatry nor biomechanics. He has spent the last 20 years opposing change because he doesn’t have any education in the field other than that which his daddy told him; for him the status quo suits. For me, as someone who wanted to push the profession forward through research, we were always destined to clash heads. Crappy opinion piece written by a mate and he’s all over it because it fits his narrative; well performed PhD’s that oppose his view and he’s picking through them with a tooth comb. Poor scientist, but then he’s not a scientist, he’s a ex-fireman who would have no role in this if weren’t for his daddy.
     
  24. Dr Rich Blake

    Dr Rich Blake Active Member

     
  25. Rich. I once thought as you did, 20 years ago. But soon it became clear that whatever research was presented which opposed the work of Root. Jeff and occasionally Daryl Phillips would find some reason why it didn’t apply or was invalid, the finest minutiae. It became clear about 10 years ago that they would never accept that the things they viewed as facts where in fact highly questionable. As more and more research rolled out to refute the large percentage of none science in Root’s textbooks their excuses became more and more obscure. It became obvious that they where unwilling to change their points of view, no matter what the evidences presented to them. At that point I lost all interest in them. Couldn’t care less about Jeff Roots opinions- no formal education in the subject, biased and led by financial interest. Next.... The problem with biomechanics in the USA? Well at least the West Coast? It’s the family been controlling it IMHO.

    Rich with the greatest respect, take a look at the speakers at that conference you were speaking at: who’s published clinical data driven research, data they’ve collected themselves from live subjects lately from that faculty?
     
  26. Jeff Root

    Jeff Root Well-Known Member

    Rich, for the record I began full time employment in the lab in 1978. In 1984, after having moved the lab to the Sierra foothills from San Jose, as a citizen and as first on scene, I assisted in the rescue of a young man who was involved in a sever vehicle accident in a remote river canyon near my home. He obviously sustained a broken neck. Sadly, and I know this because I was later called to testify in court, he became a quadriplegic. After the rescue I was recruited by the fire agency as a volunteer fire fighter because they appreciated my assistance and potential. While working full time at the lab, I also responded to wildfires, vehicle and structure fires, medical and other types of emergencies from my business and during my non-working hours. I became an EMT-D and was eventually promoted to the rank of battalion chief where I began receiving pay. Not long after that I was promoted to assistant chief. I always worked full time at the lab but because I owned my own business, I regularly left work to assist in emergencies. I was not a fire fighter turned lab owner, I was a lab owner turned fire fighter. After 11 years in the fire service I left in 1995 to focus my time on my business and family. Serving as a fire fighter was extremely rewarding. Emergency medicine was extremely rewarding but personally I enjoyed fighting fire more because it is tough dealing with injury and death on a regular basis.

    Many orthotic lab owners are not podiatrist and have limited or no formal training in podiatry. An orthotic lab is a manufacturing business. Simply put, our job is to build a device to the practitioner's specifications. Having been fortunate enough to have received biomechanical and foot orthotic therapy education and training from one of the worlds leading authorities and having a significant amount of patient exposure during that process, I have more knowledge than many other lab owners who are not podiatrists. I have attended many of the same conference and lectures as my podiatrist customers and have participated in several podiatry and biomechanics forums. I have found these experiences to be highly beneficial in my career. I have no voice or influence in what is taught in the podiatry schools and my company manufactures custom foot orthoses to the specifications prescribed by our customers. My father has been deceased for for over 17 years. While there have been many changes in foot orthotic therapy over the past 40 plus years of my career, the basic foundation remains much the same. One podiatrist who you know well said we do the same thing but for a different reason. There is some truth in that statement which was made on this forum several years ago.

    The fact that some people remain frustrated that there hasn't been more change in the past decade or more has nothing to do with my business or my influence, or lack there of. If others have failed to promote change, that is their failure, not mine. As always, Root Lab will adapt to the needs of our customers but it is they, not us who determines that path.
     
  27. Dennis Kiper

    Dennis Kiper Well-Known Member

    Displacement of fluid mirrors the foots functional mechanics by integrating incoming weight bearing and pronatory forces to balance and stabilize stance phase from heel contact through propulsion-this will have a positive effect on postural stability (mechanical efficiency yields lever arm efficiency--after all, we are talking functional mechanics). The big difference is that a traditional orthotic doesn't modify pronation starting at heerl contact (unless you think that a heel post makes a difference?)--fluid does. In fact a trad orth has little to no effect until midstance and then at heel off, the MTJ pronates and you lose the momentary stability you had. With HD technology, at midstance, hydro-static pressure under the tarsus reaches an equilibrium state- of all three planes of motion, in conjunction with the fact that the increased surface area of the foot contact to the floor reduces the force per unit area (these scientific principles allows us to measure the biomechanical efficiency of the functional mechanics in all 3 planes)
    That's why the paper Jeff Root refers to as supporting neutral suspension casting is that at MS--the foot is at optimal position and the axis' of the foot is/ or near congruent. This is correct, the problem is that there are several problems to an extrinsic shell trying to manipulate an intrinsic mechanism. Displacement of fluid modifies the full motion of pronation (intrinsically) from heel contact to an equilibrium state of stability at MS and then prolongs the state of stability a moment longer as displacement of the fluid reverses to the rearfoot in preparation of the next cycle.
     
  28. Mac the Haligonian

    Mac the Haligonian Welcome New Poster

    This is really disappointing to read.

    I don’t understand why we think it’s only frontal plane, or its all sagittal plane, or maybe it’s the transverse plane???

    I also don’t understand why it has to be all Root Theory, or all TSS, or fuckin’ sagittal plane facilitation.

    In essence, this is all reductionalism. It is way more complex, and likely a combination of all these ideas….

    I’m pretty sure that people like Root, Nigg, Cavanagh, Hamill, Bates don’t and didn’t behave like some of what is displayed here.

    Why do people feel free to shit on one another, on this forum.

    Great researchers and scientists with integrity, ask great questions and realize how much we don’t understand.

    This thread is disappointing and not moving anything forward.

    Keep the faith and an open mind… Mac out​
     
  29. scotfoot

    scotfoot Well-Known Member

    Dennis ,
    What I can't quite picture is the mediolateral movement of the fluid inside the orthotic which would occur if a person were balancing on one leg (a common test of postural stability after strengthening interventions or indeed to assess orthotic designs ) .

    In such a test , if the foot pronates putting the fluid under the medial aspect of the device under increased pressure ,would the fluid migrate to under the lateral aspect of the foot ?
     
  30. Jeff Root

    Jeff Root Well-Known Member

    This is exactly my concern with this type of fluid filled device. The Root Functional Orthosis protocol was developed to apply triplane forces to resist pathological forces at the STJ, MTJ and other joints within the foot. For example, in a flexible flatfoot a non-weightbearing neutral position suspension cast of the foot with the MTJ pronated to resistance will capture the plantar contour of the heel in a less everted position than occurs in stance, it would capture a much higher medial arch and it would capture the frontal plane position of the forefoot. Using Root's orthotic fabrication technique, the orthotic shell would support the medial arch and would resit talar adduction and plantarflexion associated with compensitory weightbearing STJ pronation and would support the inverted or everted plane of the forefoot as captured in the negative cast. In a fluid filled device the fluid flows away from the area of higher contact forces to the area of lower contact forces. So in a foot like the one I described above, fluid would flow from the medial side of the heel to the lateral side of the heel as the STJ pronates. Increased fluid volume and pressure on the lateral side of the heel would increase STJ pronation moments, not reduce them like a functional orthotic would.
     
  31. Dennis Kiper

    Dennis Kiper Well-Known Member

    This technology does not fit a pes planus foot, however, for the balance (some anomolies aside) the fluid does not move in a medio-lateral manner. The major volume of fluid is encased within the borders of the template (med/lat), proximal to the met heads.
    Some fluid under the calc displaces anteriorily at HC and fills the arch space (bottom to top) instantaneously as the foot is pronating into MS position. The volume in the posterior at HC is the balance of the Rx volume which when displaced anteriorily fills the "arch chamber" (Spooner's term) at MS halting overpronation at the moment of an equilibrium state of stability of the MTJ and the STJ is already limited at optimal/neutral position. Hydrostatic pressure under the tarsus is equal throughout, pronation is halted, it doesn't further displace fluid at MS laterally (the lateral column is stable) --UNLESS the MTJ is fully subluxed, then in this case fluid would displace laterally and present an unstable platform. That's why I've repeatedly stated this technology is not for a subluxed MTJ but rather a non-subluxed platform, which represents 2/3 or more of all foot types.
    It's not like fluid sloshing around in a ballon. The fluid is very viscous (at 10,000 poise-for technical data) and moves about 1/4" forward and up into the apex of the POM. At heel off, wt bearing and pronatory forces at the MPJ displaces the fluid back (about 1/4"-prolonging stability of the forefoot and MTJ) under the calc in preparation of the next HC.
    I do not use a one legged stance test for postural stability, this is unnecessary in my opinion for this technology.
     
  32. Dennis Kiper

    Dennis Kiper Well-Known Member

    this is part of Root theory, but it does not apply triplane forces, Gait pressure systems recording traditional orthotic technology “have been inconsistent and unreliable for anything other than GRF”, according to author Gary Cronin in LER 08.11, because the figuration of a traditional orthosis cannot flex to give accurate data in all three planes--( In my opinion, this should cause doubt in the accuracy of GRF to be unreliable as well)
     
  33. Dr Rich Blake

    Dr Rich Blake Active Member

    I will, I have never I attended this seminar so it will be interesting. Rich
     
  34. Dr Rich Blake

    Dr Rich Blake Active Member

    Jeff, Thanks for that history as I only knew alittle of that side of you. It is very apparent from this thread, that US Podiatrists have little or no access to research any more. I will be interested at hearing what is going on in New York. I am presently there for the Richard Schuster Biomechanics seminar. I know that your dad sacrificed a lot for biomechanics, to teach and do research, and John died too early. I hope something in this thread puts a spark to our butts to get going. I really have no clue if US podiatrist make better orthotics, or understand biomechanics better than someone in another country. I know we have some great podiatrists trained in biomechanics, and I practice with 2 of them: Dr. Ron Valmassy and Dr. Jane Denton. Neither though do research or lecture now. I think this thread will help me understand things better. I hope anyone, including you, that has my book gives me honest critique so I do not get a warped view of my biomechanics. Rich
     
  35. Dr Rich Blake

    Dr Rich Blake Active Member

    Dennis, I am assuming from your comment that you make some form of fluid orthotics. Very interesting. How can it be tested?
    In a pronatory foot at heel contact, would it produce the force to control that motion say in a stage 2 PTTD patient vs a Kirby Skive or Inverted 25-30 degrees?
     
  36. Dr Rich Blake

    Dr Rich Blake Active Member

    Thank you! Rich
     
  37. Dr Rich Blake

    Dr Rich Blake Active Member

    My thought exactly! Rich
     
  38. Dr Rich Blake

    Dr Rich Blake Active Member

    Jeff, This is what I see daily also. Rich
     
  39. Dr Rich Blake

    Dr Rich Blake Active Member

    Dennis, the only way for me to wrap my head around it somewhat is to see one, and then re-read your thread. Can you send me a size 14 men’s pair to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109, and please include a bill, and I will check it out. Please also include indications for its use. Is it all or nothing with this device, or with a select group like the Inverted group for me? Rich
     
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