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Investigation of the podiatric model of foot biomechanics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Nov 2, 2013.

  1. NewsBot

    NewsBot The Admin that posts the news.

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    INVESTIGATION OF THE PODIATRIC MODEL OF FOOT BIOMECHANICS
    Hannah JARVIS
    Phd Dissertation; University of Salford. 2013
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. I don't like the way the author suggests that the Root model = the podiatric model. Somewhat dated view point in my opinion. The carte blanche in the conclusion is totally over the top.
     
  4. bob

    bob Active Member

    Simon - would it be more accurate for the author to say that the static assessments by whoever it was that did them did not reflect measurements made using the author's gait analysis equipment?

    How accurate is a six segment model of the foot in describing real foot function? And how reliable are the measurements made by the author (or whoever she had do the measurements) for static and dynamic measurements? I have seen a few different gait lab set ups and whilst some cost a lot of money and take hours to produce a report, I wonder how clinically useful they really are? Is sticking shiny balls to feet really that much better than foot wiggling?

    Bob
     
  5. JB1973

    JB1973 Active Member

    I agree Simon. Ive not read the paper, only whats shown above but no real surprise with the findings. We have known for a good while now that the Root model is no longer valid but its not the "current model used to describe the biomechanical function" anymore.
    cheers
    JB
     
  6. Ian Linane

    Ian Linane Well-Known Member

    "current model used to describe the biomechanical function" anymore"

    I think this might be context dependent? I know a couple of tutors who "have" to teach it, even though they would prefer not to. Don't know if they have latitude to minimise how much emphasis it is given. Certainly a source of frustration for them at times
     
  7. JB1973

    JB1973 Active Member

    Aye, fair point Ian. It is still part of the undergrad curriculum in a lot of Uni's but you can emphasise the problems with it and give all the alternatives as well. It's certainly not " the current model" as the authors allude to. I don't think there is a current model, just various theories. All of which can be and are taught.
    Cheers
    JB
     
  8. There are a number of very big problems with this abstract:

    1. Root never said that all feet and lower extremities would function the same way. Root acknowledged the variability in function and structure of the human foot and lower extremity. He did, however, propose that the ideal or, as he put it, the "normal" foot, would function a certain way during walking gait and would have a certain morphology. In Root's mind, just because a person was "asymptomatic", this did not also make their feet and lower extremities "normal".

    2. There is no one "podiatric model of foot biomechanics". There are numerous models of foot biomechanics now being taught around the world. Maybe 30 years ago, the Root model could have been considered "the podiatric model of foot biomechanics". However, this is no longer the case and anyone who has taken the time to read the literature over the past 30 years would realize that.

    3. I agree with Simon that the last sentence of the abstract: "This suggests that the key principles of the current model used to describe the biomechanical function of the normal foot in podiatry are incorrect and the methods used by podiatrists in clinical practice are not valid" is not only "over-the-top" but is also inaccurate and insulting, to say the least.

    Since when have all podiatrists used the same methods of clinically evaluating the feet and lower extremities? Answer: Never.

    Since when have any foot-health care practitioners had their methods validated by research so we can say that all their methods of evaluation are "valid". Answer: Never.

    I would think that if one were to change the final statement to the following:

    "This suggests that one the key principles of the Root model used to describe the correlation between foot and lower extremity structure and biomechanical function is incorrect so that any health-care specialist who assume that there is a close correlation between structure and function of the foot lower extremity are likely to be mistaken",

    then I would think that the researcher had more objectivity, less bias against the knowledge and practice of podiatrists, and had done their homework better.
     
  9. DrLCT2

    DrLCT2 Member

    If it wasn't for Mert Root, Tom Scarlotta, John Weed, and Bill Orien, their research, publications, and lectures in the late 1960's and 70's there may not be a field called "biomechanics"!
    I was fortunate to be in the Bay Area at the time serving my general rotating internship and foot surgery residency and was VERY fortunate to be able to learn from these terrific pioneers! Almost 50 years later and there's still not that much wrong with their theories and biomechanical examination of the foot and lower extremities. The real problem is that most practitioners and clinicians have never been taught or learned the basics properly - resulting in each examination being purely subjective to each examiner and leaving lots of room for lack of validity and reliability!
     

  10. I doubt that, we may not be where we are today better or worse.

    The issue is if you think Biomechanics is a Podiatric only field or not.
     
  11. DrLCT2

    DrLCT2 Member

    To Mark Weber: Biomechanics is certainly not "just a podiatric field"! After all, everybody and their brother is into it these days and have been for quite awhile! The field originated, however, with the pioneers that I mentioned - all of whom were D.P.M.'s! At the time (the mid-1960's) 2 other physicians (both M.D. orthopedic surgeons) in San Francisco, Verne Inman & Roger Mann, also had an interest and contributed to the development of the field by conducted some of the earliest research. Prior to these individuals that I've mentioned (whom I worked closely with) the only thing that was available at the time was the old "arch support" concept and theory. At least the earliest biomechanists were able to assign positions, motions, functions, and new terminology to what was then an emerging field with lots of skeptics - most of whom didn't know their "you-know-what" from a hole in the ground and struggled with the new terminology let alone the theories! ☺
     
  12. It did not Originate with them, they did a huge volume of work of their interpretation of Biomechanics, made some advances and certainly put their interpetation into a text, probably the 1st time someone had done that.

    and we have the same issue today when discussing mechancis
     
  13. With the greatest of repect, the field of biomechanics did not orginate in California in the 1950's. The origin of biomechanics can be traced at least to Borelli (1608-1679). http://en.wikipedia.org/wiki/Giovanni_Alfonso_Borelli. Nicolas Andry de Bois Regard 1658-1742 was recommending shoe modfications for the flat feet of children at least a couple of centuries before Root.
     
  14. DrLCT2

    DrLCT2 Member

    Boy, are you out of touch! If you think what Borelli was doing with "shoe modifications in the 1600's" was "biomechanics", I can only imagine how little you know about what Root, et. al. were talking about (just like so many others I mentioned who "didn't/don't know their you-know-what from a hole in the ground" when it comes to biomechanics!
    I thought I'd share my knowledge and experiences from being in the Bay Area and around the early pioneers in the field in the 1960's (not the 1950's as you mistakenly wrote); however, you can be sure that this is the last time you'll find me attempting to enlighten anybody again on this venue!
    There's an old expression that applies in these regards that says, "Don't do something for somebody when they don't want you to do it for them; and especially when you really don't want to/and don't have the time to do it anyway! :>)
     
  15. any modification will be " doing biomechanics " as for being out of touch I know where my vote would sit. ;)

    You also make assumptions that many here have not looked at great detail the feild of biomechanics.
     
  16. Rob Kidd

    Rob Kidd Well-Known Member

    Out of touch? I don't think so. It is not often I agree with Simon, but I do here. Please, read your review of the literature carefully, and come back with a fully educated platter. Rob
     
  17. blinda

    blinda MVP

    Good advice, Rob. Although I do often agree with Simon. In particular with regard to the history of orthoses which I believe he has lectured on internationally. DrLCT2 would do well to learn from him...Sorry to talk about you as if you`re not in the room, Simon. Does he take sugar?
     
  18. Unfortunately, this belief among many US podiatrists that "biomechanics" began with Merton Root, Tom Sgarlato, John Weed and Bill Orien, is widespread. Why? Because these podiatrists have not taken the time to read the early biomechanics literature out of their own podiatry journals, or read articles or books which review the great historical development of biomechanical concepts over the centuries.

    In addition, many US podiatrists also think that the term "biomechanics" means "making orthotics" and nothing else. They often don't realize that the definition of "biomechanics" is broad and describes the forces, moments and their effects which occur in all biological systems and not just to the foot and lower extremity.

    I wrote a short article about this common misconception among US podiatrists as to what the term "biomechanics" actually means and doesn't mean. Orthotics Are Not Biomechanics.

    Simon and I both gave lectures on the history of foot orthoses and foot biomechanics at a podiatry seminar in Ghent, Belgium in March 2012 and I know both of us spent a lot of time researching these topics. Once an individual has done the research to see how our knowledge of biomechanics and the concepts of foot orthosis therapy have developed over the past few centuries, it is unlikely that they would still make the statement that biomechanics originated with Root, Weed, Sgarlato and Orien.
     
  19. Agreed. What I would ask is exactly what was it that Root was the first to describe?
     
  20. Good question, Simon.

    From what I know from my personal interactions with Root, Weed, Orien, Sgarlato and the Biomechanics Professors at CCPM, including my research and reading on the subject, here is what I would say that Mert Root first described/created.

    1. First to define the subtalar joint as having a neutral position that was neither "pronated nor supinated".

    2. First to develop Biophysical Criteria for Normalcy, including eight criteria which he felt described the ideal foot and lower extremity structure.

    3. First to develop a more complete taxonomy system for classification of foot and lower extremity structure.

    4. First to describe the "Neutral Suspension Negative Casting Method" with the subtalar joint "neutral" and the midtarsal joints "maximally pronated".

    5. First to develop the "Root Functional Orthosis".

    6. Began first department of Podiatric Biomechanics at any podiatric medical teaching institution in the world. He became the first chairman of this department.

    7. Coauthored first book devoted solely to Biomechanical Examination of the Foot.

    I have contacted Jeff Root, Daryl Phillips and Eric Lee to see if they agree with me or if they have any further suggestions.
     
  21. Thanks Kevin. Generally I agree with the majority of your points. However, regarding your no. 1, I know that Daryl references someone other as providing the concept of subtalar neutral. Is it valid/ important? That's another question- probably not. No. 2 is questionable since the "weak foot" era guys were working from a nominal "normal" as were the "forefoot imbalance" guys in the 1930's led by Morton; certainly Saunders and Inman had talked about "normal and pathological gaits" in the 1950's. Your No. 3. is neither here nor there- "more complete than what?" Morton would have argued that his taxonomy was "complete" yet complete and valid is another question? With regard to your no. 7, I have a book on my desk right now entitled "Foot Mechanics" by Leslie R. Smart published by Bailliere, Tindall and Cox (London) in 1950. Although this book included more than just examination of the foot, examination was included as a chapter or two. No-one can deny that Root developed the Root orthosis but wasn't it John Weed and Tom Sgarlato who were responsible for the rearfoot post which has become synonymous with the "Root orthotic"? Having worked in higher education for a number of years, surely he didn't create a whole department all on his own? Does that department still exist? My money was on neutral suspension casting, but even that book is co-authored. I guess a caveat is probably needed- that is, what was Root the first to describe which has proved to be valid and useful still in the 2013 version of podiatric biomechanics?

    Anyway, has anyone read the whole thesis yet?- I should have time tomorrow (first day off in ages).
     
  22. Ian Linane

    Ian Linane Well-Known Member

    "I thought I'd share my knowledge and experiences from being in the Bay Area and around the early pioneers in the field in the 1960's (not the 1950's as you mistakenly wrote); however, you can be sure that this is the last time you'll find me attempting to enlighten anybody again on this venue!"

    Sorry, I thought he'd switched the light off! However if he needs help with lights my son-in-law specialises in industrial explosion proof lighting (seriously). Judging by the above fierce and dull comments the above gentleman could do with some.
     
  23. Your comments amply demonstrate that the vast majority of podiatrists in the United States of America are lagging so far behind the rest of the world right now when it comes to podiatric biomechanics that it has become ludicrous and even embarrassing to attempt to discuss this subject with many DPM's (undergrads here in the UK have a wider knowledge base and a better ability to critically evaluate the literature regarding podiatric biomechanics than too many DPM's that I meet). My sympathy's lie with those in the US who have moved on beyond the 1970's and have attempted to push the science forward in the face of the luddites. By the way, what is that DrLCT2 came here to sell?

    And, for the record, one of the guy's DrLCT2 mentioned:
    was one of my all time biomechanical hero's: Verne T. Inman (I wear similar glasses in his honour) who was working in the Bay area and publishing studies on the lower limb in the 1950's as well as the 1930's- 1970's (so... wind your neck in). For example: The lower-extremity clinical study--its background and objectives. INMAN VT, EBERHART HD. Artif Limbs. 1955 Jan;2(1):4-34. and obviously: The major determinants in normal and pathological gait. SAUNDERS JB, INMAN VT, EBERHART HD. J Bone Joint Surg Am. 1953 Jul;35-A(3):543-58. etc. See more of Inmans monumental publication record here: http://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=Inman VT[au]&dispmax=50 So... since it was you who mentioned Inman, I stand by my statement regarding the 1950's. The question is how much did Mert "lend" from Verne? Even so, these guys didn't invent biomechanics; biomechanics didn't begin in Calfornia in any decade nor century. In other words, some people might know more about a subject than you do DrLCT2, whether you were there or not. Being there and moving with the times appear to be too difficult for some to juggle.

    I've probably said this before, I've certainly been intimating this in my lectures for the past 15+ years: I honestly believe that having reviewed the literature, the publications of Merton Root set back the development of podiatric biomechanics in the UK by 20-30 years. Despite the over-statements of it's abstract, this PhD thesis appears to add support to my point of view.

    Anyway... "Here comes the Son"... http://www.youtube.com/watch?v=ZfGDFgdmdvo "what do you know about this world anyway?"
     
  24. blinda

    blinda MVP

    :good: `Watching the world wake up from history`
     
  25. Welcome to my world.:craig::bang::cool:

    Sometimes it does feel like US podiatrists are "lagging behind" many other podiatrists in other countries in regards to biomechanics of the foot and lower extremities. However, I wonder if the biomechanics knowledge is better in the average podiatrist in the UK, Australia or Spain compared to the average podiatrist in the US. I don't think so. I think the average podiatrist in all these countries has a fair understanding of biomechanics. Each country has very many podiatrists who have a bias toward what ever they were taught in podiatry school and have spent little time adding to their biomechanical knowledge since podiatry school.

    However, that being said, there are a number of podiatrists in the US who do have a great interest and great proficiency in using biomechanical principles by which to treat their patients, just as there are in most other countries.

    All in all, I would have to agree with your statement, Simon, that the majority of podiatrists in the US have not kept up, and do not keep up, with the latest theories and concepts in foot and lower extremity biomechanics. In addition, I agree that these podiatrists would have a difficult time having an intelligent conversation here on Podiatry Arena about foot and lower extremity biomechanics since many of them assume that Mert Root and his colleagues "invented biomechanics" and that all Mert Root and his colleagues taught is permanently etched in stone.

    As long as I'm alive and my brain is still in good working order, I will continue to attempt to rectify this issue within my home country. I'm now working on my fourth book on Foot and Lower Extremity Biomechanics, write frequently for US podiatry magazines, still do lecture at the California School of Podiatric Medicine and also lecture two to three times a year here in the US. I believe that there is still hope for the USA to gradually increase their biomechanical knowledge so that at least a few US podiatrists will be able to lecture nationally and internationally on these important concepts for our profession long after I can no longer do so. I haven't given up yet.:drinks
     
  26. Phil Rees

    Phil Rees Active Member

    Wasn't it Nicolai Bernstein who first used the term "Biomechanics"
     
  27. toomoon

    toomoon Well-Known Member

    I really don't get it at all.. why are we still talking about 'podiatric biomechanics'.. as if somehow the foot has sucked a major branch of science into its own vortex. The laws of physics, which dictate all we know about human movement, have nothing to do with podiatry. I know that Kevin, Simon, Ian and many others are aware of this.. but the whole point is that many of us moved on from 'podiatric biomechanics" years ago.. not because we did not value what it brought to the table, and in some ways continues to do, but because we were not content to subscribe to a theory, and one that is now pushing 50 years old, and had fallen out of step what scientists in the lab could teach us!
    Theories are great, but evidence is better. There is no doubt whatsoever that the foot generates the most complex joint/joint, joint/muscle, foot/interface interactions of the human body, with enormous human variability.
    The sooner we are able to convince all practitioners interested in movement and gait to lift the eyes, accept that gait is complex and multifaceted and understand forces.. the sooner we will be able to expand our narrow little universe of "podiatric' biomechanics.
     
  28. PodAus

    PodAus Active Member

    Nice 'nut-shell' Simon... I'm gonna use that one if you dont mind... ;)


    The structure v function correlation must still be strong, in the context of kinetics... we're just re-inventing 'the language and punctuation' in relation to the foot and lower limb.
     
  29. Rob Kidd

    Rob Kidd Well-Known Member

    I agree with you, but that is not why I am posting - Derbyshire eh?! I am a Buxton Boy - give my regards to the Peak District, even though I am nearly as far from it now (Adelaide) as you can get)

    Rob
     
  30. Phil Rees

    Phil Rees Active Member

    Hi Rob,
    The Peak District's still there, as beautiful as ever especially at this time of year.
     
  31. rdp1210

    rdp1210 Active Member


    Kevin has asked me to comment on what Mert did and didn't do. I've read most of the comments by others and find most of them to be biased either toward or against Root, with few facts and a lot of "throw the baby out with the bathwater" mentality. I think that Eric Lee did one of the most exhaustive works on trying to explain what came before Root and what he added. If you haven't read Eric's treatise, please do so before you jump on the "get-rid-of-Root" boat.

    In regards to what Kevin listed for Mert's accomplishments.
    1. Mert renewed, unknowingly, an idea that had been sitting in the wings since 1898. In the Aug 4, 1898 edition, Lovett and Cotton (Boston Medical Journal) described the characteristics of the pronated (not flat foot), and the kinematics. They made this statement, "In contrast to the word pronation the word supination will be used here to designate the corrceted position of the foot in which, by the influence of voluntary muscular contraction, the foot is placed with its outer border touching the ground, in its normal relation to the leg, and the inner malleolus not unduly prominent." There is then drawn a picture showing the normal and pronated foot. I think that many people reading the full article will get the distinct impression that this must have been Mert Root's father writing it. However I do not find this article highly referenced in most of the biomechanics works of first half of the 20th century. I do know that Mert Root was not cognizant of this article. We find that Lovett and Cotton were X-raying feet in two different positions, static and in the 'normal' position, something Mert did clinically for many years. One of their observations was, "No distinction can be drawn between the relation of the bones in in the painfully pronated foot and that of the relativery normarl foot when allowed to pronate."
    As I noted in the very first page of the chapter I just wrote for Steve Albert's book, "Root did not just dive into an unknown mechanics world and develop a number of postulates that no one had ever thought of before..." Mert was well aware of the works of Hicks and Manter, as his 1964 paper with John Weed and Tom Sgarlato show. As to the STJ neutral, I am not aware of anyone else, except the two mentioned above, that described it like Root did. Root has been accused by some of lifting and then misquoting Wright and Desai's definition of neutral, in which the heel is perpendicular to the ground. However it will be noted by those who make the accusation that Root published his paper "An approach to foot orthopedics" one month before the Wright and Desai paper was published.
    Root utilized the neutral position idea as a reference point, from which point the words "pronated" and "supinated" could be utilized. Without such a reference point, the words "pronated" and "supinated" would be meaningless. My reaction for many years was that the Root definition was meaningless, until I started thinking about a mathematician trying to define the word "zero" without using the words positive or negative. Mert tried to visualize an idea of a "normal" neutral position as being one in which compressive forces would be maximized and shear stresses minimized across the subtalar joint. A nice idea. Indeed his idea that this normal neutral position should be one in which minimal ligamentous and muscular forces were needed to equalize the pronation and supination moments around the joint is a nice idea, but has to be considered rudimentary in concept and not fully developed.
    Eric Lee also pointed out that the Root concept of normal was the Platonic view. Most research is based on the Aristotelian view. It's mathematicians fighting the physicists (which often happens).

    2. Certainly Mert defined a set of criteria for normal that may be found in bits and pieces in the literature, but not as a single group. For example, Harris and Beath did a lot of work in regards to tight calf muscles. Also Mert did not define the determinants of gait, as others did that before. Mert did integrate his normal ideals with the normal determinants of gait to show they were harmonious. As I have tried to read the historical literature, the one truly unique idea that Mert had, that I have not found anywhere else, is what I have come to call, "The Root Postulate." This is the idea that in normal stance, the midtarsal joint should be fully pronated around all of its axes of motion. He stated that this midtarsal joint position should be reached as the heel lifts off the ground in order to maximize the "rigid lever" effect of the foot on both the sagittal and frontal planes. Please note that a common mistake made by Root critiques is that Root taught that the STJ reaches neutral position in the middle of midstance. This is false. Root taught that the STJ reaches neutral position at the time the heel lifts off the ground. One of the problems with the Root Postulate is that it was tied to the Elftman concept of EROM of the MTJ. Even when that was disavowed before pulication of volume 2, there are still indirect references to it. To date, I am still unaware of anyone that has measured the forefoot-rearfoot relationship with various amounts of torque across the joint.

    3. Root definitely had a major impact on the terminology. He defined things in the plane in which the deformity was present. Metatarsus varus became metatarsus adductus. Hallux valgus became hallux-abducto-valgus. The word forefoot varus I found first in the literature in the 1948 paper by Perkins, however Root reinvented and popularized it. I do not find the term "forefoot valgus" in the literature before Root. Root defined these forefoot abnormalities in terms of the Root Postulate, not in terms of a resting or relaxed state (I'm not aware of anyone before him doing such). Pronation indicated a movement that had to have angular displacement in all three cardinal planes. I do not find the idea of subtalar varus in the literature before Root. Yes, some of the terms were already in the literature, but not in the day-to-day vocabulary of the average practitioner. Root was heavily criticized for trying to instigate a new vocabulary. Root also tried to make the profession more precise in their use of words, e.g. valgus was to be utilized only for a deformity, not for a motion or for a position.

    4. The supine NWB casting technique was truly a Root invention. I have not seen this elsewhere in the literature. Eric Lee points out that Root started out as a semi-weightbearing caster, but developed the NWB technique in order to take advantage of the Root Postulate. Someone may be able to find a NWB casting technique that I am unaware of, however I'm sure that none made an attempt to dorsiflex the forefoot on the rearfoot. Even the UCBL (Inman's orthotic) utilized a semi-weightbearing casting technique. Schuster could not accept the Root postulate, and as a result continued the semi-weightbearing casting technique. Glaser has totally rejected the Root Postulate, and actually plantarflexes the forefoot against the rearfoot.

    5. The Root Functional Orthotic was based on the Root Postulate. Lots of other devices were out there, but since the Root Postulate was a unique idea, the Root orthotic is also unique. Heel posting was a later addition, as was intrinsic forefoot posting.

    6. The other 4 US schools had departments of Orthopedics, but none had a department of biomechanics. Yes, there were people earning PhD degrees in biomechanics from major universities, and Mert never got one of those. Mert in no way invented biomechanics and he never claimed such, but he was a leader of our profession by telling the profession that we needed to jump on the biomechanics bandwagon -- i.e. we either jumped on it or we would be run over by it. He advocated measuring things instead of giving illdefined and nondescript diagnoses, e.g. weak foot, flat foot, cavus foot, etc. He advocated development of well founded re-producible theory. He was idealist who had a vision that inspired a lot of people, and these people started having better clinical results, and these people spread out through the country. (Bill Orien was one such person) We may today criticize his science, but for his time he was one of very few in our profession who advocated more scientific and more engineering approach to understanding foot mechanics. Yes, there were many other important people, some of them in the UK, some elsewhere who made significant contributions. (I personally have a great big place in my heart for Wheeler Haines.) However we have to measure the impact of Mert Root on the profession, both in the US and internationally, few have made as big of an impact. (A comparison may be the likes of Henry Ford, who indeed did not invent the Auto, but his impact on the industry is greater than any other individual). Mert, in setting up the department of biomechanics at CCPM, was trying to lead the profession to a new paradigm of scientific investigation. He believed that biomechanics was a science and should be taught as a basic science, not a clinical art. Unfortunately many of his ideas about such teaching got twisted by the institutional politics and have never been fully realized.

    7. I think that Kevin may be right here, that Mert's volume I was the first book devoted to biomechanically examining the foot. Certainly I have on my shelf many pre-Root books. I don't want to take a thing away from Dudley Morton, or Marion Broer, or Norman Lake, etc. All added to the knowledge base. I have found, though that Root's first book is only a jumping off point, being more of a concept book. It is not detailed enough to be used as an instruction book in teaching everyone the same techniques so that good intertester reliability is achieved. One example of this is that you'll notice in my papers on STJ examination, that I try to better define the coordinate system in which the STJ measurements will be made. Root didn't pay a lot of attention to the details of setting up coordinate systems and being precise in the plane in which things were being measured, he only gave basic concepts.
    I notice on first glance that Jarvis looked at the reliability of experienced clinicians to measure, "1) NCSP and RCSP, 2) range of dorsiflexion at the ankle joint, 3) Position and mobility of the first ray, and 4) Examination of limb length." Each of these measurements are fraught with imprecision for a number of reasons. a) One of the first and most important is that Root didn't fully define what constituted a calcaneal bisection. We all have a basic concept of what a bisection of the heel is, but the simple fact is that no one really has fully defined it. As such intertester reliablity will be poor. I'm hoping that the new PedCat system will allow us to do a better job. b) Ankle joint ROM is again very nebulous. Several years ago, Greg Young did an interesting discussion on how ankle joint ROM was very different WB than NWB. What we really should be doing is drawing a passive ankle torque-ankle joint dorsiflexion curve for every person. Much of Root's discussions on ankle joint ROM are couched in the Harris-Beath model. c) Mobility of the first ray is based on a number of factors relating to joint positions around it. I have noted that if I invert the 2nd and 3rd metatarsals, the ROM of the first ray is greater than if I evert these metatarsals. I've never published anything on this because I don't have adequate instrumentation to measure it. The thumb/finger is still being used as the basis for measurement. Pretty sad commentary. d) I don't think I need to discuss LLD variances as these have been well documented in the literature. Root recognized its importance and lectured on it, but wrote little in volume 1 or 2 about it. I'm surprised, therefore, that Jarvis put into the the four big things. I would think that she would want to put forefoot to rearfoot relationship into the equations instead of LLD.
    Today, over 40 years after the publication of this first Root volume, we still have the majority of people taking clinical measurements with cheaply made hand-held double arm goniometers, that were never developed for doing the measuring that was proposed. We should be using electrogoniometers that measure the angular movement and break it into its component projections for ease of visualizations.

    In summary, Mert Root was surprised that a better model of the foot had not been accepted by the profession by the year 1994 (first Weed Seminar notes). He saw himself as the person to get the horse out of the barn. He expected those coming behind him to make it better. I have downloaded the Jarvis thesis and will try to more thoroughly evaluate it. I have found many of the "throw-Root-out-with-the-bath-water" discussions to be very flawed themselves. Sometimes we judge history from a pinnacle of perfection that we think we ourselves stand upon. I looked at the table of contents of Jarvis, and do like the way it is organized into specific topics and tries to discuss one small point after another. I get tired of those who take just one topic, think they have totally negated it, and then conclude that every topic that the questioned authority made has to negated. :butcher: Yes, we ourselves are often as guilty of bias as we each try to establish our own little niche in history.

    Kevin, you did a great job in compiling the list; hope that I colored a little between the lines with my current view of Root's place. He was an indomitable person for his time. I do agree that everything he said has to be questioned. "Only if you are unafraid of truth will you find it." It is also just as important that we be as critical of our own selves as we are of him.

    Best wishes, :drinks
    Daryl
     
  32. rdp1210

    rdp1210 Active Member


    Kevin has asked me to comment on what Mert did and didn't do. I've read most of the comments by others and find most of them to be biased either toward or against Root, with few facts and a lot of "throw the baby out with the bathwater" mentality. I think that Eric Lee did one of the most exhaustive works on trying to explain what came before Root and what he added. If you haven't read Eric's treatise, please do so before you jump on the "get-rid-of-Root" boat.

    In regards to what Kevin listed for Mert's accomplishments.
    1. Mert renewed, unknowingly, an idea that had been sitting in the wings since 1898. In the Aug 4, 1898 edition, Lovett and Cotton (Boston Medical Journal) described the characteristics of the pronated (not flat foot), and the kinematics. They made this statement, "In contrast to the word pronation the word supination will be used here to designate the corrceted position of the foot in which, by the influence of voluntary muscular contraction, the foot is placed with its outer border touching the ground, in its normal relation to the leg, and the inner malleolus not unduly prominent." There is then drawn a picture showing the normal and pronated foot. I think that many people reading the full article will get the distinct impression that this must have been Mert Root's father writing it. However I do not find this article highly referenced in most of the biomechanics works of first half of the 20th century. I do know that Mert Root was not cognizant of this article. We find that Lovett and Cotton were X-raying feet in two different positions, static and in the 'normal' position, something Mert did clinically for many years. One of their observations was, "No distinction can be drawn between the relation of the bones in in the painfully pronated foot and that of the relativery normarl foot when allowed to pronate."
    As I noted in the very first page of the chapter I just wrote for Steve Albert's book, "Root did not just dive into an unknown mechanics world and develop a number of postulates that no one had ever thought of before..." Mert was well aware of the works of Hicks and Manter, as his 1964 paper with John Weed and Tom Sgarlato show. As to the STJ neutral, I am not aware of anyone else, except the two mentioned above, that described it like Root did. Root has been accused by some of lifting and then misquoting Wright and Desai's definition of neutral, in which the heel is perpendicular to the ground. However it will be noted by those who make the accusation that Root published his paper "An approach to foot orthopedics" one month before the Wright and Desai paper was published.
    Root utilized the neutral position idea as a reference point, from which point the words "pronated" and "supinated" could be utilized. Without such a reference point, the words "pronated" and "supinated" would be meaningless. My reaction for many years was that the Root definition was meaningless, until I started thinking about a mathematician trying to define the word "zero" without using the words positive or negative. Mert tried to visualize an idea of a "normal" neutral position as being one in which compressive forces would be maximized and shear stresses minimized across the subtalar joint. A nice idea. Indeed his idea that this normal neutral position should be one in which minimal ligamentous and muscular forces were needed to equalize the pronation and supination moments around the joint is a nice idea, but has to be considered rudimentary in concept and not fully developed.
    Eric Lee also pointed out that the Root concept of normal was the Platonic view. Most research is based on the Aristotelian view. It's mathematicians fighting the physicists (which often happens).

    2. Certainly Mert defined a set of criteria for normal that may be found in bits and pieces in the literature, but not as a single group. For example, Harris and Beath did a lot of work in regards to tight calf muscles. Also Mert did not define the determinants of gait, as others did that before. Mert did integrate his normal ideals with the normal determinants of gait to show they were harmonious. As I have tried to read the historical literature, the one truly unique idea that Mert had, that I have not found anywhere else, is what I have come to call, "The Root Postulate." This is the idea that in normal stance, the midtarsal joint should be fully pronated around all of its axes of motion. He stated that this midtarsal joint position should be reached as the heel lifts off the ground in order to maximize the "rigid lever" effect of the foot on both the sagittal and frontal planes. Please note that a common mistake made by Root critiques is that Root taught that the STJ reaches neutral position in the middle of midstance. This is false. Root taught that the STJ reaches neutral position at the time the heel lifts off the ground. One of the problems with the Root Postulate is that it was tied to the Elftman concept of EROM of the MTJ. Even when that was disavowed before pulication of volume 2, there are still indirect references to it. To date, I am still unaware of anyone that has measured the forefoot-rearfoot relationship with various amounts of torque across the joint.

    3. Root definitely had a major impact on the terminology. He defined things in the plane in which the deformity was present. Metatarsus varus became metatarsus adductus. Hallux valgus became hallux-abducto-valgus. The word forefoot varus I found first in the literature in the 1948 paper by Perkins, however Root reinvented and popularized it. I do not find the term "forefoot valgus" in the literature before Root. Root defined these forefoot abnormalities in terms of the Root Postulate, not in terms of a resting or relaxed state (I'm not aware of anyone before him doing such). Pronation indicated a movement that had to have angular displacement in all three cardinal planes. I do not find the idea of subtalar varus in the literature before Root. Yes, some of the terms were already in the literature, but not in the day-to-day vocabulary of the average practitioner. Root was heavily criticized for trying to instigate a new vocabulary. Root also tried to make the profession more precise in their use of words, e.g. valgus was to be utilized only for a deformity, not for a motion or for a position.

    4. The supine NWB casting technique was truly a Root invention. I have not seen this elsewhere in the literature. Eric Lee points out that Root started out as a semi-weightbearing caster, but developed the NWB technique in order to take advantage of the Root Postulate. Someone may be able to find a NWB casting technique that I am unaware of, however I'm sure that none made an attempt to dorsiflex the forefoot on the rearfoot. Even the UCBL (Inman's orthotic) utilized a semi-weightbearing casting technique. Schuster could not accept the Root postulate, and as a result continued the semi-weightbearing casting technique. Glaser has totally rejected the Root Postulate, and actually plantarflexes the forefoot against the rearfoot.

    5. The Root Functional Orthotic was based on the Root Postulate. Lots of other devices were out there, but since the Root Postulate was a unique idea, the Root orthotic is also unique. Heel posting was a later addition, as was intrinsic forefoot posting.

    6. The other 4 US schools had departments of Orthopedics, but none had a department of biomechanics. Yes, there were people earning PhD degrees in biomechanics from major universities, and Mert never got one of those. Mert in no way invented biomechanics and he never claimed such, but he was a leader of our profession by telling the profession that we needed to jump on the biomechanics bandwagon -- i.e. we either jumped on it or we would be run over by it. He advocated measuring things instead of giving illdefined and nondescript diagnoses, e.g. weak foot, flat foot, cavus foot, etc. He advocated development of well founded re-producible theory. He was idealist who had a vision that inspired a lot of people, and these people started having better clinical results, and these people spread out through the country. (Bill Orien was one such person) We may today criticize his science, but for his time he was one of very few in our profession who advocated more scientific and more engineering approach to understanding foot mechanics. Yes, there were many other important people, some of them in the UK, some elsewhere who made significant contributions. (I personally have a great big place in my heart for Wheeler Haines.) However we have to measure the impact of Mert Root on the profession, both in the US and internationally, few have made as big of an impact. (A comparison may be the likes of Henry Ford, who indeed did not invent the Auto, but his impact on the industry is greater than any other individual). Mert, in setting up the department of biomechanics at CCPM, was trying to lead the profession to a new paradigm of scientific investigation. He believed that biomechanics was a science and should be taught as a basic science, not a clinical art. Unfortunately many of his ideas about such teaching got twisted by the institutional politics and have never been fully realized.

    7. I think that Kevin may be right here, that Mert's volume I was the first book devoted to biomechanically examining the foot. Certainly I have on my shelf many pre-Root books. I don't want to take a thing away from Dudley Morton, or Marion Broer, or Norman Lake, etc. All added to the knowledge base. I have found, though that Root's first book is only a jumping off point, being more of a concept book. It is not detailed enough to be used as an instruction book in teaching everyone the same techniques so that good intertester reliability is achieved. One example of this is that you'll notice in my papers on STJ examination, that I try to better define the coordinate system in which the STJ measurements will be made. Root didn't pay a lot of attention to the details of setting up coordinate systems and being precise in the plane in which things were being measured, he only gave basic concepts.
    I notice on first glance that Jarvis looked at the reliability of experienced clinicians to measure, "1) NCSP and RCSP, 2) range of dorsiflexion at the ankle joint, 3) Position and mobility of the first ray, and 4) Examination of limb length." Each of these measurements are fraught with imprecision for a number of reasons. a) One of the first and most important is that Root didn't fully define what constituted a calcaneal bisection. We all have a basic concept of what a bisection of the heel is, but the simple fact is that no one really has fully defined it. As such intertester reliablity will be poor. I'm hoping that the new PedCat system will allow us to do a better job. b) Ankle joint ROM is again very nebulous. Several years ago, Greg Young did an interesting discussion on how ankle joint ROM was very different WB than NWB. What we really should be doing is drawing a passive ankle torque-ankle joint dorsiflexion curve for every person. Much of Root's discussions on ankle joint ROM are couched in the Harris-Beath model. c) Mobility of the first ray is based on a number of factors relating to joint positions around it. I have noted that if I invert the 2nd and 3rd metatarsals, the ROM of the first ray is greater than if I evert these metatarsals. I've never published anything on this because I don't have adequate instrumentation to measure it. The thumb/finger is still being used as the basis for measurement. Pretty sad commentary. d) I don't think I need to discuss LLD variances as these have been well documented in the literature. Root recognized its importance and lectured on it, but wrote little in volume 1 or 2 about it. I'm surprised, therefore, that Jarvis put into the the four big things. I would think that she would want to put forefoot to rearfoot relationship into the equations instead of LLD.
    Today, over 40 years after the publication of this first Root volume, we still have the majority of people taking clinical measurements with cheaply made hand-held double arm goniometers, that were never developed for doing the measuring that was proposed. We should be using electrogoniometers that measure the angular movement and break it into its component projections for ease of visualizations.

    In summary, Mert Root was surprised that a better model of the foot had not been accepted by the profession by the year 1994 (first Weed Seminar notes). He saw himself as the stimulant for podiatrists to get the biomechanics horse out of the barn. He expected those coming behind him to make it much better. I have downloaded the Jarvis thesis and will try to more thoroughly evaluate it. I have found many of the "throw-Root-out-with-the-bath-water" discussions to be very flawed themselves. Sometimes we judge history from a pinnacle of perfection that we think we ourselves stand upon. I looked at the table of contents of Jarvis, and do like the way it is organized into specific topics and tries to discuss one small point after another. I get tired of those who take just one topic, think they have totally negated it, and then conclude that every topic that the questioned authority made has to negated. :butcher: Yes, we ourselves are often as guilty of bias as we each try to establish our own little niche in history.

    Kevin, you did a great job in compiling the list; hope that I colored a little between the lines with my current view of Root's place. He was an indomitable person for his time. I do agree that everything he said has to be questioned. "Only if you are unafraid of truth will you find it." It is also just as important that we be as critical of our own selves as we are of him.

    Best wishes, :drinks
    Daryl
     
  33. Daryl:

    Thanks for the great summary. I would love to get Jeff and Eric Lee's opinions on this subject. I e-mailed them. Maybe you can ask them also for us since I find this subject fascinating.

    I actually got to know Mert a little bit through my interactions with him at his seminars. You probably knew him better so I greatly appreciate your comments and insight. I am very much interested in how things developed in our profession over the last 50 years in regards to biomechanical knowledge, theory and practice and also am interested in opinions on how Mert Root and his colleagues shaped where we are today.

    Hopefully, also, this thread will be a good history lesson for those who never knew Mert Root and/or are younger than us (that's pretty common these days).

    Thanks again for your thoughts.:drinks
     
  34. DrLCT2

    DrLCT2 Member

    Thanks, Daryl & Kevin, for defending Merton Root's contributions.
    I only jumped into this discussion last weekend to say what Daryl included in his recent post; i.e., "Don't throw the baby out with the bathwater before you jump on the 'get-rid-of-Root' bandwagon!"
    All I said on my post was “If it wasn't for Mert Root, Tom Scarlotta, John Weed, and Bill Orien and their research, publications, and lectures in the late 1960's and 70's there may not be a field called "biomechanics" as we know it today!
    I was fortunate to be in the Bay Area, at the time, serving my general rotating internship and foot surgery residency at Highland in Oakland and feel I was VERY fortunate to be able to learn from these GREAT pioneers! Almost 50 years later and there's still not that much wrong with their theories and the biomechanical examination and NWB NP casting techniques they developed. The real problem is that most practitioners and clinicians have never been taught or learned the Root basics properly - resulting in each examination and casts being purely subjective to each examiner and leaving lots of room for lack of validity and reliability!
    And all of a sudden, several of this sites “Veteran Posters” jumped all over my butt! :>) Would it hurt so much for them to “step down from their ivory towers” and “give credit where credit is due”?
    Yours sincerely,
    "Lewis"
     
  35. Thank you for your comments Daryl. I've always found the use of the idiom above interesting since it has been applied multiple times to Rootian biomechanics, I think it's worthy of further analysis here.

    From wikipedia:
    "Throw out the baby with the bath water is an idiomatic expression and a concept[1] used to suggest an avoidable error in which something good is eliminated when trying to get rid of something bad,[2] or in other words, rejecting the essential along with the inessential.[3]
    A slightly different explanation suggests that this flexible catchphrase has to do with discarding the essential while retaining the superfluous because of excessive zeal.[4] In other words, the idiom is applicable not only when it's a matter of throwing out the baby with the bath water, but also when someone might throw out the baby and keep the bath water.[5]"

    In reference to the above, the Rootian model is assumed as the "baby", yet when the sieve of science is applied to investigate the Rootian model, it has more often than not shown the model to be erroneous and/ or flawed. I don't understand why we're assuming that there is even a "baby" in the bath in the first place until someone shows that to be the case. How do we know it's a "baby" and not just some flotsom and jetsam blocking up the plug hole as the science seems to indicate?
     
  36. Ian Linane

    Ian Linane Well-Known Member

    I'm sorry Lewis but I do not consider the veterans did jump all over you but, especially considering that some of those veterans have extensive knowledge of the history of biomechanics (not me per se), chose to place Root and colleagues into a historical context. Something that has been discussed many times before on the arena, so what you conveyed in your post was not new nor insightful. Neither did I interpret that as any more aggressive than some posts have been on this sites. If anything it was rather tame!

    By contrast those same quite knowlegable people being told "Boy, are you out of touch!" or that you would chose not to "enlighten" us again was something akin to picking up your ball and taking it home.

    Perhaps it is their highly knowledgeable base and understanding of the latest research that has contributed to their assigning an approach into a historical context and possibly into history. Time will tell. This is not the same as throwing the baby out with the bathwater but more a recognition that baby has grown up and moved on.
     
  37. toomoon

    toomoon Well-Known Member

    " How do we know it's a "baby" and not just some flotsom and jetsam blocking up the plug hole as the science seems to indicate?"

    Thanks for my first good belly laugh of the day Dr. Spooner.. looking forward to catching up at BSS..!
     
  38. wdd

    wdd Well-Known Member

    I've probably said this before, I've certainly been intimating this in my lectures for the past 15+ years: I honestly believe that having reviewed the literature, the publications of Merton Root set back the development of podiatric biomechanics in the UK by 20-30 years. Despite the over-statements of it's abstract, this PhD thesis appears to add support to my point of view.

    Before R, W & O'R's Vol. 1& 2 of Normal & Abnormal Foot Function plus Scarlato's Compendium of Biom. arrived in the UK about 1980 there was no podiatric biomechanics and there was little/no sign of it developing within the UK profession.

    For me the problem in the UK at least was not with the new information but with the professional environment into which it was introduced. The profession of podiatry at that time was slowly moving towards degrees. The intellectual criticism that should be associated with degree study was therefore understandably lacking. The books were therefore read as inerrant holy books rather than as simply an accumulation and synthesis (best guess) of 'all' current thinking and research, ie as a basis for future thought and research.

    The fact that thirty years after the introduction of these texts podiatrists are still banging on about them, in this way, suggests that in reality not much has changed.

    Bill
     
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