Is SALRE a "Single Axis Theory"

I just attended a demonstration from the man himself. He drew little ‘x’ marks on the bottom of the foot and drew where he found the axis.
He never drew where the thought the axis should be or would need to be.

Certainly orthotics can influence posture. Posture in the foot is directly related to the geometric shape of the plantar surface of the foot. We make a cast when the foot is in MASS posture and with soft tissues evenly compressed. That yields a certain geometry, which is the correct shape of the orthotic.

What do you think should determine the shape of an orthotic? The guy with the trowel of plaster adding fill to the plaster positive: does he decide? It is the same thing when it is done in the software. Fill is fill.

We will discuss at length the moment created by the COP in a few days. That is a whole thread to itself.

Because I believe Posture Controls Function.

Patience Grasshopper.

 

The concept that posture drives function is a universal truth not debated in all of orthopedics, physical therapy and chiropractic. I've been an orthopedic outpatient PT for 27 years and I found it one of the easiest concepts for my patients to understand when addressing their neck, shoulder, back and knee problems. It is truly odd that podiatry, a subspecialty in orthopedic medicine, seems never to use the term, even though it's core subject is at the foundation of the orthopedic chain and the foot's common postural faults cause so many difficulties for itself and well up that chain. We state commonly that the foot cycles through two opposite postural states, pronation and supination, that re-supination is often difficult to achieve. Yet Eric asks why Ed thinks posture is so important. You might as well ask why framing is so important to a house and why should things be level. Seriously, you doubt it is important?

 

Struck a nerve Ed?

Getting personal is fine with me but now you've stepped over the line. You have written some of the most petty and despicable diatribes I've ever read here on PA because you couldn't convince anyone that I can recall contributing to this forum that your theories had any weight. You still cannot, instead you continually attack Kevin because he is credible. In fact you perpetually verbally evacuate your bowel all over the whole of the rest of us when you run out of the poop du jour pet ideation to explore to prove everyone else wrong and you correct. That is your entire modus operandi, don't feign scientific knowledge or interest now. We disagree with your theories so we are sheep, we use a method other than MASS so we have drunk Kool-Aid. It's tiresome Ed and it is insulting.

Apparently if someone questions your ideas and motives they are automatically incapable of evaluating things for themselves? Talk about narcissism Ed. You started this pettiness and perpetuate it, turning offensive and mean when frustrated and backed into a corner.

In one thread you resort to pettiness and name calling, in the next you're a paragon of virtue and professional ethics. Perhaps you're bipolar or have manifest some organic illness that prohibits you from a) interacting in a professional manner consistently b) discussing rather than name calling c) accept that despite your expansive ego, you have not discovered anything new or of interest to the learned.

I don't claim to be an expert and I keep an open mind. I think for myself. I evaluated your system and disagree with it for many patients. I wouldn't waste my time discussing biomechanics with you or your employees because even if presented with irrefutable evidence to the contrary, none of you would ever accept that evidence because you are too financially invested to be objective.

I know a lot of DPM's and none of them behave in the manner that you do, they are in fact professional and respectful, admired by their colleagues and patients. Anyone reading this can search any previous post on MASS and see that I have asked you questions in the past and participated at which point you declined to answer and resorted to name calling and insults.

Anyone reading this: Please do not judge all Podiatrists by Ed Glaser, DPM. Most can carry on an intelligent conversation and keep the debate relevant. They are committed to the advancement of pedal biomechanics, conduct unbiased research, publish peer-reviewed studies, many have a clinical practice and serve their communities. They do not sell their colleagues out to competing professions, train massage therapists and foot store chain owners to sell their products....you get the idea.

Enough Ed. Don't respond. You and I are finished, I will sit back and enjoy the show. You'll snap eventually and resort to your real self.

 

However, posture is a term that is not used in the international biomechanics community. Don could you educate us on the definition of posture. It sounds a bit like alignment of the anatomy. I might agree with you about posture if I knew what you were talking about. That is why I asked Ed about his definition. He didn't answer.

When you wear the white coat, patients will want to believe you know what you are talking about. Patients will say that bloodletting and STJ neutral position will make sense when you use those terms to explain their pathology. So, when you say that it easy for a patient to grasp the concept, they may just be nodding their head yes just so they can get on with the visit.

Tell me if this example is something that you would consider a postural problem. A patient has bowed legs with genu varum. The alignment is not straight up and down. You could say that the alignment is bad and this person has bad posture. But why do they have pathology. If they get medial compartment knee arthritis you can say that it is caused by bad posture or you could say it is caused by increased frontal plane bending moment at the knee causing increased compressive forces at the medial knee. You could even say that the bad posture causes the increased medial compressive forces. However, the point is you need to explain why the "bad" posture causes the pathology. And to do that you need the physics or biomechanics. So, is your definition of posture a less precise description of the word biomechanics?

So, you think posture is a universal truth. At one point in time it was universal truth that the earth was flat. You should be able to explain why universal truths are thought to be so. For example Newton's laws have been found to be true through extensive experimentation (as long as you don't get near the speed of light.)

you said:

"Yet Eric asks why Ed thinks posture is so important. You might as well ask why framing is so important to a house and why should things be level. Seriously, you doubt it is important?"

Humor me, and tell me your justification for why posture is important. The argument that it's obvious the earth is flat, everyone believes it; is not a good one.

Eric

 

Posture refers to the habitual 3D relationships, both static and dynamic, of skeletal bones to one another that either promote or detract from optimum function (defined as the least energy expenditure and tissue stress required for an activity). One classic example is forward head posture, something which a good many of you reading this right now are probably demonstrating since computers tend to elicit it. An average head weighs about 16 pounds. For that weight to balance well on the neck vertebrae without excessive muscle strain to the cervical paravertebral and shoulder muscles such as the upper trapezius muscles (to name only a few) and many supportive ligaments, the head must remain aligned with the shoulders and thoracic spine in the sagittal and frontal planes. But in most of us, especially with age, the head drifts anterior of this position for a number of reasons: our work draws us forward as we watch what we are doing; computer monitors draw us forward as we move closer to read things. As this tends to become habit, muscular recruitment patterns change to reinforce the behavior: anterior neck muscles become weak from disuse; posterior neck and scapular muscles become tight and overused. The pattern is self-reinforcing and generally rigidifies with age. That's why so many older people are slumped forward with their heads well in front of their chests. This causes eccentric loading patterns on the lower cervical discs and why C5-6 and C6-7 disc herniations are by far the most common. This is also why OA is so common at the cervicothoracic junction and why people spend small fortunes trying to rub and medicate all the trigger points in the affected muscle groups. It is all avoidable, though, short of the odd traumatic accident, were people to learn and focus on tucking their chin, sliding their head posterior, using head supports in cars in such a position. In short, practicing good posture. The shoulders (glenohumeral joints) also are very negatively affected by this posture because with forward head posture the shoulders drift too far anteriorly as well, putting much more strain on the rotator cuff muscles, acromioclavicular joints, resulting in tendonitis and OA. Trust me, these conditions and their precipatory causes, unlike a flat earth, are not imagined. This is common sense leverage stuff, anyway.

Or the low back. One of my favorite demos for a patient was this: I handed them a stick with a weight on top; hold the stick straight up and down, the weight was managable; let the weight start hanging forward and the strain on the hand and wrist was obvious and uncomfortable. This is why you keep you back straight when you lift.

In the foot, posture also shows a clear pattern of devolvement towards a flattened arch, thanks to the relentless force of gravity, hard floors that create a perfect environment for overstretching ligaments leading to tarsal hypermobility, the prevalence of obesity and sedentary living (muscles not trained or used to help support the arches of the foot). I'm not aware of anyone, unless reformed traumatically, gaining in arch height as time goes on. With arch flattening comes higher re-supination resistance and loss of optimal re-supination prior to forefoot loading. Loss of re-supination means we now bear weight on an increasingly unstable forefoot with all the attendant compensations that lead to bunions, metatarsalgias, neuromas, FHL, etc. Should I go on? So if there is a way to restore a functional posture to the foot, that should be a more primary and effective way to avoid foot pain and deformity rather than cushioning, padding, otherwise offloading tissue stresses/strains to the collapsed foot architecture. That is what MASS theory states. It has yet to be proven just how much any one person's posture can be restored with this approach, but I have experienced the change to my own very flat, flexible feet (more in terms of knee relief than the foot) and have seen it work very well on many different patients since 1996. For over five years I used MASS devices on the lineworkers at Nissan, a tough foot environment due to prolonged standing/working on concrete for often 60+ hour weeks. Many of these had conventional custom orthotics that were not getting it done for them, too.

I brought the postural concepts to Ed because it fit the MASS model and mirrored all the other orthopedic areas that suffered from poor posture that I'd been treating for decades. Podiatry should take on the postural problem of the foot rather than focus on making poor posture more pain-free.

 

Don I´ll read you post again but I have a huge problem with the term Posture.

If for argument sake we have a patient who you decide has bad foot posture, and I´m in the room with you.

My 1st question to you will be how do you define normal posture?

How is this patient posture not normal?

and then I´m going to ask you when during the gait cycle is the posture normal and abnormal ( as I guess we can agree that the foot changes shape during the gait cycle)

and then after that well there will be more questions, but maybe we can start with that.

 

Don a quick point: SALRE is used to describe STJ axis location and Rotation Equilibrium buts its part of Tissue stress theory and while SALRE can be discussed in isolation it is only part of a treatment approach.

So in reality if the purpose of this thread is to look at a two different approaches to treatment it should be MASS and Tissue stress ( which would include SALRE)

 

The original quote was:

A straw man argument is when you mis -state an opponents position and argue against the misstated position. I mis-read your post when I first looked at it. I'm still not sure what you were saying about kinetic force distribution, so I'm not sure if you are characterizing SALRE at all. However, in the past you have made inaccurate characterizations about what SALRE is and then proceeded to attack those characterizations. In this thread you have been focusing on the importance of a single axis. We have been trying to anticipate where you are going with this. (SALRE is a subset of tissue stress.) So, I don't see the reason for the emphasis on the single axis. Why do you care if it's a single axis or not?

So, Kevin draws a line on the foot. Why should he draw the line in a location where he thought it should be? He should draw the line where he thinks it is. When you calculate moments about an axis you should use the location of the axis where it is, not where you think it should be.

This shape will work for some people and be painful for others. So this one method cannot be correct for all people.

Ed, what do you mean by posture. Could you translate that into anatomy and engineering terms?

I don't think that I can accurately predict what the best arch height is for each individual. I am sure that some feet need more fill than others. I am also sure that more than one arch height will relieve symptoms. Relief of symptoms is what patients care about.

Eric

 

I've got a rather busy day today and I won't have time to dispute every point I disagree with. However, the high points...

Of course it is. So is neutral. But my question is, is it true to say that regardless of pathology, assessment, history etc, you advocate simply casting everyone in the MASS position?

Well Excuse the F*** out of me!! I think you'll find that there IS disagreement. From me at least.

I think I see where this is going. I suspect Ed and Don are trying to make the following point. That foot function / treatment / pathology etc is concerned with foot posture, which incorperates lots of joints and lots of axis. That MASS consideres all of these and SALRE considers only one facet (the sub talar joint axis) and thus MASS is a better model. Is that the point you are trying to make?

If so, then once again I say you are comparing apples and oranges in comparing a clinical model / protocol to a study on a particular part of that whole.

If you really are keen to find an opponent to the MASS model, the tissue stress paradigm would be much more appropriate.

And consider this. If SALRE WAS a clincial model in the complete sense, and it was a single axial model then a SALRE insole would technically have no bulk whatsoever lateral to the axis for most people. If it was a uni axial model then logically one would simply put a huge amount of bulk medial to the axis and nothing more.

Obviously that is not the case.

 

So nobody misses this important point, see bold from Eric, Robert and myself

So just to make it clear as the 3 of us have just highlighted the same point.

SALRE is a part of the tissue stress paradigm

 

morning all,
i dont really want to deflect away from the subject and talk about individuals but heres my tuppence. i dont know ANY of you people. i take people as i find them at face value on here. My honest assesment of the majority is that they are good well intentioned, helpful people who are trying to improve the knowledge base and evidence in podiatry which ultimately will make me a better clinician (hopefully). i have agreed with some and disagreed with others but rarely thought " he is a tool".
However Ed you have managed to to be the first - well done. From what i have read in the previous cancelled post and this one, you are a destructive, negative force who is doing nothing to improve anything and is only interested in your own nefarious gains.
Ignore or dont ignore the personal attack, not really interested.
cheers
JB

 

Don't be daft, JB - he's priceless! Ed and Dennis are to podiatry what Don Rumsfield and Dick Cheney were to military planning. The only difference being Ed and Dennis don't kill anyone!

 

As usual NO Substance just Persnoal Attacks: Ingonred

 

Extremely well said, Don. I give much credit for our realization that Posture Controls Function to Don. Because of his extensive experience treating and studying full body posture....the podiatric profession can benefit greatly from his ideas. I agree whole heartedly.

Ed

 

I honestly believe that question ("how do we define normal posture?") is the one that has been begging to be asked and answered since the dawn of our attempts to help the ailing foot (non-traumatic).
But first, let's address the "we have a patient who you decide has bad foot posture" statement. The patient, not I, has decided to seek care for a problem (maybe they know it is foot related, maybe they don't) because nothing motivates people to see doctors like pain. If they exhibit foot deformities or calluses of the usual sort; if their arches kiss the ground or conversely the forefoot inverts away from the ground and the arches are high; if they complain of pain in the foot; if the over-pronated posture of the foot relates to observed valgus and internal rotation at the knee (and which corrects during relaxed stance when the arches are supported) –these are the clues that the foot is not functioning properly due to postural faults. But feet can look OK without obvious deformity and yet still there is a complaint like plantar fasciitis. You tape their arches into a more supinated posture and their symptoms improve. That foot would likely benefit from a more supinated posture induced by an orthotic (or they could opt to tape their feet fresh every day –not likely). Because the extra supination has a direct effect on the amount of fascial tension accruing at the calcaneal insertion. You could do injections, wear a heel cup designed for “heel spurs”, even undergo a plantarfasciectomy. But the comprehensive care would be to address the cause of the tissue stress (that does not remove the critical arch support function of the fascia as in plantarfasciectomy).
People have been trying to address the obvious structural faults in severe pes planus since Egyptian times. All one has to do is look at a bad case of flat feet and there is little wonder about whether there is a postural issue. The real question, though, has been how do I change the structure of that foot and to what degree and with what support shape? That question has been answered historically with a lot of guess work. Royal Whitman is a great example. Intuitively he felt we just had to restore (more supinated) posture to the foot, but he guessed at the amount and used a horrifically uncomfortable device to do it. His failed experimentation drove a lot of practitioners away from aggressive, high-arched devices and that stigma is alive and well today. But the problem was not the aggressive/high-arched strategy. The problem was he guessed. Individual foot anatomy and morphology is way too varied to simply guess at a means of affecting it. And feet do need to be able to move into some pronation with impact, so you can’t use thick steel plates or blocks of wood that don’t move.
If you look at stance phase gait, we do know that the foot should heel strike in a relatively high degree of supination, allow some pronation, but not so much that re-supination is compromised. So if a foot is over-pronating as so many do, how much correction do you give that foot towards supination, in what shape and with what amount of corrective force? Ed Glaser took a stab at answering that in the early ‘90s. But rather than guess at the target arch height, he used the foot itself, capturing the amount of available arch height for that foot when it was impressed in foam (seated, semi-weightbearing), using the same order of contact as in gait (heel strike first, then the lateral foot, etc.). At the end of that sequence the heel and met heads were all on the same plane as the floor so that there was no inversion (over-supination) of the foot relative to the floor. Foot architecture and motion is extremely complex, but each foot is a 3D puzzle that solves itself when cast in the right way. No need to guess if each foot will tell you.
So that yielded both a functional maximum of supination and the custom shape of the individual foot (with the added bonus of soft tissue compression by the foam, since these same soft tissues will be compressed against the orthotic with weight-bearing). But now how much force? He had to come up with some scheme that accounted for the variations in patient weight (how hard will that patient work at flattening the orthotic?) and foot flexibility (more foot flexibility means more supportive force is necessary and vice versa). Eventually that lead to developing a calibration algorithm to cover the full spectrum of possibilities. Because the device needs to flex some for comfort and function: refining just how much is still a work in progress but I think we are close right now.
He realized that the full contact nature of his MASS orthotic, supporting the foot in full MASS correction, also had the advantage of comfortable load distribution (force per unit area). So even highly flexible, collapsed feet (like mine) could be given a lot of supportive force without discomfort because the forces were evenly distributed (not concentrated) along the entire plantar surface. This design also minimized hot spots, places of concentrated shear forces, because there were no discreet pads or bumps on the surface of the orthotic and preventing excessive pronation also controlled splay and slide of the plantar foot along the orthotic surface. This same property of load distribution proved successful when dealing with more rigid, pes cavus feet, since these suffered a tripod loading effect that hammered small surface areas of the plantar tissues.
After I started collaborating with him in ’96, I pointed out that he was trying to control posture of the foot much like physical therapists like me strive to control head/neck/shoulder/back/hip and knee posture. Then we both realized how foreign the posture concept was to podiatry, even though, as I’ve said, I believe it to be the Big Question that had been haunting the hows and whys of noninvasive foot care forever. Historically, MASS has been more focused on the MLA in casting. I believe and press for during our discussions that the entire plantar vault is equally important, that we need to take care that the lateral arch is not obliterated with our casting technique. Because in the foot, the whole is more than the sum of its parts, and all the arches coalesce to give tarsal stability
This has been a very long post and I hope it has made some sense. I do need to address your question of where in gait the foot exhibits normal and abnormal posture. First of all, we are not talking absolute dimensions here: every foot is different. The majority of us probably lack enough supination at heel strike to help delay the onset of pronation, so that is abnormal. Then we over-pronate through midstance: abnormal. Then we cannot re-supinate enough to stabilize the first ray against GRF during forefoot loading: abnormal. Then the plantar fascia, over-tightened from the collapsed arch, restricts dorsiflexion of the hallux and we have a FHL: abnormal. In general, most feet need a supination boost. The more rigid, cavus foot has other issues and their lack of flexibility limits the extent of postural change possible. In most of those cases, force re-distribution and shock absorption is the key intervention. If the first ray can’t get to the ground adequately (rare), even we will add a valgus extrinsic FF post to assist this.
Is MASS methodology the answer to all non-traumatic foot problems? No, especially the fragile Charcot foot or the traumatic “train wreck” foot or the absolutely rigid pes planus foot. But the biggest part of the bell curve respond well and comfortably to at least our best attempt to improve foot posture. And Dr. Scholl’s orthotic kiosk can’t mimic what we do.

 

Just as in any paradigm. There is a goal, and ideal. For Root it is functioning around "neutral". For SALRE it is balancing the kinetic forces around the shadow of the STJ axis in the frontal plane with wedges and mods. For MASS it is giving each patient and orthoses that reflects the geometric shape of the foot, with the soft tissues compressed at the highest arch that they can comfortably accept at midstance with the heel and forefoot on the supporting surface, going full contact to more evenly distribute the corrective force and applying a calibrated corrective force and flexibility to encrouage the foot into a more functional foot posture for ambulation.

How is each patient's posture not normal? To the degree it is functioning inefficiently and creating deformities, pain, disability, injury etc. it has deviated from an ideal posture. MASS posture is not a desired posture for the foot. It is the posture that yields a geometric shape that begins its functional control or application of a corrective force at the earliest point possible within the postural ROM to add as much functional change as is possible with their anatomy. MASS is the correct posture to capture the most corrective geometric shape because it decreases impact and shear forces....and to some extent acts as a plastic leaf spring to support the all of the joints of the foot into a more efficient posture. In short....it works.

There are many measurable indicators that a person's foot function has changed for the better. O2 consumption, BEQ, I believe that Mike Piernowszki has a new validated method that is even better. I may ask Leslie to give the reference. It is in some engineering journal. Forefoot abduction, navicular differential, knee rotation, are among some of the many kinematic parameters.

I hope that is useful.
Ed

 

This has been good education, I appreciate it. Thanks

 

Don there some terms in there like over-pronation which get under my skin and there will be others who may want to bring it up -I´ll not bother but just make the statement - I know what you mean but don´t like the terms.

Alot of what you say fits into the tissue stress way of thinking but explained differently using mechanical terms - but using tissue stress Ive got many more options.

1st Motion does not lead to injury force on tissue does.

So when the patient comes in and a diagnosis is made ie what tissue or tissue is stress, then a treatment plan is made to reduce loads on said tissue.

The device may have a high arch, it may have a flexiable shell, it may have a FF Valgus post.

It may have a lateral skive and very low arch it may be very stiff - It all depends on what I beleive is the best way to reduce loads on the stressed tissue. You get what I mean.

So I have many, many options the device you describe above is 1 option Not the only one, and this is why MASS and only MASS doesn´t work for me.

By using tissue stress approach Ive got options, Root device, Medial skive, Blake, Mass etc all designed to increase external supination moments. With tissue stress I can also pronate the foot to reduce loads, Mass doesn´t allow this.

And that is why there is some much debate A bag full of options v´s one- I´ll take the bag. The other great thing with the tissue stress approach if the patients not improving or has pain in another area, I´ve got options using orthosis - with Mass it appears to me 1 strike and your off to the surgeon.

So I don´t have problem with Mass I´ve a problem with Mass for everyone.

 

Ed most of my reply to you will be the same as my reply to Don.

Basically 1 option Mass type device verse many options to reduce loads on stressed tissue, including Mass type device . Many options better = Tissue stress approach much more flexiable.

I don´t think anyone has said Mass type device is wrong I think they have said Mass type device is not right for everyone. I beleive this sentance to be the crux of the issue here.

Do you or Don beleive there is such times a Mass type device is not the correct device to be used ?

 

So posture is biomechanics. I will agree that assessing the mechanical properties of anatomical structures is important and engineering concpets are necessary to do that.

I don't have to trust you on the explanation of the above. I can explain your observations with free body diagrams and force vectors. It's more scientific than calling it posture and common sense. Although it is common sense, or should be.

You can explain this with the use of center of pressure and center of mass. Center of pressure under the stick is an upward force on the stick. Gravity creates a downward force at the center of mass and stick. Since most of the mass is concentrated at the "weight" at the top you can consider the center of mass to be at the weight. When those two forces point at each other there is no force couple. When the upward force on the stick is not aligned a force couple is created. The magnitude of the moment from the force couple is equal to the perpendicular distance from the line of action of force.

I've used the mass and stick model to describe the task of standing upright. I'm well aware of it.

Don, have you read my paper?
Fuller, E.A. The Windlass Mechanism Of The Foot: A Mechanical Model To Explain Pathology J Am Podiatr Med Assoc 2000 Jan; 90(1) p 35-46

In that paper I explain the forces that cause arch flattening. It's not just gravity, it's the combination of gravity and ground reaction force. So, what you call the clear pattern of development can be, and has been, explained by biomechanics. Is your concept of posture biomechanics without the mechanics?

The increased resistance to supination can be explained by SARLE. When you just think posture you just accept that posture affects supination resistance without explanation. However, with arch flattening there is also talar adduction and medial shifting of the STJ axis. If the STJ axis shifts more medially than the center of pressure does you will get increased pronation moment from the ground and this why supination resistance is greater.



Yes, you should go on. You should explain how "posture" or loss of resupination makes the foot more "unstable" and causes all of those things. And while your at it, provide a definition and measurement for the term unstable. My paper gives an explanation of bunions and plantar fasciitis and that explanation can be connected to SALRE.

Now we get the crux of the problem I have with MASS theory. How does a MASS orthotic change posture? A foot stands in a certain position without an orthotic. You are claiming that when the foot is standing on the orhtotic the position changes. What forces are produced by the orthotic that change the position of the foot. Again, we have posture as biomechanics without the mechanics.

I've worn MASS orthotics. They make me more painful than shoes alone. My less high arched devices make my foot more comfortable than no orthotic or the MASS orthotic. There is a too high.

Eric

 

I am completely on board with the tissue stress model, as is anyone involved in orthopedic care of the human body. I definitely do not agree with your point that quantity of options beats quality. If that makes you feel more free then, well, go for it. If I know I have a methodolgy that minimizes the most possible tissue stresses and simultaneously improves foot function, I'll gladly trade freedom of choice for that any day of the week. I only care about the results. If you can get better pain relief and function doing what you do, by all means do it.

 

how would you treat medial knee pain with an orthotic device ?

edit would you us a Mass type device?

 

So would you agree there nothing wrong with SALRE being a single axis model that can be combined with tissue stress to make an orthosis.

So, you agree that the SALRE should work. I've got no problem here.

Can you provide a situation where the SALRE model does not apply. I gave an example of PT dysfunction where SALRE applies and second metatarsal stress fractures where it does not apply. Is this what you mean? Can you provide an example of SALRE not working?

I described how SALRE explains this effect in an earlier post. We're not saying that MASS orhtotics don't work. We're saying they don't work for everyone because there is a too high of an arch.

So Ed, on average how much sooner does a MASS orthotic stop pronation? Is pronation stopped by muscular activaty caused by pain avoidance, or is it a direct supination moment from the orthotic? Is it the same for all people?

Where is the criticism of SALRE? I have seen nothing in this thread that says it doesn't work. If the STJ is pronating after heel contact, something has to stop it sooner or later.

Cheers,

Eric

 

Of course any posture can be analyzed in mechanical terms -was i disputing that? The issue was the importance/relevance of posture in the foot or other orthopedic regions. My point was you can enginner all kinds of mechanical forces to try to offset tissue stresses wherever they occur, it is just easier and more efficient if you pay attention to bony alignment relative to gravity and to themselves (posture). If I were in the habit of holding my arm forward in front of me and I went to a provider complaining of pain in my rotator cuff, he could tell me to relax my arm by my side (posture) or devise an ingenious set of braces to change the tissue stresses on my shoulder. Relaxing the arm to the side makes alot more sense, easier to comply with, and more likely to yield good results into the future. So, in a way, practicing the benefits of good posture is a subset of Occam's Razor.

I'm sure I'm not the first to use that demo and ,again, of course it can be analyzed in terms of simple newtonian physics. Patients are generally terrible at grasping physics, though. I can tell them to keep their back straight or I can simulate what they are doing to their backs if they don't with the demo. Posture made tactile, sensible is all.

Come on, Eric, do you really think I don't get that the ground is part of the equation? Don't need a paper for that. Excuse me for being economical in my phrasing. From here on, readers, when I talk about gravity it is understood that there is something else (ground, solid object) pushing back and squeezing the body between them.

If I change the posture of the foot, I don't need to worry about the relative position of the STJ. Do I really need to explain that lifting a fallen arch, aka supinating it, will change supination resistance. Craig's paper on it showed a direct correlation of the amount of supination resistance with the amount of arch flattening (pronated posture).

OK. When a foot fails to re-supinate the tarsus remains too flexible in loose-packed position/posture. This has a direct effect on the metatarsals as well, the most important of which for function is the First. With forefoot loading an unlocked first met will travel in the direction of dorsiflexion and adduction thanks to GRF. Now the first met's ability to accept the majority of FF loads is compromised with a number of potential diagnostic sequelae (bunion, metatarsalgia, neuroma, tailor's bunion). I can't give an absolute measurement or definition of unstable: it is a relative state with biomechanical consequences and a matter of degree. I'm sure you can explain it in terms of SARLE, but my point is that SARLE is just another, I would add superfluous, term that correlates directly to posture. But addressing SARLE is done with a collapsed foot, yet addressing the collapse is the more primary and efficient intervention just as in the postural example given above.

It is really very simple. You elevate the tarsal anatomy of the foot with a properly casted and desgined support. just like during the supination resitance testing with the sling under the arch pulling it upwards, supinating the foot. Posture already includes the biomechanics: you can't change posture without affecting mechanics. There is no logical or practical separation.

I would not wear anything that hurt my feet, either. We can agree on that. Some feet, generally the more rigid ones, need to be elevated in stages, though that is relatively rare. I think Ed cast you. Did you work with him on that?

 

Most medial knee pain related to the foot comes from arch collapse/over-pronation/pick your term for the foot you see puddling out to the floor. This tends to transfer a medial rotation up the leg and increases valgus at the knee. The resultant eccentric postion of the knee joint causes eccentric joint and medial compartment loading which generally results in OA, muscle weakness/imbalance, pain, inflammation.

I would use a MASS device because it would do the best job of altering the postural set of the foot, derotating the leg and putting the knee back in the sagittal plane where it is happiest.

 

Don got a thread for you to read http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=867 it appears lateral wedging is the way to go, this can be explained using tissue stress .

Have a read and you can see why more options is better than 1

 

I had a patient referred to me once with a prescription for a lateral wedged orthotic for her medial compartment OA. Her feet were already significantly pronated in relaxed stance, so lateral wedging would have encouraged more. I convinced the referring MD to let me try a MASS device and she did quite well, in spite of being rather end-stage OA. It helped her put off her total knee surgery for a few years. So, according to the article cited, my extra medial support should have made it worse which it clearly did not. I see that Kirby talked about using varus/medial wedging for medial compartment relief as well. Maybe I'm just a babe in the woods, but I have never seen a case where increasing pronatory forces in an already over-pronated foot make anything better. i have used a lateral/valgus wedge under the forefoot, though, for a cavus foot with insufficient first met contact with the ground.

 

You've been wanting to do that for a while, haven't you Mike .

As my rt hon colleague points out, there is something of a flaw to the logic being promoted.

This sounds plausible, even logical. It is, however, not true. There is COPIOUS evidence that Medial knee OA is treated best with a LATERALLY wedged orthotic. And indeed a solid rationale, based on the RE bit of SALRE for why this should be the case.

Unfortunatly the myth of "pronation bad, supination good" is still alive and well.

No, it would'nt. It would actually increase Adduction moments in the knee and worsen the condition.

Of course you can read the above and say I'm talking rubbish. Which may be true, its a statement made with only sketchy evidence. But then, so was yours! Claims made like this are worth precisely eff all.

No its not. The forces around the Sub talar joint are always balanced by definition. How do you balance something already balanced? Either you've expressed yourself badly or you've missed the point of the application of SALRE in the tissue stress model.

No, go back.

One of the clinics I do has a high proportion of afro-carribean patients. They have, almost to a one, "flatter feet" than caucasian feet. And yet most elite sprinters are from this group. And I don't notice that there is a particularly higher prevelance of the sequelae you mention among them in later years.

Look at hussain Bolt. Feet like pancakes. Fastest man alive. Unstable forefoot? Poor function? I think not.

You just can't generalise like that without supporting it. Flat feet do not equal bad feet and high arches don't equal good feet.

This, I think, is key. If we all agreed that flat feet were the root of all the evil in the world then MASS makes perfect sense. I for one don't. You just can't generalise like that as Mikes illustration of medial knee pain illustrates rather neatly. At least one, solid, evidence based case where pronating the feet MORE actually HELPS.

 

Thats why we have research Don. Go read some. Its not just "the article cited". Its lots. and a meta-analysis.

My anecdote trumps your anecdote is futile.

 

Heres what Kevin Kirby wrote in the thread I linked.

So not sure where you got that from Don, also there is tons of evidence in peer review journals re rearfoot Valgus or lateral posting and medial knee pain. Have a read it´s very intersting stuff.

 

Little while, love EBM

 

Thanks, Robert, for the arrogant heads up. Research, you say? Let me write that down. Stupid me, thinking anecdotes told the whole story. My bad.

 

Really, can you show me within Kevin's peer reviewed articles where he admits that SALRE is not in itself a paradigm but just a small piece of the tissue stress model?

I am having a hard time finding it in any of the aforementioned articles.

We will get into the misapplication of tissue stress later. I have a lecture to go to this evening as stated earlier.
Bye for now,
Ed

 

I quote from Kirby's post:
"I have successfully used lateral (i.e. valgus) wedging for lateral compartment knee osteoarthritis (OA) and medial (i.e. varus) wedging for medial compartment knee OA for about 15 or more years in my patients."

 

There is also some evidence that long term benefits are questionable.........

Reilly KA, Barker KL, Shamley D. A systematic review of lateral wedge orthotics--how useful are they in the management of medial compartment osteoarthritis? Knee 2006 June;13(3):177-83.
Abstract: Studies on the use of lateral wedge orthotics in the conservative management of medial compartment osteoarthritis are widely quoted. This approach, however, does not consider the disruption of the interaction between lower limb and foot and ankle function that lateral wedges would produce. This comprehensive, systematic review was therefore undertaken to evaluate all available literature to determine whether evidence exists to support their use. MEDLINE, EMBASE, CINAHL, Allied and Complimentary Medicine, PubMed, EBSCO HOST and PEDro, Abstracts of Reviews of Effects in the National Electronic Library for Health for Cochrane Reviews and manual searching were used to identify studies. was searched for trials in progress. Data extraction was performed by the three authors using a paper data extraction form which was based on the CONSORT statement and Critical Skills Appraisal Programme (CASP) guidelines. Overall, the results of this review suggest that, based on current evidence there are no major or long-term beneficial effects with the use of lateral wedges

 

Hi Don,

Actually if you re read that thread properly you will notice that Dr. Kirby made a mistake and later corrected himself.

 

No problem buddy. Lean on me. :drinks

Its pretty simple really. If there is a solid evidence base for something, an anecdote of a single patient you saw once which went against that grain amounts to really very little. If I told you I'd given a patient a MASS device and it caused them a catastrophic lateral ligament strain how seriously would you take it? And thats just my anecdote vs yours. Rather than your anecdote vs mine and a sod of a lot of evidence.

You say much, Don, about causes, effects and what "we all know" happens. You confidently state what "causes" pathology. I'd have an easier time taking what you say as true if you smattered it with some more evidence and less anecdotes.

Can you show me where in this thread it was decided that this was about what Kevin thinks / has written about? We are talking about SALRE. Eric, Mike and I have all told you that WE use it as a part of the tissue stress protocol.

but since you're having a hard time, you also may lean on me.

This from an article written by kevin, on the tissue stress paradigm and how modeling (thats RE or SALRE) fits into the tissue stress paradigm.

Am I not like the santa claus of the arena today?

Hey Stu Nice to have the set.

No. There is a meta-analysis which points out that there is little evidence of long term benefit. Two things. Firstly, as Ed points out so often, lack of evidence is not evidence of lack. Secondly, there IS evidence for benefit over the length of most of the studies. The only evidence I've seen for MASS insoles is the Trotter study. Would you like to examine the long term benefits of MASS from that?

Same rules for everybody. Compare the Trotter study to the lateral wedging studies, then tell me about the "questionable" benefits...

But lets not be having the bait and switch boys. The point was, evidence which shows benefits (in some conditions) for pronating the foot shows that pronation is not universally bad and supination not universally good.

 

http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1248&context=etd
The effect of arch height on tri-planar foot kinemetics during gait

No association was observed between foot structure, as represented by arch
height, and foot kinematics as represented by excursion or coupling during the stance
phase of gait. This surprising result provides no evidence to support the assertion that
foot structure influences mobility during gait in individuals without foot pathology.

http://www.jbiomech.com/article/S0021-9290(96)00136-4/abstract
The relationship of static foot structure to dynamic foot function:

We conclude that, in normal subjects, only about 35% of the variance in dynamic plantar pressure can be explained by the measurements of foot structure derived from radiographs. This implies that the dynamics of gait are likely to exert the major influence on plantar pressure during walking.

The concept of foot posture as controlled by orthoses I recalled seeing in the following article by Stu, Don and Ed that I was able to find.

http://www.lowerextremityreview.com/article/active-stance-orthoses-functional-relevance-of-the-arch
Active Stance: Orthoses – Functional relevance of the arch

This concept is illustrated by studies of the cervical spine, which have demonstrated that changes in joint position and moment arms affect the moment generating capacities of muscles,1 and that posture has an effect of motion coupling.2

2. Panjabi MM, Oda T, Crisco JJ III, et al. Posture affects motion coupling patterns of the upper cervical spine. J Orthop Res 1993;11(4):525-536.

I do have some sympathy for the idea of posture as a chiropractor but I feel it has been misapplied because the study you reference by Punjabi includes motion segments of the spine which contain a spinal disc. Stu asked for a citation supporting Graham's statement and two are offered for digestion, at which point we can explore the postural claims made by the SS team.

regards,

 

My word. Evidence .

 

Ed come on mate we were having a nice discussion. As you also know alot of Kevins writing is in his books, the Chapter on tissue stress that Eric and Kevin wrote is coming out I think next year, so because he discussed SALRE in some papers about SALRE does not mean it´s not part of tissue stress approach to patient treatment, it is part of tissue stress .

Don I have enjoyed the discussion. two different ideas, discussing .

As I said earlier SALRE can be discussed on it´s own but is part of Tissue stress.


and the other major point is this.

I don´t think anyone has said Mass type device is wrong I think they have said Mass type device is not right for everyone. I beleive this sentance to be the crux of the issue here.