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Is There Such a Thing as SALRE Orthoses?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Dec 9, 2008.


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    Is There Such a Thing as a SALRE Orthosis?

    Simon, you were right on then and still are right on, you punk rocker....you!

    I needed to publish the SALRE paper the way I did since a longer and less-focused paper would not have been accepted in JAPMA for publication. Those who have read and understand my other publications regarding the other joints of the foot and lower extremity and on orthosis design, as Simon, Eric, Craig and many others on this forum have, don't seem to think I am fixated only on the subtalar joint. That notion seems to come only from those who have not read my other papers, or choose to not understand these papers. I believe that the ideas of rotational equilibrium (i.e. joint kinetics) and tissue stress can and should be applied to every joint of the human foot and lower extremity so that the clinician and researcher can gain a better understanding of the biomechanics of each of the joints of the lower extremity.

    For all those following along, I don't know what a "SALRE orthosis" is! I use some aspects from Subtalar Joint Neutral theory, some aspects from SALRE theory, some aspects from the Sagittal Plane Facilitation theory and some aspects from Preferred Motion Pathway theory in order to design orthoses using the goals of Tissue Stress Theory for my patients. I have made over 12,000 pairs of orthoses in my 23+ years of practice. I see between 20-40 patients a day in my practice. I evaluate and cast up to 8 patients a day for custom foot orthoses. In all those patients, I can very plainly say that I have never made a "SALRE orthosis". Theres is no such thing as a "SALRE orthosis".

    As Simon so nicely explains, foot orthoses need to be individually designed for each patient in order to achieve optimum results. Some need a high arch, some need a low arch. Some need topcovers, some don't need topcovers. Some need forefoot extensions, some don't need forefoot extensions. Some need varus correction, some need valgus correction. Some need to be more rigid, some need to be more flexible. Some need to have rearfoot posts, some don't need rearfoot posts. The permutations of orthosis design are limitless and anyone that tells you otherwise, implies that their orthosis design is the "best" or the "only true functional orthosis" and that orthoses need to all look a certain way to work the best, doesn't know what they are talking about.

    Thanks for bringing me out into the clear blue sky again, Simon.:drinks
     
    Last edited: Dec 10, 2008
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    It all comes down to definitions and terminologies. There are many different methods of negative model production (of which MASS is one); there are many different methods of positive model production and orthotic shell production. There are also many different prescription variables that can be incorporated into each of the negative model, positive model and shell production (of which the medial heel skive is one prescription variable).

    There are many different theoretical frameworks that can used to base decision making on when deciding on which of the different prescription variables to include in the negative model, positive model and shell production.

    SALRE is a theoretical framework that can be used to inform clinical decision making (so is the "Bottom Block Theory(TM)" that advocates the use of the prescription variable of MASS positioning for negative model production). SALRE, as a theoretical framework is useful when making decisions re the amount of a medial heel skive to use or not; it is also useful as a framework to explain the amount of forces that are seen around rearfoot motion (ie tissue stress theory)
     
    Last edited: Dec 10, 2008
  3. Thats what i thought!

    It worried me though when Ed kept talking about a SALRE orthotic. Thought i'd missed something.

    In essence Simon hit the nail on his head when he said that ALL orthotics are tissue stress orthotics. We agree that the goal of our orthotics is to reduce tissue stress in the affected tissues. Where we fall out is how best to acheive this.

    Thanks for the clarification.:drinks

    Robert
     
  4. EdGlaser

    EdGlaser Active Member

    Craig,
    You hit the nail on the head here. I would then think it would be useful to establish gradient scales. Two valued logic does not work here.

    One could establish a gradient scale between, for example, custom and prefab.

    One could have a gradient scale between flexible and rigid feet which would correlate closely to a gradient scale between possible change in foot function and accomodation.

    One could have a gradient scale between accomodative and functional, even though I believe both can be achieved simultaneously. This scale would correlate closely with a scale between kinetic and kinematic change. An accommodative orthotic would be one that allows the foot to pronate and then attempts to reduce terminal tissue stresses possibly through the balancing of forces and a functional orthotic would be one that made a kinematic change in the gait cycle by imposing forces that reposition bones thereby manifesting a change in gait.

    Foot posture could be put on a gradient scale between totally pronated and fully supinated. SALRE orthoses would be closer to fully pronated and MASS orthoses closer to fully supinated although neither reaches the extreme.

    Tissue stress reduction could be put on a gradient scale in many ways. In terms of timing of the application of corrective force. One variable in the reduction of impact or impulse is time. When the counter force is applied, where it is applied, with what force per unit area, is its application linear and certainly what moments it creates about all axes that it affects.

    Gotta go,
    Ed
     
  5. Ed:

    You obviously didn't read my last posting. There is no such thing as a "SALRE orthosis"!! Those are your words only, no one elses! The subtalar joint axis location and rotational equilibrium theory of foot function is only one of the important considerations that a clinician might use in prescribing orthoses and understanding how their orthoses might work in making the patient function more optimally, make the patient have fewer symptoms and preventing the patient from having other pathology. Please stop assuming that SALRE theory has anything to do with your preposterous assumption that I want patients to function "closer to fully pronated" with my orthoses.

    I am trying to be civil with you, Ed, since others are, rightfully so, getting very tired of all of this on Podiatry Arena. However, I will not let you continue to misrepresent what I have taught and written on over the past 23+ years without it being corrected. I have worked too long and hard for the podiatry profession to let something like that happen.
     
  6. Kevin,
    I just spotted the evolution of my name in the quotes within your post at the top of this thread.:cool:

    I do try to achieve this in chronic lateral ankle instability. That is I try to increase pronation moment, which may or may not limit extremes of supination motion. Hence we could say that we are making patients function closer to maximally pronated in such cases. But it is equally true to say the opposite in cases where I am trying to increase supination moment. Just depends what I'm trying to achieve.

    Agreed.
     
  7. EdGlaser

    EdGlaser Active Member

    Simon,

    Shame on you for nipping at Kevin's slip.

    Ed
     
  8. Yeah, great come back :sinking:. Don't give up the day job. You know what dog's are like when they get into the hen house with the chickens.
     
  9. David Smith

    David Smith Well-Known Member

    Ed

    Eh! WT#**!!#?

    Twas brillig, and the slithy toves
    Did gyre and gimble in the wabe:
    All mimsy were the borogoves,
    And the mome raths outgrabe.


    Are you competing, on a graded scale, with Lewis Carol? I believe your calibrated arch support is no more real than the Jabberwocky or the Snark. You are an illusionist without wit or scruple. You talk much and say little barring nonsense, squared. And yet I waste my time on you Doh!:bang:

    Apologies to Phil


    Luv Dave
     
  10. Agreed! How is it calibrated Ed? Calibrated for what?
     
  11. :D

    I thought that was quite pithy actually.:D

    So far as the gradient scale for foot posture i'm not sure that really works. To take pronation / supination as an example, how do we measure it? By maximum excursion? By time spent below a certain point on a curve? What of a foot which has a "normal" range but little effective supination moments going on until it hits a bony stop at sinus tarsi hotel. Certainly pathological but where would it fall on the scale. What of feet which are mobile but correct well vs feet which are in fixed supinatus? They might pronate to the same degree but are very different animals and require different treatment.

    Also you descibed it as pronated vs supinated posture. Does this not ignore the vital and oft neglected 4th dimension?

    Custom and pre fab are not diametric opposites. As Dr trotter demonstrated a 4mm flat foam and a high arch interpod (for eg) can both be described as pre fabs yet could not be more different. Could they be considered as the same point on any scale? Likewise customs range from UCBLs and SMAFOS, through to the simplest of simple (flatbed) orthotics.

    Also not sure what you meant here.

    I think that to characterise an accomodative device as one which effects only kinematics and a functional one as a device which affects kinematics is fallacious. I've issued freelans with holes cut in them to offload lesions which caused a kinematic change (planterflexing a met for eg). I also don't see how a device which ONLY effects kinetics, if such a creature exists, could be said to not be functional.

    Personally i think an orthotic is functional by definition. When i describe one as accomadative i am describing my intention rather than the orthotic's effect.

    This is all quite negative. I'm not trying to jump on you Ed, please don't get defensive, but respectfully, i don't think these are workable notions.

    Oh and re the SALRE orthotic thing, as kevin says the whole point of this thread is to demonstrate that such a creature does not exist. If i did'nt know better i'd think you were being deliberatly provokative. ;)Perhaps it would be more accurate and less inflammatory to refer to "orthotics with cast correction", or "traditional orthotics" or even " non MASS orthotics".

    That would be more accurate, and less likely to turn this into another Academic brawl!

    Whaddaya say, shall we try being nice to one another? It is, after all :santa:. Season of goodwill on earth and that.

    Regards
    Robert
     
  12. Whoops. Long post. Missed the last two.

    What say we start a fresh thread for the calibrated thing guys?

    Robert
     
  13. David Smith

    David Smith Well-Known Member


    Robert :good: you ole diplomat
     
  14. I try.:drinks . Had lots of practice ;).
     
  15. Go ahead. First, please define supinatus? You've talked a couple of times about a fixed supinatus. Like I said previously, isn't this an oxymoron? I thought a supinatus was a reducible soft tissue contracture, if so how can it be fixed? Isn't a fixed inversion of the forefoot, a forefoot varus? How are these different? Are you using congenital versus acquired to differentiate? Can a forefoot supinatus become a forefoot varus through bone remodelling?

    Just interested.
     
  16. To be honest i've never found a proper set of definitions! I always thought of Supinatus as an aquired inversion in NWB, Varus as the congenital and invertus as a supinatus which has become bony. I use fixed when i should perhaps use non correctable but its often damn hard to know if it is soft tissue or bony anyway!

    Also, can't use correctible can i? Cos i'm not sure what correct is! I just read a paper which examined 120 asympomatic patients and found a 83% (i think) of the feet were inverted at the forefoot from the perp calc (if thats even measurable) and the average forefoot inversion was 8 degrees! Which i have to say matches my experiance. So is a varus even i digression from normal? A condition? A description OF normal? I dunno any more! Reduceable is'nt much better, when does a varus stop reducing and become a valgus? Reducable to what? And that study was looking at forefoot to rearfoot useing a bisection of the calc. Which we know to be unrepeatable as hell (6 degrees -+ at best isn't it?)

    I remember when biomechanics used to be simple :boohoo:

    What we need here is a professor of life the universe and everything who has a pet peeve about FF varus. Know we of such a bird?

    Regards
    Confused of Maidstone.
     
  17. efuller

    efuller MVP

    The definition of functional is tricky. The definition of functional orthosis is often that it is meant to change position. I don't really like that definition. I would like the function of the orthotics that I give to my patients to be to relieve their symptoms. So, when folks use the term functional, they should expand a little more on their definition. I appreciate that Ed added some to his definition.

    Now on to the repositioning of bones and SALRE. If your orhtotic achieves a change in foot posture that includes a more supinated position of the STJ, moments are being applied about the STJ. Without an orthosis a foot will achieve a certain resting position. In gait, without an orthosis a foot will attain a certain dynamic position. In the case of the resting foot, an equilibrium is achieved with internal and external forces. Now when an orthosis is underneath the foot, and the foot is in a more supinated position of the STJ then the orthosis, or the muscles, have changed the moments about the STJ so that the different equilibrium position is achieved.

    So, if the repositioned bones include a more supinated position of the STJ, a subtalar supination moment has to have been applied by the orthotic, or something else, to achieve that position. Moments about the STJ axis are determined by the location of the forces about the axis relative to the axis. The location of the axis is important for determining whether the applied forces are capable of changing the position of the STJ. As others have said a MASS casted orthosis has to obey Newton's laws just as an orthosis with a medial heel skive does.

    Repositioning of bones = changing of joint equilibrium.

    You cannot reposition the bones of the foot because you casted the foot in a certain position and then made an orthotic from that cast. The piece of plastic under the foot has to apply the forces to the foot to get any change in the position of the foot. You can choose not to analyze those forces, but they are still there.

    Regards,

    Eric Fuller
     
  18. Just wanted to see if you were truly paying attention.;)

    And this is the whole point of why there is no such thing as a "SALRE orthosis". If the patient has a medially deviated STJ axis and a stage II posterior tibial dysfunction, then I might use a 3-4 mm medial heel skive, a 18 mm heel cup, a rearfoot post, minimal arch fill, balance the orthosis inverted 3-5 degrees so it has a fairly high medial arch contour for that patient. However, if the patient has a lateraly deviated STJ axis and has a chronic peroneal tendinopathy, I might use a 3 mm lateral heel skive, maximal arch fill, balance the orthosis 3-5 degree everted to make the medial arch very low and also use a forefoot valgus extension on the orthosis.

    Even though both of these orthoses use the concepts of SALRE theory in order to determine the optimal orthosis shape to improve the patient's symptoms and function, they will look much different from each other. The orthosis made for the patient with PTD and a medially deviated STJ axis is designed to increase the external STJ supination moments and the orthosis made for the patient with chronic peroneal tendinopathy is designed to increase the external STJ pronation moments acting on the plantar foot.

    Simon and others, I am just about ready to quit contributing to Podiatry Arena for now since Ed Glaser is really pissing me off (i.e. making me mad). After this much time and effort in trying to make a difference in podiatry for nearly half a lifetime, I guess I am just getting too tired of having to defend my theories to individuals whose motivations are very different from mine. Christmas is just around the corner and, in this special time of year, I feel I should be doing more important things that do make a positive difference in other people's lives.
     
    Last edited: Dec 11, 2008
  19. Cameron

    Cameron Well-Known Member

    netizens

    This thread should be compulsive reading for future students of podiatry and definately a case of "Look back in Angst."

    Time is the only healer here and I am far too old to care whether anyone has ever paid one ounce of attention to my procastinations on the mysteries of the metatarsals. Time will out of course and as they say everything comes around again - so maybe in a decade or so Kirbology will be reinstated, unquestioned and untouchable ;)

    Meantime its exciting to read all the emotive postings on podiatry. What a wonderful group of people we are to care with such passion. Keep it up I say.

    I know what I want for Christmas......... and that is a SALRE orthoses.

    Seasons greetings, Dudes and Dudesses.

    Pax
    :santa:toeslayer
     
  20. Being younger, and far more handsome than you Kevin I've already passed that milestone, I've been "doing podiatry" longer than I haven't. For what it is worth, I feel your frustrations and wish you and yours a peaceful Christmas.

    Acrobat- U2

    And you can dream
    So dream out loud
    And you can find
    Your own way out
    And you can build
    And I can will
    And you can call
    I can't wait until
    You can stash
    And you can seize
    In dreams begin
    Responsibilities
    And I can love
    And I can love
    And I know that the tide is turning 'round
    So don't let the bastards grind you down

    Best wishes,
    Rover (woof, woof)
     
  21. Asher

    Asher Well-Known Member

    Robert and Simon,

    Maybe the terms 'forefoot varus' and 'forefoot supinatus' as we have used them in the past aren't as relevant now with our new focus on stiffness. So maybe we should say stiff forefoot varus or compliant forefoot varus.

    Rebecca
     
  22. markjohconley

    markjohconley Well-Known Member

    Kevin, fair enough; and you, along with Simon, Craig, Eric and a few more, do make a difference in my and I gather a lot of other posters podiatric 'lives', mark c
     
  23. Cameron:

    It is nice to be recognized for having made a positive contribution to your profession within your own lifetime.

    When Santa makes the first ever SALRE orthosis, you will, Cameron, be the first to have one placed in your Christmas stocking. Until that time, I am glad to see that what normally occupies the inside of a baby's diapers isn't the same substance that occupies the inside of your new headgear.:rolleyes::drinks
     
  24. Mark:

    It is you, along with many others on Podiatry Arena, that make all the time I spend on this forum seem well worth the effort. Thanks for the support.
     
  25. Thanks for that, mate. Despite the fact that you have signficantly calmed down your evil punk-rocking twin that occasionally peeks out now and then, you have become, whether you like it or not, a respected member of the international podiatric biomechanics community.

    Anyone special that you have in mind that fits the "bast**d" category??:rolleyes:
     
  26. Lawrence Bevan

    Lawrence Bevan Active Member

    Indeed - "ne te confundant illigitimi" as my old latin teacher once told me.
     
  27. DTT

    DTT Well-Known Member

    Hi Kevin et al

    Your words and writings are followed THE WORLD OVER and are respected by the majority of those interested and or practicing biomechanics.

    To add answer your question to Simon

    ANY B**TED YOU WANT Kevin !!:rolleyes:

    If you give it up on here and elsewhere YOU WILL BE MISSED of that you can be sure.

    Christmas is a good time to reflect on ones position in life ?

    Perhaps your final decision will wait till then

    Have a good one:santa:

    And a peaceful 2009

    Cheers
    Derek ;)
     
    Last edited: Dec 11, 2008
  28. Phil Wells

    Phil Wells Active Member

    Kevin

    I know that there may not be such a thing as a true SALRE orthotic but the premise of applying a force either medial or lateral to the StJ axis was part of the evolution of a new orthoses we are currently in the process of manufacturing.
    The insole is pre-fabricated and allows a 15mm arch insert to be placed into a concavity in the shell. The arch inserts are varying densities and can be fitted into the medial and lateral arches. The original idea was to allow patients to control their comfort level but as we developed it we began to realise that that they were capable of applying varying degrees of resistance to the foot -i.e. supination resistance test - due to the variable loading of the ABS 'functional' shell = increased/decreased forces.

    This is definately no sales pitch but I would rather use something like this than the 'calibrated' (What a crock of S*$t) orthoses that are out there.

    Phil
     
  29. Interesting,

    I've been using a new device I developed to measure supination resistance with this idea in mind. The problem as I see it is extrapolating from static to dynamic supination resistance. You can use in shoe data to resolve this though.
     
  30. Phil Wells

    Phil Wells Active Member

    Simon

    I think that this problem was why this orthotic came to be - the only way to evaluate this specific patient response was to 'suck it and see' and then adjust the orthotic accordingly.
    This may be a bit cheeky but if you want to market this device than we may be interested in working with you to acheive it. I am responsible for R & D so I have to ask!!

    Cheers

    Phil
     
  31. Sure, still fairly crude at the moment, but give me a couple of weeks and it'll be there or there abouts.
     
  32. Phil:

    Like music to my ears....I'm getting a little bit of that old Christmas spirit back every day with wonderful comments like this.:drinks
     
  33. Derek:

    Thanks for that one. Have always enjoyed your postings here on PA. Christmas season is a special time, isn't it? Have a great Christmas and New Year!
     
  34. David Wedemeyer

    David Wedemeyer Well-Known Member

    Amen Mark.

    Kevin

    I am particularly fond of the saying "no good deed goes unpunished". Apparently there are a few people who covet your critical mind and the volume of excellent work that you have given your profession over the years. Don't allow them to ruffle your feathers too much.

    Truly without the benefit of this web board (thank you Craig) and the superstar contributors such as yourself, my professional direction would have probably maintained a very steady course of constant frustration.

    Never underestimate the need for people of your caliber in any profession or the effect that your individual contribution has made daily in other peoples lives, especially our patients.

    Merry Christmas to all and thank you, sincerely.

    :santa:
     
  35. David:

    Thanks for the kind words. It really is all about our patients, isn't it?!

    Merry Christmas....Ho Ho Ho!!:santa::santa:
     
  36. Steve The Footman

    Steve The Footman Active Member

    :empathy:Kevin I feel the same frustration about the way most of the discussions are hijacked by Ed and others to push their own agenda. Every interesting thread seems to degenerate into a defense of their so-called "theories".:craig: If we heard no more about MASS etc. I would be much happier. It is like we are talking in a different language and it is not Portuguese. Intelligent discussion seems an impossibility and I am sick of it.:bang:

    I think that Podiatry Arena is a fantastic resource and your contributions are one of the main things that makes it worthwhile for me. The allure and addiction of the forum would be greatly diminished by your absence. All of our posts supporting your contributions far outweigh the small, vocal, crackpot minority that try to undermine your work. While they are annoying and make a lot of noise there is really very little support for them that I can see. You on the otherhand are a podiatry legend.
     
  37. Steve:

    Thanks for the nice comments. I am starting to realize I must not let certain individuals diminish my enthusiam for teaching since teaching is probably what I do best.

    By the way, Steve, I have greatly enjoyed your contributions to Podiatry Arena and find your postings very thought provoking and intelligent. What is your last name??
     
  38. Steve The Footman

    Steve The Footman Active Member

    Hi Kevin, Thanks for your nice comments too. My last name is 'Manning' and my practice is just near the CBD of Australia's third largest City - Brisbane. I have changed my signature to give more details so hopefully that will work.

    I really enjoy teaching as well and have been directly involved with continuing education in sports medicine and podiatry for a long time. I do a guest lecture at the state Podiatry University on sporting footwear and footwear prescription and modification. I am also involved in a current review of the Podiatry course in the areas of Sports Medicine, Physical Medicine, Orthotics and Biomechanics.

    I met you at the after party when you came to Sydney to do a course on Biomechanics, but I am sure it would be hard for you to place me amongst the thousands you have met over the years.
     

  39. Steve:

    I checked out your website and can see you are a man after my own heart. I was a competetive marathon runner before I started podiatry school nearly 30 years ago and still run, but much less and much slower than before. I have been doing a free-screening clinic at Fleet Feet (a running shoe store) here in Sacramento, one Saturday a month, for over 20 years. I give shoe, training and injury advice to runners and walkers at the store which the store loves for their business and is a free way for me to advertise my services.

    By the way, Fleet Feet is one of the largest running shoe chains in the US and started here in Sacramento in 1976 when I was a freshman in college. I ran the Boston Marathon with a group of runners including the old owners of Fleet Feet in 1979 when I was 22 (2:31:30). Those were the good old days when the legs were young with lots of spring still left in them.

    Keep up the great comments!
     
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