Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

Therein lies your problem, Jeff: It's not you who should be telling the practitioner how to prescribe a foot orthosis, it is the practitioner who should be telling you what to make for them.

 

No doubt it IS a problem for any orthotics lab when there are orders being received from Podiatrists that don't know the difference between flexion vs. extensor contracture, for example.

 

Simon,

Well then why the hell has Kevin written hundreds of clinical newsletters for an orthotic lab that he has turned into educational books? All those who clicked like on your comment demonstrated the tissue stress love fest effect that I referred to and also demonstrated how little you and they understand the lab/client relationship. Orthotic labs have all kinds of clients. Some are new practitioners who are just learning how to use orthoses clinically and are going through the learning curve for the first time. Others are seasoned practitioners who may want to try new methods or techniques or just need some clinical advice. Orthotic therapy should be a continual learning process and good labs help their clients learn.

Simon, there is a big difference between "telling the practitioner how to prescribe" and offering educational information and clinical recommendations. Ironically Simon, you just committed a straw man argument by attempting to turn this comment by me

into this comment by you

Nice try! Don't let me get in the way of your love fest while I continue to ask what types of prescription protocols exist in the tissue stress model. No agreed upon examination approach or orthotic methodology. Just change the forces man! How, who cares?

Jeff

 

Jeff:

I feel your pain. I "liked" Simon's comment since it really is true that the podiatrist should know more about foot and lower extremity biomechanics and foot orthosis therapy than the orthotic lab personnel, but, as you know, this is rarely the case. Of course, foot orthosis labs need to provide education to podiatrists who are less knowledgeable but wouldn't you rather it be the case that all your clients were telling you how to best prescribe foot orthoses, rather than you telling them how to best prescribe foot orthoses, especially when you have never had the opportunity to examine the patient?

As far as this "tissue stress love fest" as you call it, welcome to how it feels to be the odd man out in a group that doesn't think like you. I spent many hours in the 1980s in seminars led by your father where it was a "Mert Root love fest". In these "Mert Root love fest" seminars, everything your father said was taken to be gospel. Those of us, including frequently myself, that dared to disagree with Dr. Root risked being blasted by the flame of Dr. Root's wrath.

That being said, I think you make some very good points and I, for one, appreciate your comments since I know that our goals are the same for the podiatric profession and our patients.:drinks

 

Kevin,

I'm sure you must have heard Mert tell the audience at those conferences that he did not want to create followers, he wanted to inspire thinkers who would go beyond where he was.

I think it is important for you to recognize that I'm not so much defending Mert's work (I have regularly acknowledged many of the flaws in it) as I am trying to stop a runaway freight train called Tissue Stress Theory, so that you don't end up in the same place as "Root Theory", with lots of followers, no future leaders and a very misunderstood treatment paradigm.

I think I have a pretty good grasp of how most DPM's (doctors) think. Most want a cookbook (spell it all out) or at least a roadmap (a path with several options to arrive at their destination). I think Ian is attempting to address some of my concerns. Its important not to be surrounded just by supporters as they may be the one to slow your progress more than your critics. When you attended those Root seminars you chose to stand up and voice a contrary opinion. That was important. And Mert, John and Bill didn't always agree and had some spirited discussions at those conferences as well.

What I see lacking in tissue stress is a way to connect the dots from the examination process all the way to the orthosis. In "Root Theory", some tried to follow it strictly while others chose to deviate from it, using it as a foundation for their approach. I don't think the Tissue Stress approach is well enough defined for this to happen at this point in time.

Jeff

 

The dots are understanding of basic physics, surely it can not be to much for Podiatrists to understand basic Physics?

At it´s ground

work from a diagnosis

Work out why it is being stressed and then begin a treatment program

To 1 reduce pain and 2 rehab the damaged tissue

Why does it need to be more defined than that

Sure we talk and discuss in much greater detail, but working from a diagnosis which as far as I sit is a much better way forward

Jeff why does TST need to be more defined ?

Do you beleive Podiatrist not smart enough to work this way ?

 

Mike,

If I was doing a study and wrote this as my orthotic prescription protocal

what would be the response from the scientific community? Laughter!

Tissue Stress Theory as I see it is an individualized approach that lacks any real consistency from one practitioner to the next. I can't say it any more clearly than that! You will never be able to test it as a treatment theory because it has no real structure.

Jeff

 

Jeff, see all those patients out there? They are all individuals requiring an individualised treatment approach. And we all know about the lack of consistancy from one practitioner to another when performing the Root recipe measurements.

If you had a patient with a high index of suspicion for peroneal tendonitis, what would you do first?

a) Stress test the peroneal tendons

b) draw a bisection line on the skin overlying the posterior surface of the calcaneus

 

If I was doing a study by claiming that "foot deformities" were predictive of either pathology or function what would be the response from the International Biomechanics Ccommunity? Laughter.... then "show me the research evidence!"

 

Who said anything about that as prescription protocal

I said you need a basic understanding of physics and a diagnosis

So unless you want to discuss like an adult what´s the point


why would you even write that ? I was explaining my basic though process with a patient

you would do what it says and explain it using Mechancial terms

ie Diagnosis Grade 2 Tib Post tear

Major biomechancial findings
Medial STJ axis
increased supination resistance
Increase Navicular drop and associated increased stiffiness in mechanical lifting
increased Dorsiflexion of the 1st on weightbearing
etc

Orthtoic prescription
Medial skive 6 mm 15 degress
no arch fill
medial flange
reverse mortons extension

etc etc

what I said was the process you should go through

and it would remoe the tick for Lab meat pie orthotics

 

You keep trying to show that Tissue Stress Theory is better than "Root Theory". Forget "Root Theory" and just tell me how to use Tissue Stress Theory and why it works.

 

You keep trying to show that Tissue Stress Theory is better than "Root Theory". Forget "Root Theory" and just tell me how to use Tissue Stress Theory and why it works.

 

????????????????????????? I thought this was an adult conversation.

They call this a pathology specific approach and it can be done with a check box.

Jeff

 

And In my Opinion Tissue stress theory when it comes to writing a orthotic script is a pathology specific approach, how you get to this point is a mechancial based theory

 

And you just keep trying to show why Root theory is better than tissue stress- touche!

How to use:

a) Identify the tissue that is dysfunctional

b) Create a treatment strategy to modify the loading that the dysfunctional tissue is exposed to and if possible, in the longer term, increase the tissues ability to withstand the loading it is exposed to.

Why it works:

It works because as Hunter noted: tissue dysfunction occurs when:

1) Healthy tissue is being loaded in ‘abnormal’ way
2) Unhealthy tissue is being loaded in ‘normal’ way
3) Unhealthy tissue is being loaded in ‘abnormal’ way

Hunter G.: Specific soft tissue mobilization in the management of soft tissue dysfunction. Manual Therapy (1998) 3(1), 2-11

And as Mueller and Maluf described, tissue health is related to levels of stress that the tissues are exposed to. Mueller M J, Maluf K S: Tissue adaptation to physical stress: a proposed "Physical Stress Theory" to guide physical therapist practice, education, and research. Physical Therapy (2002) 82, 383-403

So, as a "lab-owner", if you really want to assist in the education of practitioners in employing the tissue stress approach, you need to be able to describe to them how each of the modifications and design permutations your lab is able to provide are likely to impact upon the loading of the tissues of the lower limb; do you have the knowledge base to take on this role? I believe that this is exactly what Kevin has been attempting to achieve in his four books of collected newsletters. It is certainly the reason I undertook the FEA studies of foot orthoses design permutations and why I have dedicated the last 15 or so years to trying to figure out exactly how "foot orthoses work", so that I might be better equipped to help the patients I manufacture foot orthoses for. However, the reflective practitioner also realises that there is more to "load management" than foot orthoses, and that sometimes foot orthoses are not required at all.

 

So when the book called The Practitioner's Guide to Tissue Stress Theory comes out, will I be able to read a list of orthotic prescription modifications and options and see how each of these alters the load on the various tissue structures of the lower extremity or is the practitioner just supposed to figure it out on their own by thinking like an engineer. Engineers use math to calculate loads. Is the practitioner, in thinking like an engineer, going to calculate loads and load changes or just guess as to how a combination various modifications might influence the forces acting on tissue?

For example, if I use a traditional Root Type Functional Orthosis, an inverted functional orthosis with a medial heel skive and additional medial arch filler, and an everted functional orthoses with a medial heel skive, how are each of these devices individually going to change tension in the plantar fascia. What guidelines are offered in the guidebook that help the practitioner make treatment decisions?

I think you need to look at how students learn to see what the future of tissue stress theory may look like. Perhaps Eric can post his teaching syllabus so I can get a better understanding of how you teach TST.

Jeff

 

Most ( not all ) students are lazy ( I was ) , but that doesn´t mean you should not teach them something based on sound prinicples of Physics and then in combination with knowledge of anatomy and physiology get them to start thinking for themselves.

 

I should have hoped that as a "lab-owner", President of PFOLA and an "educator of clinicians" you should have already been thinking about how the various design permutations of a foot orthosis might influence the loading of tissues. As a humble clinician in private practice, I certainly have. I take it from your response above that you are waiting for someone to do that kind of work for you. I've also realised that the response to foot orthoses is subject specific and will vary according to the locomotor task and environment.

If you read the biomechanics literature you will see that many of the publications relating to the influences of foot orthoses have used "math" to calculate loads, load changes etc which provides clinicians who read such literature with an understanding of how our orthoses might be influencing such things. We then use modelling to provide a clinical indication of loading.

To appease you:

Depends on the foot the "traditional Root Type Functional Orthosis" was manufactured for.

Inversion during the balance will tend to increase the stiffnesss of the medial longitudinal arch section of the foot orthosis since it will increase the second moment of area. This will tend to shift the centre of pressure medially from forefoot loading to heel off: increasing the external supination moment during this time period and should therefore reduce the magnitude of required internal supination moment from the plantar fascia to maintain a preferred movement pathway. May require additional arch fill / shell thickness reduction / plantar fascial groove to avoid irritation of the fascia though.

Again, will tend to shift the centre of pressure medially (see above), will also increase the surface angulation under the heel, so will result in a decreased vertical component and an increased shear component to the GRF vector acting at the rearfoot.

Depends how much arch fill. Will though decrease the stiffness of the medial longitudinal arch section of the device and potentially could negate the effects of the inversion by decreasing stiffness in the medial longitudinal arch portion of the foot orthosis.

Relatively decreases stiffness in the medial longitudinal arch section of the device while increasing the stiffness in the lateral arch section of the the device. Potentially pulling the CoP more laterally earlier on during the contact phase. Increased dorsiflexion moment under the lateral metatarsal necks, increased eversion moment about the anterior-posterior MTJ reference axis. Potentially could pull the centre of pressure laterally as the heel begins to un-weight off loading the dorsiflexion moment on the first metatarsal head, reducing tension in the band of the fascia which supplies the hallux, but likely increasing it progressively more 2-5 toes.

There's more to it than that, for example we could differentiate when a medial heel skive causes a kinematic change (as oppose to just a kinetic change) at the rearfoot which results in "stacking" of the CCJ and TNJ, increasing the second moment of area across the MTJ and increasing dorsiflexion stiffness, thereby decreasing the load borne by the plantar fascia, but I really don't have the time nor inclination to write that textbook for you, Jeff. But I'm sure you get the idea. Personally, with plantar fasciitis I generally aim to include other design modification to lower plantar fascial tension as well as compression, but I've just provided very brief responses to your suggestions here.

Jeff, you should really take the time to read Kevin's four books as he covers most of these things, therein.

 

Relatively decreases stiffness in the medial longitudinal arch section of the device while increasing the stiffness in the lateral arch section of the the device. Potentially pulling the CoP more laterally earlier on during the contact phase. Increased dorsiflexion moment under the lateral metatarsal necks, increased eversion moment about the anterior-posterior MTJ reference axis. Potentially could pull the centre of pressure laterally as the heel begins to un-weight off loading the dorsiflexion moment on the first metatarsal head, reducing tension in the band of the fascia which supplies the hallux, but likely increasing it progressively more 2-5 toes.

There's a lot of physics here. This Craig, is your real "pseudo-science"

 

Jeff,

I was a student of Root. He was a genius, without the advent of computerized gait analysis. He was right about almost everything he wrote.

Because of the precision biomechanics of dynamic fluid technology, only then can you read the biomechanics of a gait scan and truly understand it. Ive been amazed at what he was able to see.

No one can supplant Root mechanics in theory. He only needed an orthotic that did exactly what it was supposed to do and see Root mechanics come to life.

 

Not as hard a question as it might appear. First, the patient hasn't made the diagnosis, prior to being seen by a Podiatrist, so they "may" have gotten that information from the referring PCP. The first thing I would do, is obtain a history, ie., how long they've had the discomfort, what activities the patient is involved with, any new activities in the recent past, (from just before the time they began to experience pain), any other contributing systemic diseases, shoes worn, work-type activities, history of lateral instability and inversion type sprains, etc.

Once the diagnosis has been determined, whether it be by peroneal stress testing, (only if there is no history of injury), simple palpation or isometric resistence. Then I would take an X-Ray in order to determine foot type after I had examined that foot with static procedures.

If no history of injury, then I don't typically need an MRI to make the diagnosis of tendonitis vs. tendonosis/tear/split. Chances are this patient has an uncompensated rear foot varus deformity, which can be determined with static examination and gait analysis along with plain film radiographs. Bissecting the calcaneus can make this determination easier for the young practitioner and the parent, (if the patient is under 18 years of age). It is not only a tool to be used by less experienced docs, but a great visual aid for other members of the family. Further, with the patient stand in RCSP, they can be asked if they can evert, (pronate) further at the STJ...this would confirm my diagnosis above. If the calcaneus is slightly inverted or the bisection is perpendicular without further eversion available, then it becomes an easier task to determine degrees of inversion required from the orthotic in order to hold that foot at closer to neutral, by comparing RCSP to NCSP. High-Dye strapping can be used to treat at the time, with follow-ups to determine the necessity for orthotics.

Root biomechanics. Simple, concise, subject to practitioner variance...but still the best we've got.

Now...how does TST approach this patient?

 

Jeff, see all those patients out there? They are all individuals requiring an individualised treatment approach. And we all know about the lack of consistancy from one practitioner to another when performing the Root recipe measurements.

Any recipe other than a precise scientific measurement is a poor result. A Rx must accurately balance the planes of motion at the tarsus to a congruous/neutral position of the foot at midstance. And carry it through propulsion. Is that a clue or what?

 

Jeff, you have been asking for prescription writing protocols. A few pages back I posted a prescription order based on tissue stress principles and I asked if you could make an orthotic from what I wrote. You did not respond. I'll go back and look for that and repost that when I get the time. That was just the orders that were sent to the lab. Now, I will go into the thought process for designing the orthothic.

Identify the injured structure. Many foot complaints are related to the windlass mechanism. Plantar fasciitis, hallux limitus, and hallux valgus are all related to the windlass mechanism. So, if you identify any of those diagnoses as the problem you will want to reduce the load on the windlass. Things that will increase load on the windlass are pronation moment at the STJ and high loads on the first metatatarsal head.

Sources of pronation moment: Ground reaction force where the center of pressure is lateral to the STJ axis. Another source of pronation moment is the peroneal muscles. (When there is a laterally deviated STJ axis, the peroneals will tend to work harder than average to keep the foot from rolling into supination and be active enough to pronate the foot far enough so that the first met head will get very high loads.)

So if you want to correctly reduce pronation moment you need to find the location of the STJ axis. If the axis is medial you add a medial heel skive to reduce pronation moment from the ground. Or you could increase the medial arch height of the orthottic. If the axis is lateral you increase the pronation moment from the ground. You can do that with a lateral heel skive or an intrinsic forefoot valgus post.

If the pathology is related to the windlass mechanism you will want to reduce load on the first ray. Supination of the STJ will tend to shift load from medial to lateral on the forefoot. So increased arch height and medial skive work here too. Other ways to decrease load on the first met head are to shift the load to the lateral forefoot. Intrinsic forefoot valgus post, reverse Morton's extension and forefoot valgus extensions should shift the load to the lateral forefoot. (With a long second met choose the forefoot valgus extension over the reverse Morton's extension.)

So, that is how you can choose orthotic modifications based on mechanical modeling of the foot. If I ask a lab for an orthotic with a medial arch height of 22mm a 3mm intrinsic forefoot valgus post, a 2mm medial heel skive, a full length extension with a reverse Morton's extension that lab should be able to make it for me without even having to bisect the heel.

Eric

Eric

 

It's not a clue. The phrase "accurately balance the planes of motion" is just ... marketing to the uneducated. Where's the hydrodynamics? How are the forces, applied by the fluid, creating balance? How do you balance a plane of motion?

Eric

 

Eric,

I find it very interesting that one of the biggest criticism about "Root Theory" from you and other TST advocates have been concerns about reproducibility of technique. You all have pointed to studies like Payne et al to argue that variability in casting, measurement technique, etc. make inter and intra practitioner repeatability a problem. However, with TST and the lack of any defined clinical examination approach and no orthotic prescription protocol, you can't even begin to examine the reliability and repeatability of the TST approach, because it is a totally individualize approach depending on the whims of the practitioner.

I can't even begin to imagine how you can possibly create a curriculum for teaching TST and teach students how to treat with orthoses when there are no standards and no agreed upon approach. For example, how should one cast the foot? According to Simon it doesn't matter. How should you position the cast in the frontal plane? According to you, it doesn't matter. I though one goal was to make prescription foot orthotic therapy more scientific, not less scientific. I see TST as going in the opposite direction of that goal. The concept seems logical on the surface but the approach is vague at best, and completely inconsistent and unrepeatable.

Jeff

 

Eric

Because you either don't understand the science behind hydro-dynamic tech or you don't want to, explains your repeated questions. Over all, I find them ignorant and because you're unfamiliar with this technology you refer to my terminology directed toward the uneducated. It is you sir, who is among the uneducated.

Where's the hydrodynamics? -Archimedes Principle—displacement of fluid under pressure

How are the forces, applied by the fluid, creating balance?--hydro-dynamic pressure

How do you balance a plane of motion?--you supprt the planes of motion in a neutral position and disallow overpronation/instability

 

There was a study showing the reliability of STJ axis location by the palpation method. This is an improvement over the "in house" attempts that have been made at measuring reliability of heel bisections and forefoot to rearfoot measurement.

One advantage of tissue stress over Neutral position theory is that the main part of the exam is identifying the anatomical structure that hurts. In neutral position theory there is a disconnect between the pathology and the measurements that are performed. The majority of the time there is no theoretical connection between the measurements and the pathology. For example, does forefoot valgus or forefoot varus cause bunions? Why do you treat the measurement instead of the pathology. A notable exception to the disconnect between the measurements and the pathology is sinus tarsi syndrome. When you see a partially compensated varus, you can understand that the STJ is at its end of range of motion and very likely has a high pronation moment from the ground. However, even in this example, neutral position can be ignored.

Now an interesting question to the group of adherents of tissue stress theory is whether we would agree on orthotic modifications for specific pathologies. I think that everyone would agree with the use of medial heel skive for a medially deviated STJ axis. I think that the vast majority would agree that you would use a lateral heel skive when you see a laterally deviated STJ axis. With first ray pathology, I'm willing to bet that most tissue stress adherents would use a reverse Morton's extension with their orthotic (extension sub 2-5).

I can see how it would be hard for a neutral position theorist to imagine creating a curriculum without neutral position. Bill Orien has said that neutral position was a figment of Mert Root's imagination. We have run around the neutral position stump many times.

Jeff, here is a proposed standard. When a 2mm medial heel skive is asked for you make the heel look like a vertically bisected heel that has had a medial heel skive performed on it as described in Kevin's paper. I've heard of people using a method of "bisecting" the heel by placing the heel on the counter, looking from posterior and moving the cast so that the contact point is in the center of the heel and volume of space under the cast, on either side of the heel contact point, is equal. A 2mm heel skive will have more volume of space under the medial side of the contact point and the contact point will no longer be in the center. When this is done, there will be a varus wedge effect in the heel cup of the orthosis.

Jeff, what I am saying is that you don't have to position the cast in the frontal plane. You have to know what you want the finished orthotic to look like in the frontal plane. Traditionally, a lab has used the heel bisection to figure out this allignment. However, if I ask for a 3mm intrinsic forefoot valgus post, you can use the same technique you used to use to make a 5 degree inverted heel bisection vertical with an intrinsic forefoot valgus post. For example, you could take a negative cast, put a heel bisection on it, and see that you have a 2 degree forefoot varus. You could take that cast and add a 3mm intrinsic forefoot valgus post and then make the heel cup look like it had a 2mm medial heel skive relative to the anterior edge of the orthotic.

So, I feel that this is more scientific than the neutral position approach because we are looking at the piece of plastic that touches the foot. Some neutral position adherents believe that there is a voodoo effect that comes from where you place the heel bisection of the positive cast. Specifically, they would believe that when you balance the heel bisection of the cast 1 degree inverted, the heel of the foot will become one degree inverted when it stands on the orthotic. Speaking of scientific, we should examine the belief that casting the foot in neutral position will move the foot, that is standing on an orthotic made from that neutral position cast, toward neutral position. How does that work?

Eric

 

Dennis, you can call me uneducated, or you can educate me.

So, when the fluid moves around it creates "accurate" forces?

Where are the forces applied and how is this different from the forces applied by a solid plastic orthotic? How are these more forces more accurate?

Dennis, the standard definition of plane of motion makes no sense in the above sentence. What do you mean? Neutral position of which joint(s)? Why is it good for a joint to be in its neutral position? How do tell the difference between overpronation and regular pronation? More ..... Marketing

Eric

 

No kidding. Part of some studies that I did to see how surface angulation influenced the relaxed standing position at the rearfoot are attached. If you think you are measuring angles and dangles and "negating the need for compensation by bringing the ground up to the foot" then, quite frankly, you're trippin':

 

Eric

Dennis, you can call me uneducated, or you can educate me.

I don't think you're educable in this subject

So, when the fluid moves around it creates "accurate" forces?

The fluid doesn't “move around”--it is displaced under pressure to the areas of less resistance and greater need.

Where are the forces applied and how is this different from the forces applied by a solid plastic orthotic? How are these more forces more accurate?

With fluid tech, there are four areas of loading forces, with static tech (traditional tech) there is only one loading area.To answer the rest is too complicated for you. You have to understand more, before you can move on to the other.

Dennis, the standard definition of plane of motion makes no sense in the above sentence. What do you mean? Neutral position of which joint(s)? Why is it good for a joint to be in its neutral position? How do tell the difference between overpronation and regular pronation? More ..... Marketing

I can't believe this question is coming from a scientist and colleague.

 

Simon,

Using an external angle finder to determine internal position is just nuts. Six degrees change of the calcaneous is a difference of 60 mg of fluid in my world. That's 60 different Rx. Each mg, affects the angles of the entire foot and the planes of motion.

Your angleometer could however be used in the scientific world of Batman and DC comics

 

I recently showed photos of an employee of mine that demonstrated how orthoses can change the frontal plane position of the heel. I demonstrated it live and in person for Kent and Ben Sweeting who own an orthotic lab in Australia. Contact them if you doubt my photos.

There is a significant different between applying an inversion force from an inverted flat plane acting on the rearfoot alone or the entire foot as unit as compared to the forces created by a functional orthotic, which has a triplane heel cup and a medial arch. Orthotic reaction force acting plantar to the head of the talus and navicular can create a strong anti-pronation force within the foot, in part due to the influence on the MTJ which influences the position of the STJ. Inverting the cast increases the height of this area of the orthosis, which in turn, increases the orthtotic reaction force in this area. That's why the frontal plane orientation of the cast is extremely important when manufacturing orthoses and why quantifying it is beneficial.

Jeff

 

What it does show is that there is a significant inter-subject variation in the change of the angulation of the calcaneus in response to the angle of rearfoot wedging. You honestly think that you achieve a 1:1 ratio of "correction" with your foot orthoses, don't you Jeff. Of course you have data to support this... maybe you could explain to me why Williams et al. found no statistical difference in rearfoot kinematics between no orthosis, "Root" and Blake inverted devices then? In fact, while not statistically significant, why they found increased rearfoot eversion with both the Blake and the Root, but more so with the Root compared to no orthoses at all- the subjects in this study didn't get better with the Root device, yet they did with Blake- please explain these findings using "Root theory"... Williams, D.S., Davis, I.M., Baitch, S.P., 2003. Effect of inverted orthoses on lower- extremity mechanics in runners. Medicine and Science in Sports and Exercise 35, 2060–2068. Rhetoric question, since Root theory cannot explain these findings.

 

Simon,

When did I ever say that I believed we can achieve a 1:1 ratio of "correction" with foot orthoses? I have never remotely said that. You are king of the straw-man! In some cases, but not all, we can alter the frontal plane position of the heel. It really that simple Simon!

Jeff

 

So, how do you determine how many degrees the orthoses that you manufacture will change the rearfoot position by, in each patient given the "completed prescription protocol form" and the casts you are sent from the people who are paying your lab to produce foot orthoses for them? Or, do you agree that the response to foot orthoses is subject specific?


Anyway, rather than falling for your deflection of the question: back to Williams et al. (2003) study: please explain the findings of this study using Root theory... Personally, I think it was because who ever cast the feet for the Root devices "didn't cast the foot in the correct position"- not.

 

Simon,

I (we/Root Lab) don't determine it, the prescribing practitioner has that option. We have a Rx form. The practitioner can choose lab defaults, modify the defaults or write the Rx from scratch. It is up to the client. In many cases we don't know the chief complaint or the pathology being treated because the practitioner (mostly doctors) take responsibility for their prescriptions.

Jeff

 

Jeff, I thought your "Root" orthoses were designed to place the heel bisection at vertical if the practitioner followed your prescription writing protocol? Isn't that why you posted the photo's of the boy who works for you wearing your orthoses at the start of this thread? For the record I'm (mostly a doctor) too.

 

The positive cast is positioned with the heel in a vertical position by laboratory default (Blake Functional Orthoses obviously excluded) unless the practitioner changes the default position of the heel, which many do.

 

Simon still attempting to resurrect his credibility here? Who cares if you get a 1:1 correction, as long as the foot is held in a more biomechanically correct position? All one would have to do is ask the orthotics labs what percentage of them are ordered with any degree of medial heel skive. The results would be elucidating and refute many of the points the TST Podiatrists are promoting, it appears.

If the practitioner only looks at the singular complaint/pathology in their patients' foot/feet, they will oversimplify the condition and probably miss the big picture. I've already submitted an anecdotal example...but one that I've witnessed numerous times...too many to count.

http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=360439&postcount=15

By focusing on the one pathology that the patient complains about: 1) The practitioner places too much credence in the patients' ability to determine the source, and 2) Continues the trend of "dumbing down" Podiatry, as if any more force needs to be applied there.

While many want to describe every condition as a result of one foot structure/mechanism, (eg. windlass), there's more to the story than that oversimplification. Look rearward first, then determine the forces acting on that.