Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

But you accept then that this will not necessarilly place the patients heel in this position when standing on the orthosis?

Anyway back to the Williams et al. 2003 study- please explain the findings of this study using Root theory....

 

Dennis, you can continue to insult me, I don't care. If you wanted to show other people you know what your talking about you would answer the question.

How do you know that some areas have greater need than others?

There is really no difference between move around and displace.

Dennis are you talking about the interface between the orthotic and the foot or the orthotic and the shoe?

Dennis, you could show that you know what your are talking about if you answered the question for others.

Why can't you believe the question? I believe that you don't know the definition of term "plane of motion" or you would not have used it in that sentence that way. People will think that you are just trying to baffle them with ...... marketing if you can't explain the terms that you use. If you would rather belittle the people that ask you questions rather than explain your technology why are you bothering to post here?

Eric

 

It really that simple Simon!

We have a Rx form. The practitioner can choose lab defaults, modify the defaults or write the Rx from scratch.

Just guessing



Jeff, I thought your "Root" orthoses were designed to place the heel bisection at vertical if the practitioner followed your prescription writing protocol? For the record I'm (mostly a doctor) too.

Doctor of Chiropody—totally valid

 

Instead of paying attention to the frontal plane orientation of the cast one measure the height of the medial arch of the finished orthotic. That way one could get around the "how much fill do I put in" problem. Jeff, you talk about the need for precision in orthotic fabrication. Medial arch fill is a huge area of randomness for the "modified" Root device. My foot cannot tolerate a minimal fill device. Other feet can. We can skip all this complicated angle/dangle stuff and go right to the arch height of the finished device.

Eric

 

The position of the heel will be determined by the net forces. Here is an example of an order in the lab that I just photographed:

Pouring position (heel bisection position in the corrected cast): 10 inverted B/L
Shell material: 5/32 polypro
3mm plantar fascia accommodation B/L
3mm medial heel skive B/L
Decreased medial arch fill B/L
Heel cup depth: 24mm medial, 14mm lateral B/L
Valgus forefoot extension to match angle of FF to RF as measured in positive cast (this patient demonstrared 5 degress of forefoot eversion or valgus B/L so this will be a 5 degree valgus extension)

No one can predict how much, if any change there will be in the RCSP with and without orthoses for this patient, especially those of us who have not examined the patient. However, I would not be surprised to see the heel less everted assuming that the heel is everted to begin with.

Interestingly enough, this is a doctor who sat in on the same Root Lab lectures given by Mert that Kevin refers to.

 

Eric,

The frontal plane orientation of the cast influences much more than arch height. It changes the plantar plane of the heel and the plane of the metatarsals to the plane of the floor. Some individuals with severe rearfoot pronation will compress the medial flat pad of the heel. When you place the heel vertical, the plantar plane of the heel will be inverted to the floor. It looks like it had a medial heel skive but it doesn't. If we invert this cast, it will increase this effect. If I corrected the cast with the heel everted, there would be less orthotic reaction force acting on the medial aspect of the heel. So this is an example of how we can look at the foot's structure and how it is influenced by the orientation of the cast in the frontal plane.

Jeff

 

You may not "be surprised", yet your surprise or lack of it is really irrelevent here. The key is that you don't know. Nor do you know the angular change that any prescription which follows the "Root protocol" ever achieves. Given that the Root protocol is centred upon achieving angular change at the rearfoot, then that doesn't bode well, does it? What predicts the amount of change in rearfoot position when a foot orthosis is placed beneath the foot, Jeff?

BTW, I glanced for less than a second and saw the tick box, anterior width "standard", ticked- nice. "Medial arch fill"- "decreased"- tick that box- decreased by how much? A long post? etc, etc- it's all just pseudo-science, Jeff as well you know. The difference between you and I, Jeff, is that I don't rely upon this to make my living.

Anyway, once again: back to the Williams et al. 2003 study- please explain the findings of this study using Root theory....

 

This is a pointless discussion. The end.

 

I accept that you are unable to provdie an argument to explain the results presented by Williams et al. 2003 using Root theory. I also accept that you feel unable to continue to support your position within this discussion. Until the next time, Jeff. :drinks

 

Jeff & Simon

I accept that you are unable to provdie an argument to explain the results presented by Williams et al. 2003 using Root theory. I also accept that you feel unable to continue to support your position within this discussion. Until the next time, Jeff.

This applies to the discussion of fluid technology and biomechanics as well.

Dennis

 

Jeff, I agree that the frontal plane relationship of the certainly can effect the shape of the orthotic. What I am saying is that we can skip the cast part and go to what we want the finished orthotic to look like. No matter what the cast looks like when it arrives at the lab, we can make the finished product have a 3mm intrinsic forefoot valgus post and varus wedge effect in the heel cup of the orthosis.

Thinking about this, I do have a firmly held belief that shape of the lateral plantar part of the cast from the middle of the calcaneus to the middle of the shaft of the 5th metatarsal is important. This shape should represent what the foot looks like when the forefoot is loaded enough to have tension in the lateral plantar ligaments. (Locked MTJ?) It would be very interesting to do a study to confirm or refute that belief. So, when you add an intrinsic forefoot valgus post, you will be keeping the shape of the loaded MTJ the same.

Eric

 

What a shame Simon has me on ignore, but I can certainly understand why.

 

This is beautiful stuff. Envision if you will a set of vises fixing each segment of the foot (rf/mf/ff) into a position where you can lock down in even an angular position of any of the segments. I remember my own experience making my own orthotic in lab.

The first moment I tried walkinh in them was very uncomfortable. I wore them for 30 minutes and found them so uncomfortable I had to stop wearing.

This is a traditional orthotic, What are you doctors of the foot doing??

 

And I accept that you have failed miserably with traditional foot orthotic therapy while others have experienced great success with it. And I also accept the fact that there is no treatment system associated with TST and the practitioner can do whatever they want and claim to be practicing TST since there is no standards and no systems associated with TST. Double :drinks

 

Head in the sand!

 

But since you've decided to reply, it clearly wasn't "the end" in your mind as you stated about half an hour ago. As such, you can obviously find the time to answer the question I've asked 5 times now: back to the Williams et al. 2003 study- please explain the findings of this study using Root theory.... appease me, Jeff.

 

The end of TST debate with you. Not end of all postings.

 

I'll take that as, you can't answer the question, Jeff.

 

You are free to take it any way you want. Have a nice weekend.

 

I wore some silicon bag orthotics and they were better than nothing for straight ahead walking. However, I don't walk straight ahead all the time and I went back to my rigid plastic ones because they relieve, prevent my foot pain for the rest of my life beyond straight ahead walking. Dennis you have admitted that they are only good for straight ahead waking.

Eric

 

You can't answer the question, Jeff. End of Story. Enjoy your weekend.

 

Eric

. There is no question that every orthotic is not necessarlily the best for any activity. So, if you have an occasion that requires a special piece of orthotic equipment, then go ahead and use it.

BUT for everyday walking and running which is what most and all who do walk, can get the health benefit of wearing an orthotic daily, regardless of pain. Because the fluid Rx can be fit to most anyone, if you don't believe that prevention therapy is worthwhile, then I got nothing.

We as DPM should be fitting every child starting around 10, to minimize and reduce pronatory biomechanical problems in the future. During that growth period, a new pair, with a probable change in Rx will be needed every 1-2 yr. After adulthood up to 5 more Rx for the rest of their life.


Because the Rx is quantitative with as little as mg changes, I have a respected, scientific Rx orthotic.

 

Dennis...without pics from the rear and the side of the foot in RCSP vs. NCSP and on the orthoses, measurements of the feet in static stance and a pic of the orthotic itself, it's pretty hard to determine why you had such a problem wearing them. In the post above the one I'm responding to, #652, the bottom pic shows a rear view of the 15 y.o.'s foot on top of the orthotic. I have since changed that for her, as that orthotic, (while keeping her calcaneus closer to neutral), did not correct the forefoot varus condition, which would've been easier to see had I offered a side view. You can, however, see some of the skin blanching on the heel, which I am suggesting as a reaction to an orthotic that does not correct her forefoot, thus applying more sheer force on the rear.

 

Rubbish just complete and utter rubbish

orthotics for all to stop that evil pronation,

Really is shocking this sort of thinking in 2015

 

Considering that up to 40% of kids experience "growing pains" in their lifetime...it appears that you're the one that might want to take a long look in the mirror. Hope it helps.

 

A couple of questions here. We see these pathologies without a deviated axis and I have certainly seen peroneal pathology with a foot that demonstrates great pronation moments. Would you agree that the latter could happen if there was a relative weakness or mechanical disadvantage to tib post, thus over activity of peroneals? Similarly, if the foot resulted in a loss of the windlass mechanism / 1st ray plantarflexion, there may be an effect on P Longus function and potentially increased P Brevis function. If you agree (not sure if you will), it may prove that the orthosis you provide could be similar to one you provide for a tib post pathology as one would assume, increasing the pronation moments to off load the peroneal tendon further may not be the best approach in the long term.

I have looked at many, many orthoses using inshoe analysis and, perhaps not surprisingly, the way individuals respond is variable. I would agree with you that the medial skive (or post) and arch height have the potential to increase supination moments and the windlass mechanism. However, in many feet, as the whole foot starts to load, the lateral forefoot is first to load, with the transfer then to medial. Any lateral post / extension will exert an effect on the foot at this point and have the potential to counteract the benefit of any medial control. In other words, it functions far earlier than just mid to latter stance when it can affect the windlass mechanism. How do you determine this effect? I have my own thoughts but would value yours.

Finally, I have seen plenty of feet with a medially deviated axes which require a medial skive etc. but, when tested on inshoe analysis, it results in early Hallux plantarflexion as the forefoot does not adapt to the degree of rearfoot control – the patient may well respond to the tissue stress relief aspect, but this cannot be normal function and has the potential to cause another problem. I have seen this affect in less pathological feet with a range of different orthoses.

Eric, I would like to email you separately, would you mind sending me your email address. Mine is trevor.prior@premierpodiatry.com, thanks

T

 

In my clinic, one of the factors we record when we issues orthoses is the change of the rearfoot angle (amongst others). I will confess that this is historical and we just have not changed it yet. Our observations are as per you study, the effect is very variable. In some there is no change in others we may get between 1-3 degs, never any more than that.

With regards the paper, it had a number of interesting findings:

1. No change to rearfoot eversion
2. Peak rearfoot inversion moment reduced on the inverted orthoses suggesting
decreased demand on structures that control eversion
3. Significant differences in tibial rotation, knee adduction and knee abduction moment.

Their conclusion is that changes occur further up the chain and (my thoughts) it is possible that the driver for function was more proximal.

I consistently see changes in tibial rotation, knee and hip adduction with or without a change in eversion. However, this is precisely why I ask the question as to how we predict the effect of our intervention because it does have an impact on knee and hip mechanics. I would also suggest that the response to orthoses is variable because the driving force for function is outside the foot and is another reason why studies trying to marry foot structure to function fail to find a consistent relationship.

The plus with the mechanical approach to foot function (i.e. pronation / supination moments) is the ability to assess the overall effect of all the factors. Where you then apply the forces will be based on the relative position to the STJ axis but may be influenced by some structural components - the peroneal example I have asked Eric is an example, forefoot equines requiring a heel raise is another.

T

 

On a more general basis, I fear the thread is denigrating, most probably due to frustration. There has been so much of value in this discussion, it would be a shame if we lost direction. For my pennyworth, as I have just alluded to, I believe structural alignment has a role to play in the ability of someone to function and how forces may be directed, but it is not the only factor. The alignment principles from Root et al has certainly given us a basis for evaluating this but the role of managing around subtalar neutral has shown to be flawed.

I am presenting to-day to a physiotherapy group and have around 25 minutes to talk to them about ‘pronation’. I have thought about this quite carefully as I wish to get across many of the current principles. Actually, I feel outlining the principles, how various structural alignments, joint rotations and muscular activity (strength, flexibility, neuromuscular control) can place medial / lateral force on the foot may be a simpler way of teaching foot function. What you then do to manage this does depend on the structure and function of the pathological tissue but the broader picture also provides some guidance as to the likely effect (positive, negative or zero) of the intervention.

The lecture is followed by a workshop so it will be interesting to see the response from a group of practitioners that will have been trained on the traditional principles but have an inherent understanding of function of the lower limb yet sit in no particular biomechanical camp.

On that last note, I believe there is overlap between the approaches which, if we can place this into a logical format may provide a way forward.

T

 

I did something similar a little while ago, but I talked about the changes from position A to Postion B (a more pronated) on Joints axis , muscle lever arms etc etc, I spent a great deal of time talking about stiffiness Joint, muscle as well as similar stuff you mention and as the light bulbs started to go off I introduced a device into the discussion

 

Rubbish just complete and utter rubbish

orthotics for all to stop that evil pronation,

Really is shocking this sort of thinking in 2015



Just the kind of thinking I would expect in 1815

Well, he's done you proud, he's on your team!

 

Trevor,

If we were to base our understanding of foot orthoses on this paper, we would probably have to conclude that orthoses are incapable of altering rearfoot excursion and peak eversion. However, we know that orthoses are capable of changing rearfoot position and motion. So why did this small study of eleven runners not demonstrate this? Could it be methodology, subject selection (all runners with a history of symptoms), foot type (no effort was made to evaluate foot type)? It would be interesting to see what Steve Baitch might say today about this study. I did work for Steve many years ago but haven't spoken to him in a very long time.

Jeff

 

Well I'm glad you were able to help that person. However he is not me is he? what he knew and what I know will likely not be the same. And I hate to burst the bubble though but that pic you shared is hardly cutting edge. Cutting edge are things that are new and different. I'm glad though that you are helping out. That is admirable.

 

Nope, what we should conclude from this paper is that these subjects didn't have their symptoms relieved by the Root orthoses, but did have their symptoms relieved by the inverted orthoses- the symptom relief in these cases having nothing to do with the rearfoot eversion changes induced by the orthoses. Viz. in these individuals the foot orthoses did not work by altering rearfoot kinematics.

What we know is that the literature is split on whether foot orthoses alter rearfoot kinematics or not, Craig started compiling this data some years ago:

They don't change rearfoot kinematics: Rodgers & Leveau, 1982; Blake and Ferguson, 1993; Brown et al, 1995; Nawoczenski et al., 1995; Nigg et al. 1997; Butler et al, 2003; Stackhouse et al, 2003; Williams et al, 2003

They do change rearfoot kinematics: Bates et al, 1979; Smith et al, 1986; Novick and Kelly, 1990; McCulloch et al, 1993; Stell & Buckley, 1998; Leung et al, 1998; Genova & Gross, 2000; Nester et al, 2001; Woodburn et al, 2003

Why is the kinematic response to foot orthoses subject specific? Surely if we use a Root protocol, every foot should be positioned with the heel bisection at vertical?

Even if this were the case, the assumption is being made that rearfoot position and motion is predictive of pathology- guess what the literature shows?

 

Here is the link to your original post, and my response:

http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=363196&postcount=599

Did someone hijack your alias, Todd, or are you denying writing that I'm a narcissist whom lives in an Ivory Tower?

Using verifiable and published statistics allows one to determine several things...first the severity of the problem, and second, others knowledge of the subject and their depth of understanding, not to mention credibility. The fact that you think this is a game, and don't want to participate in forwarding/exposing your breadth of information, (or lack thereof), only makes my case...doesn't it? It would've been quite simple to perform a modicum of research to determine that number...even if you didn't know prior to my question.

While SMO's are not "cutting edge", the materials/techniques used in his construction certainly are. Perhaps you can forward some pics and/or articles on this very topic that supports your contention that this construction is anything but cutting edge. And did you happen to notice the forefoot varus post extension to the ends of the toes? Want to venture a guess how many degrees of correction that is, or who's idea that was which resolved his problem? Thanks in advance for a considerate reply.

 

Poor Simon...treating his patients based upon others work and his refusal to accept what he should be able to "see" in his own. If Root biomechanics doesn't work, then why are so many Podiatrists worldwide successfully treating patients using his foundational work? Merton just gave us the outline...it was up to the rest of us that followed to fine tune as we added text.

 

You are Sooo right DrHunnybun, you shouldn't base your treatments on the clinical evidence base, ever.

 

So should we be putting all symptomatic runners in Blake type inverted orthoses based on the results of this study? The Blake inverted orthoses was originally developed to treat runners who failed to respond to a standard functional foot orthosis. Does this study tell us why some runners (the vast majority) did respond well to Root type functional orthoses while a minority needed a more inverted device? No.

 

Every study needs to be scrutinized, no doubt. But also, personal treatment successes should also be factored in, and, at some point should outweigh the writings/findings of academics. Positive patient outcomes...why are you so against this Dobbs?

In your world, as well as Simon's, measurements are meaningless, standards brushed aside, foundational precepts ignored and/or steadfastly challenged ad nauseum, (especially if a Yank created that foundation), and the world only revolves around TST...which basically solves nothing in the real world of private practice. N'est pas?

 

Jeff

conclude that orthoses are incapable of altering rearfoot excursion and peak eversion. However, we know that orthoses are capable of changing rearfoot position and motion. So why did this small study of eleven runners not demonstrate this? Could it be methodology,

No, because it's not quantitative. If you could maintain the same biomechanical effect, but change the distribution of the wt bearing surface beneath the foot, you could tell.

Simon

Nope, what we should conclude from this paper is that these subjects didn't have their symptoms relieved by the Root orthoses, but did have their symptoms relieved by the inverted orthoses-

So, the pt felt better when supinated a little. Imagine if all you had to do was add a small volume of fluid???

What we know is that the literature is split on whether foot orthoses alter rearfoot kinematics or not, Craig started compiling this data some years ago:

If you had a scientific orthotic, you'd see that rear foot kinematics is consistantly altered for the better.