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Should We Abandon The Concept Of The Subtalar Neutral Joint Position?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Petcu Daniel, Jan 8, 2020.

  1. Petcu Daniel

    Petcu Daniel Well-Known Member

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    Should We Abandon The Concept Of The Subtalar Neutral Joint Position?

    This is not a new question, isn't it?
    But in my country we have the answer: we can't abandon the concept of STJN!
    Because is an unknown concept - it is not taught in school!
    It is good or it is bad?
    I'll say it is bad because when you don't have these theories [any theory - all theories] taught in schools then the debate is absent and marketing takes the place of the teacher!
  2. Rob Kidd

    Rob Kidd Well-Known Member

    I am sure I have said this before, but maybe it is worth repeating. The definition of S/T neutral by either ratios or by "that position in which the joint is neither pronated nor supinated" is laughably tautological. I think all accept that now. However that doesn't stop it being a clinically useful entity. If I practiced, which I do not, I would undertake a cursory S/T neutral examination on essentially every patient. The mistake was to try and make science out of something which is not scientific.
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  3. Rob:

    That is essentially the same reply I posted up on the Podiatry Today website this morning in response to the recent debate by Drs. Fuller and Phillips regarding subtalar joint neutral. Root's definition of STJ neutral is classic podiatric tautology that made me cringe even as a lowly podiatry student upon first hearing it. Secondly, STJ neutral cannot be studied scientifically since it is not precisely defined. Therefore, the results of any research that uses the measurement of STJ neutral must be suspect, since STJ neutral lacks the scientific precision to make such research worthwhile.
  4. efuller

    efuller MVP

    No theory is better than bad theory. If you are taught the basic sciences, and remember them, you can better question what the marketers tell you.
  5. efuller

    efuller MVP

    Does anyone have a copy of

    Houck JR, Tome JM, Nawoczenski D. Subtalar neutral position as an offset for a kinematic model of the foot during walking. Gait Posture. 2008;28(1):29-37.

    Daryl, used it as a citation to support the idea the STJ neutral was good for something in the Podiatry Today point counterpoint article.
  6. Here you are, Eric.
  7. Petcu Daniel

    Petcu Daniel Well-Known Member

    My mentor told me that a bad solution is better than no solution. This because an open mind can improve a bad solution which is only a starting point.
    If I'm not wrong Tissue stress theory didn't started started only from basic science but from the problem with STJN theory. Maybe Sagital plane facilitation is one who doesn't mention the problems with STJN.
  8. Daniel:

    I would agree that a bad solution is better than no solution at all, but only if that bad solution isn't taught as dogma. As you probably know, when a bad solution is taught as dogma, many of those taught this "dogma", who would otherwise have open minds will consider it not worth their time to try and find a better solution since the problem seemed to already have been completely solved by those who had more knowledge than they.

    Tissue Stress Theory started when a few of us realized that the previous theory we were all taught as dogma was insufficient to explain reality, was inconsistent with the known principles of Newtonian mechanics, and, in some cases, led to treatments which were actually non-therapeutic for the patient (think treating peroneal tendinopathy with an "anti-pronation" orthosis).

    That being said, many parts of STJ Neutral Theory were very helpful for me in my student days in building my base of foot and lower extremity biomechanics knowledge and certainly helped provide me with a base to build on as I moved toward "Thinking Like an Engineer" and then fully embracing Tissue Stress Theory. However, I just wish I had been taught "biomechanics" in podiatry school less dogmatically, and with more focus on Newtonian mechanics, and less on "Root biomechanics", so I didn't have to do so much work on my own, and go through so many obstacles put in front of me by others, to finally arrive at Tissue Stress Theory as being a better model of foot orthosis treatment.
  9. Petcu Daniel

    Petcu Daniel Well-Known Member

    Totally agree! Thanks!
  10. Brian A. Rothbart

    Brian A. Rothbart Active Member

    The definition of STnp is easy, it is simply joint congruity (when the STJ is neither pronated nor supinated). Whether the foot functions around its' STnp is another question entirely.
  11. efuller

    efuller MVP

    There is a difference between a bad theory and a bad solution. The interesting thing about the history of Root biomechanics is that it looks like they found a solution and then tried to fit the theory to it. In my Podiatry Today piece I found some Root quotes that support the notion that they found what worked before they tried to figure out why it worked.

    I would agree any solution is better than no solution. However, a bad theory to explain the solution is worse than no theory. If you discard, or ignore, the bad theory, and still do what works, this allows one to be curious about why it works and to then come up with a better theory.
  12. Brian A. Rothbart

    Brian A. Rothbart Active Member

    I disagree with Dr Kidd's statement (above). It is very easy to palpate the STJnp and feel for joint congruity (the STJ, like the TMJ are two of the easiest joints in the body to palpate for congruity).

    When Dr Kidd stated it "is laughably tautological and I think all accept that now", he certainly has the right to express his own opinion, but to infer everyone else feels the same, is specious at best.

    5o years of clinical and research experience leads me to the following conclusions:
    • (1) One can easily determine if the STJ is functioning around joint congruity (e.g., its' anatomical nP)
    • (2) Most, if not all, postural joints function best around their anatomical nP
    I agree with Petcu Daniel, the concept of STJnp is critical in ones' biomechanical practice and should not be abandoned!
  13. Petcu Daniel

    Petcu Daniel Well-Known Member

    This article, Hannah Jarvis thesis and many other articles studied in parallel with STJN concept I believe are a good exercise for an open mind to educate its critical thinking [with all theories!] and not to become dogmatic. We can learn to ask from us the same rigor to analyse a new theory as we are doing with old ones!
  14. Rob Kidd

    Rob Kidd Well-Known Member

    Perhaps someone would be so good as to explain to Brian Rothbart what, in the scientific context, a tautology is.
  15. I want to first know why Brian Rothbart proclaimed himself to the "Father of Chronic Pain Elimination"? How convenient it must have been for Brian to make such a self-proclamation! http://www.clinicalbootcamp.net/proprioceptive-insoles.htm
  16. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Rob, kindly enlighten us. Unless you are referring to the assumption that STJnp being presented as crucial when, in fact, it is not. And, as I stated before, I totally disagree with this inference.
  17. Rob Kidd

    Rob Kidd Well-Known Member

    AS I suspect you know, all I am referring to is the lack of scientific validity for the definition of subtalar neutral. In this context I am referring to the definitions of either of 1) 1/3-2/3 calculations, or 2) "that position in which it is neither pronated nor supinated". Both of these are tautological. I am not getting bogged down in "that position in which the joint surfaces are most congruent"; I don't doubt this is true, but fail to understand how this is clinically measurable in a scientific context. I am referring to its scientific validity, not to its clinical usefulness - which I am not being critical of at all.

    But I think you knew that.
  18. Brian A. Rothbart

    Brian A. Rothbart Active Member

    My comments are directed towards the clinical usefulness, not the scientific validity, of STJnp.
  19. and when scientific examination of the position at which maximal congruity of the joint surfaces occurs is undertaken, it’s absolutely nowhere near the position most clinicians put the foot into to represent subtalar joint Neutral.
    ”The results demonstrate that the most approximate STJ neutral position was in the foot position of 10 degrees of abduction, 20 degrees of dorsiflexion and 10 degrees of eversion” Viz. the STJ articular surfaces are most congruent toward a position of maximal pronation and not at the mid range of the joint.
  20. efuller

    efuller MVP

    In the podiatry today piece on the pro and con on whether neutral position should be discarded, the pro side only gave one reason for its clinical usefulness. You needed neutral position to know if a foot was pronated or not. Yet, there is no evidence that pronation of the STJ is related to pathology. How is STJ neutral clinically useful?
  21. No we don't need "subtalar joint neutral position". We could very easily use the maximally pronated position of the subtalar joint (STJ) during standing, as I have already been doing for the last 30 years with my patients with the Maximum Pronation Test, in order to determine STJ rotational position during standing. Therefore, instead of saying a foot, during standing, is 3 degree pronated from the STJ neutral position, one could just as easily say the STJ is 4 degrees from being maximally pronated at the STJ, which would probably have much more clinical significance for the kinematics and kinetics of gait than using the highly variable determination of STJ neutral from one examiner to another.

    As far as non-weightbearing examination of the foot, the STJ neutral position could be replaced with the rotational position of the STJ when the plantar forefoot is parallel to the patient's transverse plane on the examination table. We used a form of this measure on the bicycle study I participated in that was eventually published in the Journal of Biomechanics 28 years ago (Ruby P, Hull ML, Kirby KA, Jenkins DW: The effect of lower-limb anatomy on knee loads during seated cycling. J Biomech, 25 (10): 1195-1207, 1992).

    A "forefoot varus foot" may be maximally pronated at the STJ when the forefoot is parallel to the patient's transverse plane but a "rigid forefoot valgus foot" may be 10 degrees supinated from the maximally pronated position of the STJ when it's forefoot is parallel to the patient's transverse plane. Not too hard to see how this could very easily work clinically, with much more reproducibility than STJ neutral position.

    As one can see, nowhere in my above discussion is the concept of "STJ neutral" needed to describe the rotational position of the STJ. Researchers have tried to make the STJ neutral concept work scientifically for the past 50+ years and it has failed. Maybe we should give the maximally pronated STJ position as a reference a try for the next half-century to see if it can be used better for scientific research on foot kinematics and kinetics. I think the results will surprise many of you at how well this measure of STJ rotational position, the STJ maximally pronated position, can be reproduced both in the clinic and in the research lab.
  22. Rob Kidd

    Rob Kidd Well-Known Member

    This really should not be necessary, among a group that consider themselves to be scientists, but there we go. To Brian Rothbart, a tautology is a scientific non-event when one uses ones-self to define ones-self. pronation and supination are defined as movements away from neutral. Neutral is defined as that position in which the subtalar joint is neither pronated nor supinated. Come back when you have grown up.
  23. Rob:

    I think you misunderstand Brian Rothbart. He is not like us.

    Brian Rothbart is the Self-Annointed "Father of Chronic Pain Elimination". Brian Rothbart has had to move from Washington, then to Florida, soon after that moved Mexico, then to Italy and now to Spain for unknown reasons. Brian Rothbart has supposedly charged up to $10,000 for a pair of insoles and consultation. Brian Rothbart named a variant of an elevated first metatarsal after himself, "Rothbart's Foot".



    I say these things publicly not so much for your benefit, Rob, but for the benefit of others following along. People need to know exactly the type of man Brian Rothbart is so they can decide for themselves if his opinions mean anything or not.

    And by the way, I agree with you regarding the definition of subtalar joint neutral being "neither pronated nor supinated". It simply is a laughable definition and should be to any scientist worth a grain of salt.
  24. While I generally concur with the sentiments here, I have to disagree with the statement that pronation and supination are movements away from “neutral”. Given the ridiculous but commonly employed definition of subtalar joint neutral, one might take a foot at end of range pronation that is supinating away from this position and is thus moving toward neutral; conversely we can take a foot that is supinated yet pronating toward “neutral”. Still tautological wankerism but we need to be accurate in our take down- they not always movements “away” from “neutral”.
  25. Didn't really want to get involved but vortex sucked me in.

    Most of the inshoe orthotic devices made world wide are not made with Neutral theory involved from assessment to production.

    The company I work for now days produced About 30 000 devices last year no 1 where Neutral theory was involved .

    People got better. Diabetic ulcers improved

    Time we stop having the same conversation imho
  26. The conversation needs to continue since most podiatrists worldwide still assume that the subtalar joint neutral position is the ideal position of foot function for all feet. In fact, maybe I need to write an article on it...because this conversation is far from being over among the world's foot-health care providers.

    It is not just about the poor, ludicrous definition of subtalar joint neutral, "neither pronated nor supinated". Rather, it is all about changing how the worldwide podiatry and foot-health professions evaluate and treat foot pathologies with OTC and custom foot orthoses.
  27. Brian A. Rothbart

    Brian A. Rothbart Active Member

    This is to bring you up todate since I published on two previously unknown inherited foot structures almost 20 years ago:
    Over 1,000 healthcare providers are now using the proprioceptive insole I designed specifically to reverse the gravity drive pronation resulting from Metatarsus Primus Supinatus foot structure (PMS)

    In Australia alone, over 150 practitioners have taken their training on using these insoles and are registered as providers on this site. (https://prokineticsaustralia.com.au/find-a-practitioner )

    The concept of STJnp is central to the understanding in the use of proprioceptive insoles. The research of Inman and Close in the 1940s established the understanding of hip drive pronation. My research in the 1990s established the understanding of gravity drive pronation.

    Treamill analyses demonstrates the timing of pronation which distinguishes hip drive (normal) from gravity drive (abnormal) pronation. You can view several examples of gravity drive pronation on the following webpages:

    Gravity drive pronation resulting from PMS (aka Rothbarts Foot)
    PreClinical Clubfoot Deformity
    Pressure Plate Analysis is the Gold standard for distinguishing between these two foot structures. https://www.researchgate.net/public..._Primus_Metatarsus_Supinatus_Foot_Deformities

    However, the Knee Bend Test provides a reasonable alternative as a differential diagnostic tool to distinguish between these two foot structures
    The internet is replete with subjective outcomes using proprioceptive insoles to control gravity drive pronation. Recently a paper was published by Renee Hartz MD on her experiences using these insoles.

    All intelligent, respectful inquiries will be answered. All diatribes and immature, unprofessional remarks will be ignored, as I have done in the past and will continue to do so in the future.
  28. Petcu Daniel

    Petcu Daniel Well-Known Member

    One question remains in my mind from the first reading of the text: do you see any connection between 'the impediment to the advancement of the understanding of foot function" and the way in which Merton Root has defined the concept of STJN, respectively "standing in the shower without any thought about the foot and all of a sudden the concept of neutral subtalar joint position flashed' into his mind?. In my understanding of the text this seems to be the first impediment which also is not 'technical' one.
    "The continued use of neutral position is an impediment to the advancement of the understanding of foot function. To understand why this is so, one must explore the development of the concept and its many uses. When asked how he came up with neutral position, Merton Root said, “One morning in 1954, just by luck I guess, I was standing in the shower without any thought about the foot and all of a sudden the concept of neutral subtalar joint position flashed into my mind.”1 Root described it is a position that is neither pronated nor supinated. Later, Bill Orien, DPM, said, “Neutral position is a figment of Mert Root’s imagination.”2 "
  29. efuller

    efuller MVP

    A reason that neutral position is an impediment to understanding foot function, is that people believe that neutral position is important and useful. If you believe that, then it is hard to use, or believe, information about the foot that does not include neutral position. As an example of this, I've heard an author complain that their paper was sent back by a reviewer from JAPMA because the inventors of neutral position were not referenced.

    Is there a connection between the above impediment and the "discovery" of neutral position? I believe that is what you are asking Daniel. Root and others proselytized the use of neutral position and because of that many just accept it as a useful fact. Yet, there is no science behind it. Why is neutral position useful? Why is neutral position neutral? Some claim it is a position of least stress. Yet, there is no stress analysis. Some claim that neutral position is a good position to put the foot in to be able to compare one foot to another. Those same people admit that the foot changes shape as the STJ moves. Is it really useful to compare one foot to another in a non weight bearing position, when the feet will have an entirely different shape when the foot is in stance? Why do people accept the usefulness of neutral position. Is it because one instructor has passed on a firmly held belief to another future instructor? Has Root's "revelation" and subsequent teachings been responsible for the persistence of a not useful idea?

    The connection between the "discovery" of neutral position and its impediment to future research is weak, although I tried hard to connect the two in the last paragraph. However, the knowledge of the amount of science that went into its discovery may be helpful for people trying to unlearn their acceptance of neutral position. There are plenty of other reasons, beyond how it was discovered, to reject the usefulness of neutral position.

  30. Rob Kidd

    Rob Kidd Well-Known Member

    Eric, nicely put. Take a team point. Rob
  31. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Why do we have a normative blood pressure, a normative body temperature (which by the way has changed from 98.6 to 97.5)?
    The answer is quite obvious, it provides a reference point to evaluate divergencies, whether it be in Orthopedic, Podiatric or Internal Medicine.
  32. efuller

    efuller MVP

    A temperature of 101 is indicative of a problem. Standing in a position other than neutral position is not a problem. Sometimes, standing in neutral position is a problem. Body temperature provides useful information. What useful information do measurements based on STJ neutral provide?
  33. Brian A. Rothbart

    Brian A. Rothbart Active Member

    10 years ago I opined that abnormal foot motion changes occlusion. I remember, at that time, many of the senior members of this forum thought that was absurd. Fast forward 10 years, published research has now shown foot motion impacts the position of the cranial bones (and with it, the occlusion). Rothbart 2013, Rodriquez 2018

    I now opine that abnormal foot motion impacts neural oscillations, more specifically, hyperactivity in beta waves and absolute power. Abnormal foot motion is defined (in this preliminary study) as a deviation from subtalar joint congruity. Hence the necessity of measurements based on STJ neutral position.

    Rothbart BA 2013. Prescriptive Insoles and Dental Orthotics Change the Frontal Plane Position of the Atlas (C1), Mastoid, Malar, Temporal and Sphenoid Bones: A Preliminary Study. Journal of Cranio Manidibular and Sleep Practice, Vol 31(4):300-308.
    Rodriquez A et al. 2018 Relationship between foot posture and dental malocclusions in children aged 6 to 9 years. Medicine. Online
  34. efuller

    efuller MVP

    However, the study that Simon quoted above showed that maximum joint congruity is close to maixmal pronatiion. That study showed that maximal congruity is no where near what podiatrists consider to be neutral position. Brian, if you are using joint congruity, then your study has nothing to do with STJ neutral. What is STJ neutral used for?
  35. dottiekat

    dottiekat Member

    Be great if they stopped teaching it at University. I graduated 4 years ago and it was still taught to great lengths, I got sick of hearing the name Root in the end. Whilst important in the history of biomechanics - thats where it should stay.
  36. Brian A. Rothbart

    Brian A. Rothbart Active Member

    STJnp is NOT close to maximal pronation. Clinically, this is very easy to demonstrate: Weight bearing, place the STJ into joint congruity (easy to palpate, easy to do). Note the position of the foot, it is NOT maximally pronated.
  37. efuller

    efuller MVP

    Brian, The definition of joint congruity is where there is maximum contact of the joint surfaces. Are you using a different definition? What part of what joint are you trying palpate when you feel congruity? The largest facet of the subtalar joint is the posterior facet of the talo calcaneal joint. When the surfaces of this joint have maximum contact, this is 1, not externally palpable and 2 in the maximally pronated position.
  38. Brian A. Rothbart

    Brian A. Rothbart Active Member

    The medial facet of the talocalcaneal joint, which is easy to locate and palpate, was the landmark we were taught to use in evaluating the position of the STJ.
  39. efuller

    efuller MVP

    Brian thanks for clarifying. Do you think it really makes sense to say the joint is congruent when other, larger, facets of the joint are not? The position that we were taught was congruent, is not really congruent. Then there is the question of weather joint congruency is a valid concept any way. A joint may be able to support a load when it surfaces are partway off of total congruency.

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