STJ Pronation Not the Common Cause of Foot Problems

Dennis did you happen to notice that if this is in fact the same David Smith that his prices for mail order orthoses is 1/2 the cost of devices made custom on his Amfit system and just slightly higher than a an off-the-shelf device such as Powersteps or Vasyli? How is that snake-oil?

At least David offers a variety of casting procedures (including pop and Amfit) and devices, which personally I find more realistic than a one paradigm solution to every type of foot we encounter.

 

Thank you Sam. The long leg side does not always pronate as Dennis has suggested. This is a fallacy and one that I have only encountered being taught in the podiatric field. Perhaps one of the more learned podiatrists here can comment on the origin of this belief. I believe that Eric and Kevin have commented on this previously and quite succinctly.

I would like to see some comments on what is the agreed amount of difference that denotes an LLD and where I can find this reference. I feel that compensatory leg length differences that are not anatomical are a common finding and are normal, just as shoulder symmetry is related to hand dominance (right hand = lower right shoulder = normal finding) need to be categorized as Leg Length Inequality (LLI) and not LLD. LLD is anatomical, we all agree on that I assume?

I see LLI everyday in practice as a Chiropractor. I firmly believe that after manipulating literally thousands of human spines that LLI is a normal consequence of muscular involvement and the function and alignment of the lumbosacral spine. Nutation and counternutation of the hemi-pelvis occurs as a consequence of muscle dominance and vertebral function, or dysfunction.

I often see patients LLI level out post-manipulation (sorry Kevin) only to return again exhibiting a difference in the same pattern. Why, I do not know, perhaps it is just the way that we are wired? I do know that in quite a number of these patients where there are excessive pronatory or supinatory forces found in their feet, gait dysfunction etc., when this is corrected with orthoses this pattern often changes or resolves. I think we are on the right track but more work needs to be done. I do applaud Dennis for vehemently pursuing that work, although I do not agree with many of his assertions and foot typing in general.

Dennis I feel that you are passionate about your Neoteric Biomechanics and I find some of your theories interesting and possibly of value. I am not meaning to come off in any way condescending, on the contrary I am being sincere in that I respect your passion. You are obviously an intelligent man but your posts of late appear to be more about picking battles than expressing the depth of your knowledge.

You can of course tell me to shove off but I hope that you take criticism in the same manner that you are offered praise when it is genuine.

Regards,

 

I agree that the two need to be distnguished between to avoid confusion. Just to make a quick point on semantics, I was taught, and I know quite a few practitioners use, Functional Leg Length Discrepancy (FnLLD) and Structural Leg Length Discrepancy to distinguish between the two rather than LLD and LLI.

cheers :drinks

Sam

 

At the risk of stepping on Admin's overworked toes do you think we could keep the LBP to the LBP thread? Gets too confusing else.

At the risk of getting between Dave and Dennis can i respectfully ask that everybody count to 23, take a breath, calm down and stick to discussing the models and not the moral turpitude of one another.



Regards
Robert

(see? Ugly!)

 

Robert:
I did not start The Arena Jehad that lives on my head, I was swept into it.
I will continue to be abusive when abused. I am not the prime mover.

After your very kind post, the next two were:
Dennis

Over the last 12 years, seven of my patients in different parts of the UK have won more that £1,500 on the National Lottery (one very fortunate lady won over £3.7 million). There could be more. However, one interesting fact is that six of these patients were prescribed simple poron insoles as part of their management.

With your hawkish eye for making a buck or three, do you think there is any merit in submitting a patent?

Yours
MR

And

David’s rant where he caslled a valedictorian graduate of a college of podiatry uneducated.
????????

I continue to try to wade through the slime in order to make and take points on subject.

Sam and Dave (Soul Men if I ever met tow) have found three (3)!!! Patients that go against my paper. I’m so very proud of that.
I had a patient the other day with a runty long leg, with little muscle power and a bigger bunion on the short side that certainly went against my usual findings. I felt somewhat better when I found out that he had totally torn his tendo Achilles years ago on the longer side in a motorcycle accident. (Any profiling system will have exceptions to the rules but that doesn’t justify not implementing it for the benefit of the masses).

Dave Stated:
did you happen to notice that if this is in fact the same David Smith that his prices for mail order orthoses is 1/2 the cost of devices made custom on his Amfit system and just slightly higher than a an off-the-shelf device such as Powersteps or Vasyli?

Dennis Replies:
So he gives out pieces of crap at half price offering lesser care than optimal. In cases like that, I dispense foot centrings at a lesser fee (often for free to the homeless, etc) and do not sacrifice the same care I would offer my mom or kids.
Wasn”t it David who posted:
Seriously tho Robert I would campaign for the best and most effective system of biomechanical intervention based on solid physics, scientific research
and deductive reasoning supported by proven or at least accepted basic axiom.
And now my twelve year old will step your feet into a foam box and make you a piece of crap!!

Sam Stated:
I have also seen a couple of elderly but active gentlemen recently who have no compensations whatsoever for their LLD small (<1.5cm).. they step up and over it without either foot pronating more or less, with out either leg moving in an asymetrical way... how would your TIP system help in this situation??
Dennis Replies:
Since TIP is a clinical scenario by definition your fictitious twosome (or your poor evaluation) where there is no compensation in these cases would deduce that TIP was not in play and no care would be necessary.
Dave Stated:
Thank you Sam. The long leg side does not always pronate as Dennis has suggested. This is a fallacy and one that I have only encountered being taught in the podiatric field.
TIP requires a positive FEJA test and two or more confirmatories to consider initiating care. If compensation for TIP is not frontal plane dominant, the long leg may very well not be pronated although often it is.
As per Roberts suggestion I am counting to 23 as I make this post and I will act accordingly and in closing. I am not trying to be Dr. Kirby’s arch nemisis. I can’t begin to hold a candle to his decades of unquestioned accomplishments.
I simply am saying that the pictures of orthotics on precisions website and those that he has chosen to display on The Arena couldn’t hold a candle to Foot Centrings. How about arranging a clinical trial at The Western which I assume Kevin attends (maybe now my challenge of months ago holds more weight).
Finally,
I am so waiting for David Smiths next posting. Paraphrasing one of his recent slime statements aimed at me:
I predict you'll be having a break and leaving us with a post about closed minds and unfairness but crucially avoiding answering any questions with a contrary view to yours, lest you be forced to confront the weaknesses of your crappy scanned or foam casted orthotics, which are great and manifold.
Only a buffoon would make that leap of logical fallacy---- or a charlatan!

All the best, Dave Smith
(I mean Dennis)

 

Dennis

You really should try and find out if NYCPM has a refund policy.

Kindest

MR

 

Seriously! Chill pill! This debate goes nowhere like this! From personal experiance (no evidence ) I can tell you the best strategy when abused is to rise above it. Then YOU appear the professional and THEY appear the unreasonable one. Eye for and eye and tooth for a tooth just makes us all blind and toothless!

Ref Dave's DIY insoles. I can't really comment on whether they are "pieces of crap" having never seen them. And neither has Dennis! I would say that I see nothing wrong in patients trying a pre fab before an expensive custom device and I likewise see nothing wrong with trying a soft insole moulded to a WB cast If it is inexpensive and sold as a comprimise or 1st phase measure.

Only if this was sold as a "functional orthotic" or offered as superior to conventional devices would I start to have concerns.

Re the LLD paper.

I think this paper misses out a few points. Craig Payne has, I beleive, produced data which shows no statistically significant correlation between the longer leg and the more pronated foot. This makes it hard to describe a causal link between the two unlikely. We also have data in hand in which induced hyperpronation (always a suspect research tool IMHO) in one leg causes a frontal plane incline of the pelvis.
We DO know that supinating the foot functionally lengthens the leg and as such could be used as part of a care package for an LLD. We also know that orthotics do not always cause the effect we expect and therefore if i was treating a LBP which i suspected was caused by an LLD i would be more inclined to rely on a simple heel lift.

I think the other major element lacking in this paper was that it focused on frontal plane kinematics and neglected sagital plane. It has been shown more than once, although again with the suspect induced hyperpronation, that increasing pronation in both feet causes an increase in pelvic anteversion and can therefore influence lumbar lordosis (which, I understand, can cause LBP).

I am always unsettled when i read anything on kinetic chain theory and LBP from podiatrists, especially if it appears to simplify the thing too much. LBP is a complex and multifactoral condition with many disparate factors. We have too much evidence to ignore, but not, i beleive, enough to be conclusive about the effects of orthotics on LBP. I am therefore suspicious of "simplified" models like TIP.

My view on this paper is therefor that as a resource for patients, to introduce the concept that the feet can be significant in LBP it has value, but that it gives nothing new to the profession, we are already a little beyond it.

Kind regards
Robert

Ps FEJA? Whats one of them again?

 

What you fail to realise Dr Sha, even at this late stage as you desperately lash out and thrash around in tortuous death throws, is that I only asked relevant question of proof or reasoning, pointed out the weakness of your argument and repeated shortcoming admitted by your own writing. (with the occasional light dig)

It was your choice to refuse to give reasonable answers, admitted your arguments were weak and were incapable of answering with evidence or using reasoning of anything but passion.

You did not even answer Roberts probing and pertinant questioning even though he is one of the most affable persons on Gods green earth or at least this forum. (although, with a wickedly venomous bite when cornered I might casually warble - nice!)

So if that's the best you've got and as you fall on your sword I'll bid you farewell, ta ta!

Dave Smith

 

In my opinion this has gone from reasoned argument, to unreasonable argument, to pure slander.

At no point Dr Sha have I attacked your character or how you treat your patients and I find it appalling that you have attacked me in such a way.

You don't know me!

I am a firm believer that a practition doesn't need to know the ins and outs of moment arms, forces, newtons laws, GRF's and that a life time of dedication to his practice and doing the best by patients is more than enough to declare him a good practitioner. I do not refute the fact that you have most likely changed peoples lives for the better with your interventions. We were arguing theoretical points, which when pushed you could not defend.

This argument has ended with mud flinging and I have no interest in participating at such a level any longer. This is Podiatry Arena, not the Daily Mail.

For that reason I wish ro draw a line under this topic and will comment no further on this post.

Regards,

Sam Randall

 

Sam: I assume that you are referring to my comment:
Since TIP is a clinical scenario by definition your fictitious twosome (or your poor evaluation) where there is no compensation in these cases would deduce that TIP was not in play and no care would be necessary.
Your upset makes me realize that I got carried away and I apologize for the way I slandered your practice skills (since I have no idea what they are) and more important, you are entitled to style your work as you please as I am sure you have many happy patients and get good clinical results.
It is not fair for me to do to you exactly what makes me feel personally uncomfortable.

For my next 20 posts, I will not address nor add to any personalizations and will absorb any sent my way during that period.

Dennis

 

A graceful apology!

Who me . Never fear, i'm saving it all up for the day Mr Khan dares the forum to tell us how applying marigold paste to a bunion reduces the IM angle :butcher::butcher::butcher:. Then there will be trouble I swear!

Shall we try to grab this debate by the danglies and drag it whimpering back to the point?

What was that point again?

Oh yes. I remember. Dennis was making observations about what he beleives to be the most common foot type, rigid rearfoot and flexible forefoot.

I think it would help to clarify and redefine how one identifies such a rearfoot. The information provided states that is a rearfoot in which the calc is inverted even when in a maximally pronated (everted) position. Dennis, once again and for clarity, how are we deriving our baseline here? More inverted than what. Are we bisecting calcs and legs or using some other tool (behave Ian). Until we understand this, all further debate is fairly meaningless.

I objected to this on the basis that most feet i see have STJs capable of everting (relative to, say, a perpendicular line to the transverse plane / ground).

I also disagreed with this statement

Because it is A: unsupported and B: I don't think it holds up to scrutiny. I don;t beleive that a foot with a small evertory range behaves differently within that range when a force is exerted on it. An arthritic STJ, for example, with a tiny range which has huge residual moments from bony contact might respond very well to rearfoot wedging to increase supination moments EVEN IF THERE IS NO ACTUAL MOVEMENT AT ALL!. As Craig and others are fond of saying, forces hurt, not movements!

Dave Objected for several reasons, not least that

Leaving aside snake oil, crap orthotics, ad hominems, slime, naval engagements and all of that, what say you to the above Dennis?

Kind regards
Robert

 

Dennis, as a point of clarification, Merton Root did not recognize the existence of a "MTJ neutral position". He only recognized the:
1. The maximally supinated position of the MTJ
2. The maximally pronated position of the MTJ
3. And those points between the maximally supinated and the maximally pronated position of the MTJ.

While there is relative supination and relative pronation of the MTJ, there is no transitional point (ie neutral position) in which the MTJ is neither supinated nor pronated. This is likely due to the fact that one can only measure relative inversion and eversion of the forefoot to the rearfoot and not the actual position of the MTJ. While there potentially may be some anatomical basis for the neutral position of the STJ (such as a state of maximum joint congruity), there appears to be no anatomical basis or clinical relevance for a MTJ neutral position.

Respectfully,
Jeff

 

Simon

I had only recently got rid of that particular salty baby nightmare picture from my imagination now you've gone and put it right back, more therapy:wacko:

LoL Dave

 

Mr. Root:
Sorry again.
Such an education for me.

Rf: STJ Neutral
FF: Ground reactive pressure under the fifth metatarsal until STJ Neutral is maintained. (Imitates the MTJ in closed chain in the midstance phase of gait.)
I find chiro's PT's, DPM's and Orthot's know this position and I have always strongly felt that the bisection measurements were not reproducable or valid.
The critical thing is to state that this is a starting position for measurong and cast correcting but in no way is it "healthy" or functionally a good position.
Dennis

 

Root did not advocate a direct pressure casting technique, rather the suspension cast in which no direct pressure is applied plantar dorsally to the 5th metatarsal.

The critical thing here is that you seem to be making the assumption that foot orthoses somehow hold the foot in this position; they don't. The other critical thing here is that the area within the RoM at which the subtalar joint is neither pronated nor supinated should also correspond to the zone of optimal stress for the tissues limiting motion at this joint; this should be a "healthy" and functionally good thing.

The question then becomes: Dennis, why do you believe that "in no way is it healthy or a functionally good position"?

 

For all of us! Thats what we're all here for:drinks

With you. Measured how. Talar heads? Bisection? What.

R

 

Not me, couldn't give a toss about learning, only here to annoy and quote song lyrics.

To add to Robeers list: dell in the arc?
I'm also only here for the Robeer.

 

Get your draft robeer here! Cures infertility you know!

Just for you Simon

The moody blues

Say what you mean, mean what you say,
Look into the world of tomorrow.
Say what you mean , want what is true

Look into that world full of sorrow.

Kind regards
Robeer

 

On a semi serious note I don't know how the dell in the arc could work with the "rigid rearfoot". The arc would be between inverted and really inverted so the dell, if such existed, would be somewhere between the 2.

If we are talking Root then the most commonly accepted method of finding neutral is by talar head prominance (correct me if I'm wrong here Jeff) in which case the rigid rearfoot is one where we cannot make the medial talar head more prominant than the lateral (ie that the perm, the maximally pronated position) is inverted (supinated).

I can only think of one of these off the top of my head!

That's where I'm confused.

It might also make the model easier to follow if there was more consistancy of terminology. We have perm and serm which refer to pronation and supination (triplanar movements) which are being measured against inversion / eversion of the calc, a frontal plane movement which can arise from that triplanar movement. Then we return to the stjn, a position within a triplanar joint again!

Kind regards
Robert

 

Robert Stated:
I think it would help to clarify and redefine how one identifies such a rearfoot. The information provided states that is a rearfoot in which the calc is inverted even when in a maximally pronated (everted) position. How are we deriving our baseline here? More inverted than what. Are we bisecting calcs and legs or using some other tool.

Dennis Replies:

Starting from STJ neutral, MTJ locked in midstance (open chain) the subtalar joint is forcably inverted to Supinatory End Range of Motion (forceably would imitate no more than ground reactive force.

Rearfoot SERM: Hint: The rearfoot forced inversion generally goes to a position parallel to the axis of the ankle joint.
In the rigid rearfoot the heel remains inverted from vertical: reported as RF SERM INVERTED.
(lets say if evaluated, the STJ is 18 degrees inverted SERM.

Now the foot is forcibly everted to its Pronatory End Range of Motion and it moves anywhere from 0 to 17 degrees so that its end position is still INVERTED to vertical in PERM. This is reported as RF PERM INVERTED.

In closed chain, this rearfoot contacts in varus and then pronates the available number of degrees but does not make it to vertical.

Every individual with a rigid rearfoot functional foot type contacts and compensates differently in closed chain (note: not just gait) allowing the FFT System to be custom for each patient as to treatment, once typed.

In Neoteric Biomechanics:
The Rigid Rearfoot SERM INVERTED PERM INVERTED
The Stable Rearfoot SERM INVERTED PERM VERTICAL
The Flexible Rearfoot SERM INVERTED PERM EVERTED
Yhe Flat Rearfoot SERM EVERTED PERM EVERTED

Starting from STJ neutral, MTJ locked in midstance (open chain).

Forefoot SERM: This forefoot forceably plantarflexion and goes to a position below the fixed 5th metatarsal head. PLANTARFLEXED (FFT uses 5th, not 2nd met as reference)
(lets say if evaluated, the 1st ray is 11 degrees plantarflexed. FF SERM PLANTARFLEXED

Now the first ray is forcibly dorsiflexed and it moves anywhere beyond 11 degrees (in line with the fifth to about 15 degrees dorsiflexed to the fifth met head so that its end position is DORSIFLEXED. FF PERM DORSIFLEXED

In closed chain, this forefoot first ray contacts the ground early in midstance and then raqpidy pronates, lowering the Vault of the foot.

Every individual with a flexible forefoot functional foot type contacts and compensates differently in closed chain allowing the FFT System to be custom for each patient as to treatment once typed.

In Neoteric Biomechanics:
The Rigid Forefoot SERM PLANTARFLEXED PERM PLANTARFLEXED
The Stable Forefoot SERM PLANTARFLEXED PERM ONLINE WITH 5th
The Flexible Forefoot SERM PLANTARFLEXED PERM DORSIFLEXED
The Flat Flatfoot SERM DORSIFLEXED PERM DORSIFLEXED

Once typed, foot type-specific casting and prescribing techniques can be selected that are further fine tuned for patients within each foot type.
Dennis

 

Dennis.

Now I'm even more confused!

You put the foot into stjn. With you so far. Youinvert the foot to find a seem. Let's use your eg of 18 degrees. Fine. You then evert the foot to find the perm and if it's 17 or less it's a rigid foot.

But you just said you put the foot in neutral. If the maximally pronated position was inverted you would not have been able to put the foot in neutral would you? Cos neutral is more pronated than inverted!

I need a robeer!

 

Robert Stated:
If the maximally pronated position was inverted you would not have been able to put the foot in neutral would you? Cos neutral is more pronated than inverted!

Dennis Replies:
Perhaps Jeff Root could add to this but in my experience STJ neutral is rarely pronated (everted) past vertical!!

I believe this is a critical post because if Robert is confused here then it should either drive many THANKS or a huge negative reaction.

Example 1
1 degree varus (eversion)
18 degrees varus (inversion)
Total ROM 17 degrees

Formula
1/3 eversion, 2/3 inversion

1/3 of 17 = 6

STJ neutral is 7 degrees
Rigid rearfoot

Example 2

Minus 15 degrees eversion

17 degrees inversion

Total ROM = 32 degrees

1/3 of 32 = 11

STJ Neutral is minus 6 degrees valgus
Flexible Rearfoot

The fact that most of the feet you measure have a varus STJ neutral reinforces the fact that most rearfeet are rigid
Dennis

PS: Robert, please rearfoot type your next few patients and report.

 

Ignoring the fact that if we have 1 degree of eversion and 18 degrees of inversion this gives a total RoM of 19 degrees, not 17. The 2:1 ratio assumes that there is twice as much inversion as eversion at the STJ of all individuals. Planal dominance and variation in the spatial location of the subtalar joint axis means that calculation of neutral position using a 2:1 ratio is invalid for the vast majority of individuals.

 

More on subtalar joint neutral here:
http://www.barefootscience.com/data/research/Ar14.pdf
http://www.jospt.org/members/getfile.asp?id=3626
http://www.japmaonline.org/cgi/content/full/91/3/121?maxtoshow=&HITS=10& hits=10&RESULTFORMAT=&fulltext..
http://www.jospt.org/members/getfile.asp?id=3817
http://www.barefootscience.com/data/research/Ar15.pdf

 

Simon:
I am in total agreement. That is why my system doesn't take measurements as it must allow for the variations you suggest.
#1 By functional foot typing, you reduce many planar variables foot type specific into smaller groups (i.e the rigid rearfeet have higher transvers planar compensations, the flexible rearfoot type, more frontal).
#2 I was just trying to explain to Robert how for many feet, the neutral position can and does live inverted in feet that never go beyond vertical into pronation.

My opinion is that you are challenging here for the sake of challenging and not allowing any poetic license to make a point.
If I say something is green and you want to argue that there are different shades of green in play and I should define each and give percentages for each of those shades, addressing those points divert and deflect us away from the topic and in a live debate, I would say that we should stick to the point.
In your honor, I will call these future diversions Spoonerisms and add that to The Dyfoot Type (joke).

"Give me a chance or apply your amazingly rigid protocols to you and yours, all the time, as you do me".
Dennis

 

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=15610

 

Dennis,
As Dave pointed out: you don't appear to want to debate, nor answer questions. You merely wish to state your case. You make points which are challengeable and therefore debatable, when I point these out to you, you do not attempt to provide counter argument or defend the moot point, but rather you make it personal and tell me I'm arguing for the sake of arguing. Unless you can start to come to terms with the fact that there are some very smart people who use the Arena, people who might just know a little bit more than you about certain topics, you may soon find that no-one is willing to engage with you in threads. This will be your loss.

 

I am using Root STJ neutral as a starting place for my casting and examining. NOTHING MORE!

I do not wish to debate if that is the real STJ neutral position (which it is not) and if that healthy (which it is not) or functionally important (which it is not) or if studies are showing it to be totally wrong (which they do).

It is simply a reference point that has been teachable since 1977 and has permeated the clinical world.

What part of I am in agreement with you do I need to debate further or answer?
You are right
You are right
You are right
but I am not wrong.
Dennis

 

Dennis,
You state that the above was a "critical post" and then describe using a 2:1 ratio to calculate STJ neutral. I then comment on this and now you say you don't want to debate it?

You've said this twice now, so I'll ask again: why do you believe that subtalar neutral is not "healthy" or functionally important?

 

Simon:
Root STJ neutral (for most feet)
does not reflect an optimal support for the vault of the foot.
It does not reflect an optimal rearfoot/forefoot relationship.
It allows for the development of overuse symdromes, deformity and pain syndromes.
When Root STJ Neutral is used to cast for shells of orthotics via plaster casting, scanning or foam, produces devices that are too wide, too long, too low vaulted and not effective in promoting power and phasic activity in extrinsic and intrinsic musculotendonous units.
Dennis

 

Please define "vault of the foot". What is the "optimal position for the "vault" of the foot?

I thought we we're talking about the STJ neutral, not forefoot to rearfoot alignment? Nevertheless: what is the optimal rearfoot/forefoot relationship?

How? Any evidence for this?

That's not what the research suggests:

"Other research studies have focused on the
effects of foot orthoses on the specific electromyo-
graphic (EMG) activity of muscles. Foot orthoses
have been noted to significantly alter the EMG
activity of the biceps femoris and anterior tibial
muscles during running (48) and significantly alter
the duration of anterior tibial muscle activity during
walking (66). More recent research has docu-
mented that certain foot orthosis designs can cause
significant alterations in EMG activity in many of
the muscles of the lower extremity during running
(46) that also may be related to differences in per-
ceived comfort between certain types of foot
orthoses (45). "

Kirby, K.A.: Foot Orthoses: Therapeutic Efficacy, Theory, and
Research Evidence for their Biomechanical Effect. Foot and Ankle Quarterly
Vol. 18, No. 2.

45. Mundermann A, Nigg BM, Humble RN, Stefanyshyn
DJ. Orthotic comfort is related to kinematics, kinetics,
and EMG in recreational runners. Med Sci Sports Exer-
cise 2003;35:1710-1719.

46. Mundermann A, Wakeling JM, Nigg BM, Humble RN,
Stefanyshyn DJ. Foot orthoses affect frequency compo-
nents of muscle activity in the lower extremity. Gait
and Posture, In Press, 2005.

48. Nawoczenski DA, Ludewig PM. Electromyographic
effects of foot orthotics on selected lower extremity
muscles during running. Arch Phys Med Rehab
1999;80:540-544.

66. Tomaro J, Burdett RG. The effects of foot orthotics on
the EMG activity of selected leg muscles during gait. J
Ortho Sp Phys Ther 1993;18:532-536.rheumatoid arthritis. J Rheum 2003;30:2356-2364.

 

Simon Says (instead of States)
That's not what the research suggests:

Dennis Replies:
Twaddle

 

What a twat you are. Good bye.

 

One of the obstacles to meaningful discussion and debate here is the lack of common, consistent, and accurate terminology. For example, comments have been made as to heel (calcaneal bisection) position without indicating whether it is in reference to the leg (i.e. distal third of the tibia) or the floor. Although cumbersome, this is important. Open chain evaluation of the rom of the STJ in reference to the distal third of the leg tells us if we have a rearfoot varus (an inverted neutral position), rearfoot valgus (an everted neutral position) or a “normal” rearfoot (1/3 eversion, 2/3 inversion). These measurement values are only made in reference to the leg. An important footnote is to remember we are only measuring the frontal plane component of STJ motion and not actual range and direction of STJ motion.

Rearfoot varus is clearly the most common rearfoot condition so we can say with confidence that the average foot has a rearfoot varus. Unfortunately we don’t treat averages, we treat individuals. You don’t go to the optimists age get prescribed eyeglasses based on the average vision, they actually measure your own vision and prescribe corrective eyewear based on your individual eyesight. If in lower extremity biomechanics we do not have a standardized system of measurement, we can’t have meaningful discussions about structural variations. Although these measurement systems are not an exact science , they do have clinical, educational, and scientific significance. Until we have a better system or can develop better measurement techniques, we must live with these limitations or not engage in debate with reference to them. Both options suck!

Clinicians often attempt to make clinical judgments without actually measuring range and direction of motion. To the well trained eye, we can usually recognize a rearfoot varus or a rearfoot valgus by looking at the open chain ROM of the rearfoot without actually measuring it. This ability usually comes after mastering the measurement technique. I am a firm believer that it is imperative to use both open and closed chain methods of clinical evaluation in order to develop meaningful opinions about biomechanical function and influence of human variation. It is both an art and a science.

Dennis, I appreciate (ie understand) what it is you are attempting to accomplish. The majority of DPM’s here in the states want biomechanics to have a more cookbook like approach. Podiatrists in other countries tend to be more mechanically oriented and like an engineering/scientific approach. I know I’m generalizing, but I feel there is a basic truth to it.

I remember the conference where Paul Schere and Jack Morris introduced their foot matrix that showed nine basic foot types. My father about hit the ceiling! Given the combinations and permutations of foot types, he felt it was a gross simplification with no clinical value. I think one of the problems that I and some of the others have with your matrix is that you’re making major structural and functional assumptions that are based on vague methods of evaluation. While this approach might be embraced by the cookbook crowd, I don’t think this group welcomes that line of thinking.

 

Amen to that.

 

:good:

Nicely put, especially the highlighted comments. succinct and to the point, I think I get a bit too convoluted and effusive in my arguments sometimes.

:drinks Dave Smith

 

I'm less confused now. Still got more questions than answers though!

So you are defining sub talar neutral as the position 33 % more inverted than the maximum everted position right? As in 1/3 of the way from maximum eversion. I've been working on the basis of the modified Root technique described by Elveru (thanks Simon) in which the heads of the talus are palpated for the position of maximum congruity. This, I beleive, is the one most commonly used clinically (based on personal experiance) Thats where the confusion arose. Makes sense now.

In which case as you say both of these positions will indeed have the bisection of the calc inverted.

Would it not be simpler to describe the rigid rearfoot as one where the rearfoot cannot be everted past vertical (based on the leg) In open chain?

However.

You said earlier

So what are we measuring if not bisections? What do these angles relate to?

Sorry if i'm plodding here guys, I just don't think we can even START to discuss the hypothesis until we understand the test. And I don't understand how we go from not bisecting anything through to basing the test on the bisection of the calc (bugger to measure) against bisection of the leg (even more so!)

So

1. Can we agree on whether STJ neutral is the position of maximum congruance in the STJ as derived from palpating the met heads OR the position 1/3rd of the range from max eversion.

2. Can we discuss how to derive a rearfoot / leg angle without bisecting anything (if its unrepeatible done by pen and palpation it must be doubly so done by eye!)

I might if I can figure out how!

Oh and

This is, I feel, a little childish and more to the point adds nothing to the debate. You made a contention (Root devices don't work.) Simon answered and gave some good evidence to support his argument. Saying "twaddle" is not convincing as a comeback! I'm sure you can do better if you try!

Why twaddle? Are you saying that research is invalid? Not relevant? If so WHY? Can you point to other evidence to support YOUR argument?

Kind regards
Robert

 

This thread is titled “STJ Pronation Not the Common Cause of Foot Problems”. To which I would ask then why, when we reduce the amount of STJ pronation, do so many patients experience symptom resolution? It’s like saying that falls are not a cause of death; it’s the sudden stop at the end that causes death. Without the fall to begin with, there would be no sudden stop at the end. Prevent the fall and you prevent the death! So when you reduce the degree and or the duration of STJ pronation, you will see symptoms respond.

Pathological STJ pronation is far more common than pathological STJ supination. It only makes sense that there must be a link between pronation reduction and symptom resolution just as there is a link between reducing falls and reducing death. STJ pronation has a profound influence on the stability of the other parts of the foot (pronated foot = mobile adaptor and supinated foot = rigid lever). When the foot is pronated, potential motion within the foot is greater than when it is supinated. Therefore one might argue that when the foot is pronated at the STJ, it increases the potential for motion related foot problems within and extrinsic to the foot. For example, a patient might have excessive STJ pronation due to a congenital long 1st met which has resulted in the development of a metatarsus primus elevatus, bunion deformity, a medial pinch callous on the hallux, and low back pain. We use an orthosis (custom or prefab) to reduce the compensatory STJ pronation and the elevatus reduces, the callous resolves, and the low back pain is disappears. Did STJ pronation “cause” these symptoms, did functional hallux limitus “cause” these symptoms, or what? Did reducing STJ pronation reduce these symptoms or did altering the forces (position or motion) at the other joints resolve these symptoms? I guess it depends on your perspective.

When we take the bait (traditional orthotics don’t work) fish on the line! When we respond, they reel us in! When there is evidence that other methods work better than traditional orthoses, I will be all ears and will gladly alter my methods of treatment and manufacturing to adapt or I will otherwise suffer the consequences.

 

Thats the paradox we been dealing with for a long time:
1. The prospective studies show that rearfoot/midfoot pronation are not linked to an increased risk for overuse injury.
2. We "generally" use foot orthotics to treat what we clinically see as "excessive rearfoot pronation"
3. The patient satisfaction studies; outcome studies and randomized controlled trials tell us that when we do that, patients get better
4. Half the biomech lab based orthotic studies tell us that they don't really change the pattern of rearfoot motion and the other half tell us they do, but only by a small amount.
4. Our own work has shown that, even if you do change the pattern of rearfoot motion, that this is not correlated to clinical outcomes.

I see that as a huge paradox.

More and more data is pointing to the solution of the paradox as being one of altering moments and not motion. I believe that the 'holy grail' of foot orthoses (in the context of "pronatory pathology") is:

1. They have to reduce the rearfoot inversion moment (and not necessarily motion or position)
2. Lower and smooth the 1st mpj dorsiflexion stiffness curve.

 

Until I had gone on one of CP's Boot Camps, I would have absolutly no idea what that even meant. Now I understand it; seen the evidence that CP uses and the logical intuitive story he tells, I would have to totally agree.