STJ Pronation Not the Common Cause of Foot Problems

Robert Stated:
Why do you feel this (Varus Wedges) is used excessively and unneccessarily? Do you mean used in patients in whom it should not be, used in patients in whom it should be too too great a degree or other.

Please support what you say with EITHER research OR a reasoned deductive explanation (just as good).

Dennis Replies:
Foundational Rant to my Deductive explanation:
I “grew up” in East Coast Biomechanics that never really “got” Rooted (Valedictorian 1970, NYCPM).

Our labs did their version of Root and leaned towards making a device that was safe, somewhat effective and didn’t cause problems when dispensed and the labs (as professors) controlled the educational content at the colleges in the East (as well as the West…….TO THIS DAY).

This was the start of The East vs. West Biomechanics battle (which was never a battle since the East Coast was, and continues to be in darkness).

The labs only interest was in profiteering and in taking the $22 of plastic and crepe to make a device that was accepted by the patient and either paid for by insurance or the patient with maximum profits.
The Scanner, CAD-CAM, foam and any other diversion from hands on doctoring was the goal (Take the DOC Out of THE BOX).

As every DPM had a lab for sending casts to, new clients had to come from other professions that had no foundational biomechanicval training and so we are being herded to villift “mail order foam orthotics being sold by a white coat doctor image on the internet that mails you a box and makes a state of the art, DPM approved orthotic (Glaser) as the gold standard.

So over the years:
1. Add plaster to the positive to reduce Vault height and eliminate arch pain rejection
2. Invent the intrinsic forefoot post, The Emperers New Post and sell it by brainwashing students that an extrinsic post doesn’t fit into shoes. (It costs much more to pay labor to glue, cut, polish and paste a forefoot post and what about the time it takes to Make a cutout?) The professors sold it that it doesn’t fit in a shoe and that soundbite stlill lives (What about your Pavlovian reaction that the long side pronates when I present TIP …..???).
3. Finally, they latched on to Roots main fault..that the STJ is the center of the universe and STJ neutral casting is the healthiest position for the foot to function from (Kevin uses the term when he writes about presenting orthotics to a patient in his third book!!) Most of the upgrades and expansions of Root (with exceptions like sagital plane, glaser and I) continue to be Rooted in the STJ (want to buy a STJ Axis locator or make a medial skive or a Blake inversion?) and the STJ remains the focus of attention (how important are rearfoot posts in the big picture?).

I have fought to not succumb to these diversions and have continued to develop clinical strategy that treats for rearfoot, forefoot and Vault pathology and I hope its time for The Vault to be recognized (Since I coined the term).

Blood Typing, Salter-Harris, Wound Classification Systems, yes, they all make midjets out of our minds and our clinical skills??????
Once typed or classified, a skilled practitioner can further examine, research and treat the variations in the group and offer care that would be harmful to other types and develop type-specific advances, improved outcomes, reduced failures and open the door to performance enhancement, prevention and quality of life issues more targeted, NOT LESS custom or needy of a clinician BUT MORE!).
Why don’t you forego the blood typing test the next time your child needs a transfusion!

I lied about starting a NEW THREAD! I will post a guest editorial I published for Justin Wernick in 1989 on the Future of Biomechanics! Much of it is still true today (and note my emphasis on research!!!!..... I luv u guys!).

Now,
If you still want to waste all of our time with why we do or don’t need a rearfoot post, I will be glad to answer Roberts question in my next post on this thread!

Dennis :drinks :empathy:

 

Do please! I'm all ears.

Don't think you'd be wasting my time, i'm still labouring under the dellusion that rearfoot posts / skives can change intenal forces in the foot, reduce harmful forces and allow damaged tissues to heal!

There are a few things I might comment on in the above, but I don't wish to distract you.

Prey, continue!

Regards
Robert!

 

Robert Stated:
Rearfoot posting. Why do you feel this is used excessively and unneccessarily? Do you mean used in patients in whom it should not be, used in patients in whom it should be too too great a degree or other.

Dennis Replies:
Let’s start with why RF Varus posts are utilized (please add as you see fit).

1. reduce pronatory moments
2. to elevate the medial arch (column)
3. to compensate forefoot varus
These entities can be treated with other care reducing the need for rearfoot varus posting.

They “bring the ground up to the floor in the rigid types”
They “stop pronatory moments in the flexible types
IF NOTHING ELSE IS DONE!

But:
They exaggerate GRF to the medial heel unnecessarily
They elevate the medial rim (phlange) of the orthotic irritating the arch
They increase forefoot dorsiflexion stiffness (or is it increase?). They increase bad dorsiflexion stiffness.

They do not take into account that the body of calcaneus/posterior tubercle calcaneus relationship which is when the body of the calcaneus is vertical, the tubercle is in varus. This means you should subtract that amount of varus from your posting so
A 6 degree rearfoot varus might only be causing a 3 degree pronatory moment and so only needs 3 degrees of varus posting. Six would be too much.

In addition:
The default at many orthotic labs is 3-4 degrees varus no matter what the foot type or your Rx!! This reduces the abilty to do anythiong else without causing problems.

So if you are doing something else to reduce forefoot dorsiflexion stiffness (or is it incresase) rearfoot varus posting would lead you to believe that the "something else" was the root cause.
So do something else, varus post less.

My argument would be that if there is a ROM of the rearfoot that will allow it to go to vertical, we should be looking to remove or reduce rearfoot pronatory moments to a STJ position of 3 degrees of varus and then post that orthotic vertical or 0 degrees.
If STJ ROM in pronation can go beyond vertical then the foot should be casted in 3 degrees varus and posted vertical or 0 degrees.

If the Rearfoot goes to verticle than cast in 3 degrees and post vertical.

Honest guys, this all makes more sense when you start out by functinal foot typing the patient.

Deep heel seats reduce the amount of varus posting needed as they reduced soft tissue pronatory moments and superstructure pronatory moments and vaulting reduces the need for varus posting (and medial phlanging) as they reduce pronatory moments and plantar fascial stress.

I’m sure that I haven’t made my point by evidence but nevertheless that is my point.
Dennis

 

Thanks for playing! :drinks

Yep.

Possibly

Eh? How? If the plate is 2/3rds length it will exaggerate a FFvarus if anything won't it?

Yes. But I could walk to work rather than drive. I'll still drive if i have a choice.

Bring the ground up to the floor? Don't know what that means

No, they might reduce pronatory moments and increase supinatory moments but they won't stop pronatory moments.

IF NOTHING ELSE IS DONE!

But:

Thats one way they increase supination moments and decrease pronation ones, yes. However that is the goal in most of my devices in some way shape or form so how is it unnecessary?

I can see the thinking, but if the cast is properly modified they should not.

Lost me utterly here. What is "bad dorsiflexion stiffness?

Think i follow you here. You're saying that one should post to the planter aspect of the calc because its a rhomboid not a triangle right?

Certainly something to be aware of, but hardly a reason not to use RF posts. Also, if we are playing the "shooting for a certain position" game this assumes that a 6 degree post will invert the calc by 6 degrees. Obviously it won't! What if the 6 degree post inverts the calc 3 degrees?

Not come across this so can't comment.

Are you talking about the CCJ locking / unlocking as the foot inverts / everts? Still don't quite follow!

Hmmm. I think I see what you are driving at here. I take issue with you on a few point.

1. You seem to be assuming that midfoot wedging (in the arch) does NOT invert the heel. It can.

2. You seem to be assuming that rearfoot wedging will invert the rearfoot. It does'nt always.

3. You seem to be assuming that posting x degrees will invert the calc by x degrees. It won't.

4. You speak of " looking to remove or reduce rearfoot pronatory moments to a STJ position of 3 degrees of varus and then post that orthotic vertical or 0 degrees." as if the foot was static and had only one position. It does'nt. When are these angles extant? Mid stance? End range? At what point during the dynamic foot cycle doe the foot pass through these positions?


Perhaps it is an outgrowth of a model which segments the foot but there seem to be an few ideas underscoring what you write. One is that orthotic modifications only act on the segment sitting on them The other is that the foot functions in the position you put it in. Neither of these are true.

Try these for ideas. Give a yes no answer if you can.

Many orthotics are designed to decrease pronatory moments and / or increase supinatory moments in the STJ.

Rearfoot wedges decrease pronatory moments and / or increase supinatory moments at the STJ.

As to whether they are the BEST way, well thats another thing. However of all the points medial to the Sub talar axis where one can increase supination moments by increasing GRF i'm happiest doing it under the heel, which is designed to absorb the greatest volume of GRF. Thats not to say i'll not use other ways, like mid or forefoot wedging as well, but i think to not utilise the heel is to pass up one of the best places to push!

Regards
Robert

PS The reason I am increasingly switching to skives, from posts, is that a skive does not alter the morphology of the midfoot part of the orthotic. If I want to increase GRF in the medial part of the Mid and rearfoot, I post. If i want to increase GRF in the medial part of just the rearfoot, I skive. If i want to increase the GRF in the Medial part of the midfoot but not the rearfoot, I remove some plaster or cast inverted. If i want to increase GRF in the medial part of the Forefoot (rare), I use a FF varus extention. However Its worth remembering that all parts of the orthotic affect all parts of the foot.

 

Yes.

Depends whether they are varus or valgus posts

Agreed. Also (assuming a fairly vertical vector) you've usually got your biggest supination lever arm relative to the STJ axis in the heel region. However, if you want to increase pronation moment, the lever arm will usually increase distally (depends on axial position and vector orientation, what you are trying to achieve, at which joint and WHEN*).

When you use a skive it can alter the geometry of the proximal part of the medial longitudinal arch section of the orthosis. *You also need to think in terms of time! And the type of gait- sprinting?

P.S. Isn't a skive an intrinsic rearfoot post? In other words, shouldn't we be talking here in terms of intrinsic and extrinsic posts rather than posts and skives?

 

Further to my previous answer. This is actually a very good question. If we look at kinematic studies in which the rearfoot everson has decreased we can probably assume that there has been a decrease in pronatory moments and / or increase supinatory moments at the STJ. However, we cannot say whether this has come from the rearfoot post or from the orthoses as a whole.
To isolate the influence of the rearfoot post you need to look at the study design of Blake and Ferguson http://www.japmaonline.org/cgi/cont...on&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Which as I recall used kinematic variables and concluded that "rearfoot posts have a somewhat limited function".

And our study: http://www.japmaonline.org/cgi/content/abstract/96/5/383 which showed that posts could shift the CoP position. But, we didn't show that the STJ moment had been changed. Think about it

And remember, http://www.japmaonline.org/cgi/content/abstract/97/3/207

 

In order to focus the discussion, I've let this and a number of points in the post Dennis made above pass without comment. But, I haven't forgotten this one Robeer

 

Fair point. Depends where you draw the line!

Quite true, should have said medial posts.

Ok, I'll bite

If the COP has then the GRF in must be different in different places. If this is so, how can the Moments not have changed?

Any time good buddy:drinks.:boxing: I'll grant my terminology was not the sharpest there but the principle seems sound to me. In most feet I see its increasingly difficult to dorsiflex the foot at the CCJ as you supinate the foot. Granted that locking is piss poor terminology but is this not so? To be honest i think most are becoming bored of Dennis and I playing intellectual ping pong so divert away!

Regards
Robert

 

Tell me what you know about force... then tell me what you know about moment of force. Then, for good measure, tell me what you know about CoP

"Locking" ???????????

 

Robert, thank you. Your post today has made me question my own beliefs tonight more than any singular post here has done for some time. The above point is interesting, if the anatomical structures of the heel are "designed to absorb the greatest volume of GRF", do they also have the greatest potential to modify the orthotic reaction force? The word "absorb" is key. This topic of where to post is probably worthy of a thread in it's own right.

P.S. sorry to hear about your bad day Robert, hope tomorrow brings that Friday feeling ;-)

 

... there goes my porridge, have to change my ensemble once again!

 

Anytime! You kick the legs out from under my world fairly regularly so if i've stimulated you're brain for a change its a minor point of recompense.

I wonder what you mean by modify orthotic reaction force. Are you thinking that it attenuates? Are you thinking of the hydraulic qualities of the fibrofatty padding under the heel? Are you thinking that the heel may be designed to absorb irregularities in the terrain without transmitting vector change to the skeletal system? Think out loud and i'll try to keep up!

It's an energy field created by all living things. It surrounds us, penetrates us, and binds the galaxy together. But i'm guessing thats not what you mean.

A measure of rotational force, Force * lever arm? Is that what you mean?

More now than when you asked the question . Which, I guess, is why you asked. But not enough to get your point .

Depends where you read it.

Ok. let me try to follow here. The COP moved. Thus the average position of weight moved. Thus I would deduce that the values of pressure at points on the foot changed. The COP moved closer to the STA. From that I deduce that the only way the COP could move without the moments changing would be if the GRF remained unchanged medial to the axis and increased lateral to the axis, but medial to the previous COP. But then if the GRF was higher closer to the axis the supination moment would still have dropped cos the lever arm would be shorter.

No. I'm all out. I've thought about it and i'm stumped. Help a brother out here. Preferably with short words for the hard of thinking.

Regards
Robert

PS

Alright alright. Not locked. Crap terminology. Won't happen again.

 

Robeer,

It's late and I'm tired so I'll come back to the heel fat pad thing tomorrow.

Lets talk about moving the CoP tonight. In our paper, we reported the change in position of the CoP with different designs of rearfoot post. Firstly, force is a vector. Secondly, moment = force x perpendicular distance from the axis of rotation. So, for example: within our study we moved the CoP medially on our pressure system (which records vertical pressure) by using an internal oblique post design. We may have moved the CoP, but how do we know what we did to the direction and/ or magnitude of the net force vector? We don't. I can push with a point of application that is medial to the axis, but still create pronation moment and vice versa. You, Robert, gave one of the best examples of this I have ever read. So, we could have a situation were the CoP moves medially but the STJ moment is unchanged. Agreed?

This is distinct from the above, but interesting (and tied into our paper) none the less: lets say we see a medial shift in the CoP position with an orthosis: has the orthosis created an increase in supination lever arm, or, has it caused the foot to pronate more? Think about it

 

Should have said varus posts! Couldn't I put a valgus post on the medial side of an orthosis if I wanted to?

 

We are victims of the minsets our training creates. I was focused on how an in shoe vls works. the vectors did not even occur to me! Of course if the varus post makes the vector of force more medial -> lateral the force actually passes nearer to the true axis (rather than the projection shadow) then the lever arm is shorter!

Thanks for the reminder!

R

 

sfunny how I find myself to be slightly pedantic, addicted to podiatry arena and enjoy watching orthotic company reps and junior members of staff squirm uncomfortably under intense scrutiny after having torn huge holes in the premises of most of their statments..

Wonder where I got that from...

 

Yeah you did spend a lot of time working with marie when you were down here! That sounds just like her!u

Keep the tradition alive my friend!

 

Ahem!!

Robert, Sam,

I do follow these threads you know....

Rie :butcher:

 

Gosh! Your slight pedantry has me squirming!

Sam, you squirming?

R

 

Yes, uncomfortably so!

 

LOL!

Nice to see you post rie.

For any who have not realized marie is my boss. Woundcare guru par excellance and will accept small bribes to make my job miserable.

And, apparently, follows these posts ! :0

But we digress. No response from dennis?
Robert.

 

Robert Stated:
3. to compensate forefoot varus
Eh? How? If the plate is 2/3rds length it will exaggerate a FFvarus if anything won't it?

Dennis Reples:
I agree with you that it won’t work and often will exaggerates ffvarus.
I just said why it is used (nothing about used correctly) or if I use them in all foot types.

Robert Stated:
These entities can be treated with other care reducing the need for rearfoot varus posting.
Yes. But I could walk to work rather than drive. I'll still drive if i have a choice.

Dennis Replies:
Not if you came to a walking bridge over a river. You would get out of the car and walk or drive your car into the river. The varus posters drive into the river all too often.

Robert Stated:
They “bring the ground up to the floor in the rigid types”
Bring the ground up to the floor? Don't know what that means

Dennis Replies:
The soundbite in biomechanics is that if a rearfoot varus deformity can pronate, a varus wedge will prevent that pronation.
If my rearfoot varus deformity cannot pronate, a varus wedge will fill in the space between the varus and the weightbearing surface (bring the ground up to the foot)
Didn’t say I aspire or believe in this soundbite.

The soundbite :bang: I hear you guys repeat all the time rather than inspecting LLD is the rearfoot pronates on the long side and supinates on the short side.
When there are so many other compensations possible that are more destructive such as plantarflexion of the short sided ankle (DROPFOOT)!
Soundbites like these, when repeated over generations of academics become accepted as factual without any debate.
Sort of like STJ neutral casting position accepted as being the “healthiest” position of the foot to start your skives, posts, wedges and reverse morton’s extensions, instead of looking for a better casting position.

Question! If you have a group of patients with a bigger bunion on one side (assymetrical) what oercentage of the limbs will be short to the bigger bunion side/the smaller bunion side? or heel pain that is assymetrical, or knee pain?
I dare the short side pronators to give these a whirl!

Robert Stated:
They elevate the medial rim (phlange) of the orthotic irritating the arch
I can see the thinking, but if the cast is properly modified they should not.

Dennis Replies:
You’re slipping in a trick question, right?
So if a device posted to zero rearfoot has a Navicular height of lets say 22 mm’s and you add a three degree varus post to the rearfoot that is 4 mm thick medially, wouldn’t you elevate that naviular height by ½ the thickness of the post (2mm's)

Robert Stated:
They increase forefoot dorsiflexion stiffness (or is it increase?). They increase bad dorsiflexion stiffness.
Lost me utterly here. What is "bad dorsiflexion stiffness?

Dennis Replies:
I honestly cannot figure out whether increased or deceased dorsiflexion stiffness is good, so I called it bad.

Robert Stated:
Hmmm. I think I see what you are driving at here. I take issue with you on a few points.
1. You seem to be assuming that midfoot wedging (in the arch) does NOT invert the heel. It can.
2. You seem to be assuming that rearfoot wedging will invert the rearfoot. It does'nt always.
3. You seem to be assuming that posting x degrees will invert the calc by x degrees. It won't.

Dennis States:
I am not discussing if rearfoot wedges work or not I am simply stating that they are used without thought, reason, purpose, etc by the huge majority of practitioners and labs making orthotics.

The real debate between the two of us cvlinically is whether or not reducing rearfoot pronatory moments by rearfoot posting or skiving is more or less effectice than by balancing the rearfoot, supporting the vault and balancing the forefoot.

I will reply to your statements on the posterior surface of the calcaneus in a future post as I believe this topic to be iportant enough to have its own reply.
:drinks
Dennis

 

Hey Dennis.

Don't have time for a full reply just now, but

ROFLMFAO!

Find me one time I, Kevin, Simon, Eric or any of "you guys" said that. Bet you can't! Thats cos we DON'T. I refer you to the thread on "5 fallacies of biomechanics" and others. That particular myth got exploded years ago.

Also

If anyone said such a foolish thing here I suspect they would be flamed to a podmcnuggett in approximatly 0.000451 seconds.

The rest of your post deserves a considered answer and I (or someone else) shall in due course, but those comments? You strike at a staw man my friend.

I don't know. Neither do you. Done a study? Got unbiased data? Or are you just speaking of "in my experiance".

I suspect this might be true :boohoo:.

Fair comment. Although you imply exclusivity. I suspect few use a skive on its own!



Regards
Robert

 

Robert Quoted me and Stated:
The soundbite I hear you guys repeat all the time rather than inspecting LLD is the rearfoot pronates on the long side and supinates on the short side.
ROFLMFAO!

Find me one time I, Kevin, Simon, Eric or any of "you guys" said that. Bet you can't! Thats cos we DON'T. I refer you to the thread on "5 fallacies of biomechanics" and others. That particular myth got exploded years ago.

Dennis States:
OOps, so sorry. It was the generations of podiatrists who begin and end their discussion on LLD by the soundbite when interested clinicians realize that compensations for LLD occur almost anywhere in the closed chain and vary dramatically, patient to patient.

I tried to research the myth busting that you refer to so often as it relates to LLD and came up with a 2005 summary of Craig Payne's:
What I am talking about is a foot pronately excessively as a compensation for a STRUCTURAL LLD - something that has crept into podiatric folklore over the years.... but its just another one of those myths (...'religious fanaticisim' also comes to mind, but more on that later).I certainly do not see it clinically - I see feet pronate more on the long leg and I see feet pronate more on the short leg --- I just was not seeing the foot pronating with any increased frequency in the longer leg as I was taught and as I read frequently in the podiatric literature (...funny it does not appear in the orthopaedic or physiotherapy literature ). Invariably, when I did see a more pronated foot on the longer limb, its was often easy to find another reason for it (eg asymmetrical ankle joint ROM).

I used to get tired of students coming up to me in clinic when doing a gait analysis and saying things like "Craig, the left leg is longer, but I can't see it pronating more .... "maybe because it wasn't!!!" --- but thats what they got taught and read in the podiatric literature (they don't any more)

We did 3 studies:
1. Measured RCSP and navicular height between the short and long limb in those with a structural LLD --> there were no differences
2. A subsequent study used the FPI --> no differences
3. A Pedar in-shoe comparison --> there were some functional differences between the long and short limbs, but they were not related to any asymmetries in foot pronation.

As part of this, I also did an extensive literature review and it was not surprising that there was never any evidence to support this myth in the first place!!!!! (it is an interesting case study all this!!!!) ---- in fact the opposite was the case when viewing the literature!! (I will have to add the exact refs later when in office to get them).

The first was a study published quite some time ago that looked at 3D rearfoot kinematics and found no difference between the short and long limb in those with a structural LLD.

I am sure that you have extensive documentation on the commonality of structural vs. functional limb length discrepancy.
I personally x-ray marker and do measurements with the accuracy of determining a structural limb length in my patients at least
zero times a month for the past 38 years.
What are the relative values of Ankle equinus and STJ varus in your structural LLD population in open chain?
In a functional LLD population?

Can you produce any of the mythical long list of articles that actually justifies what you are stating? What about on religious fanaticism?
Deductive reasoning and logical thought would suggest that in a functional short leg where there is a tight capsule or positional change in a joint or segment or a loss of power or atrohic degeneration in one area of the lower extremity posture that supinating the STJ will cause an elevation of the navicular height and medial segments (like a varus rearfoot post) lengthening that limb and conversely, pronating the STJ will lower the medial segment and collapse the arches of the feet functionally shortening that limb.
That said:

In a reaction to the fact that most American DPM's do not look for or treat LLD and most labs do not encourage the use of lifts (again, never shown on websites or adverts, etc.), I believe a starting place for working with LLD is needed and debated.
TIP is my starting place, lifts are my starting treatment and my goal is to reduce the pathologicalo influence of LLD. It is not perfected and not finished.
You guys are so biased in protecting your busted myths that you are not thinking like doctors.
What the rest of us are doing is wrong and needs changing and upgrading but so are you and so do you.
:drinks
Dennis

 

Craig Payne States in 2005 as he busts the myth of long leg pronation
"when I did see a more pronated foot on the longer limb, its was often easy to find another reason for it (eg asymmetrical ankle joint ROM)".

Dennis Replies:

Could that be a relative equinus of one of the ankles?

the second part of the FEJA Test?
:deadhorse:
Dennis

 

I am not sure why my last two posts have gone unresponded too?
Is this your version of The Rothbart expected reaction of going away?

Anyhow,

back to the subject.

Is many feet are pathologic due to equinus influence, forefoot pathology, sofgt tissue rearfoot pronation, navicular sag, etc and not dreaded rearfoot pronation, why all the focus on stopping these ancillary at best moments?
Dennis

 

And why the continued use of STJ Neutral Casting positions for developing your orthotic shells????????
igs:
:drinks
Dennis

 

To date, this thread is debating my theory, my language and its lack of research.

This debate is neseccary until research proves me (or parts of me) right or wrong. Please keep your watchdog eyes wide open, I am not trying to close them.

I want to know what we are doing to upgrade the current state of affairts when it comes to diagnosing and treating the foot and postural problems of our people?

The road to that answer is long but we need a new and fresh starting point from somewhere that melds the current literature and theory towards a common paradigm.

Using "common" language,which I think is a great deterrent to understanding and explaining biomechanics to patients, MD's and each other, most feet are STJ inverted neutral, The ROM of eversion is not sufficient to cause the rearfoot to be everted in stance and therefore, rearfoot pronation (or even its moments) are not the main source of our ills.
Arch collapse (navicular sag) Forefoot collapse (sagital plane) and rearfoot soft tissue collapse are added factors that current diagnostic and casting and prescribing standards do not address. They each have their followers but there is nothing allowing these diverse theories to develop a paradigm that is the best of all worlds.

Although I couldn't get Craig to say it, in Podiatry, pronation means rearfoot collapse beyond vertical. To say that a foot is pronated or that pronation is the main cause of our ills just is not clinically common (why can't we debate this statement?).

Just today, the APMA released its Heel Pain Guide where it states:
My podiatrist told me that my feet roll
inward too much while walking, calling it
“pronation.” How can pronation contribute
to heel pain?
Excessive pronation can create an abnormal amount
of stretching and pulling on the ligaments and tendons
that attach to the bottom back of the heel bone. It can
also contribute to problems of the hip, knee and lower
back.
This justifies a STJ Neutral cast, a rearfoot varus post and a heel cup as gold standard orthotic therapy (skive it or 1st ray cutout it or reverse morton's extension it as you may).
We need new standards, new language, a new beginning place (by definition flawed and unproven).

I believe it to be so obvious that I cannot explain my theory from afar and I share in The Arena frustration over this fact.

Dr. Root examines patients in open chain in STJ Neutral and then confirms his findings by examining patients in closed chain. Foot Typing does the same.

I paraphrase the very important information stated by Ron on another thread by stating that Lower Back care has taken a great step backwards in recent times. There used to be five classifications of lower back types that were treated differently since care that helped one type is often detrimental for others. Things have been degenerated because currently, there is one etiology and treatment plan for lower back pain that reduces the need for expertise and doctor sophistication but is harmful to the back suffering public.

I feel pronation has become the one etiology and a Rootian orthotic with a rearfoot post is therefore panacetic in too many hands.
Scherer had the right idea with his classification system but it has many flaws and it failed when researched.
I have upgraded his system and eliminated some of the flaws. I have upgraded rootian STJ Neutral evaluation, casting and prescribing, foot type-specific and suggest that it should be considered as a starting place for new and fresh (Neoteric) biomechanical care.
:drinks
Dennis

 

No it doesn't... :bang:

In podiatry pronation is a term to describe movement in the foot.. it can happen in the rearfoot, mid foot or forefoot, I have seen quite a few patients that have limited calcaneal eversion (i.e. they cannot pass vertical), causing peroneus brevis insertional pain, due to the excessive strain the muscle is under to oppose inversion forces. Then after, as the forefoot loads, the leg internally rotates to compensate for the limited calcaneal eversion the foot pronates rapidly, this gives them plantar fasciitis, due to the speed and excessive forces involved in that pronation.

If you give them a STJ neutral cast with a varus post, you will make the peroneal pain worse.

I agree we need a common language, but I think as well that we need to retain our own language.. for use between podiatrists. We have a unique skill set and a way of looking at the foot and gait that many other practitioners don't. We have to make this difference obvious, in some ways, to emphasise the fact we are useful in an MDT and can bring an alternative perspective to patient treatment.

The TIP/FEJA (and other acronyms aswell) system may well be perfect for people who don't fully understand the ins and outs of functional foot anatomy and the gait cycle but I still feel, but it's very nature, that the system isn't as good as a specialist biomechanics clinician who can cherry pick from all the theories and fit the diagnosis exactly to the symptons and injured structures, rather than fitting the symptoms to one of X foot types and providing an insole for that foot type..

I don't like boxes.

Best regards,

Sam

 

:good:

What he said.

Only thing is

I always understood that pronation only described tri planar movement in the STJ. If the movement is happening in the MTJ its inversion / eversion / plantar / dorsiflexion.

However the point was well made. Pronation is simply a movement, not a pathological condition.

How many times does this happen.

Patient, "My gp/physio/chen balancer said i'm pronating and need insoles."

Pronation is no more a pathology than neck flexion / extention is the same as whiplash.

As you've said before, this terminology (moments and such) is not familier to you. As such it might be best not to use it! This sentance makes no sense whatsoever!

Robert

 

We do not know... but we don't have anything better right now so it'll do just fine until we do

 

Ian Stated:
we don't have anything better right now so it'll do just fine until we do.

Dennis replies:
This is an amazingly subjective and defeatest way of looking at this subject.
David and Robert: Is there one ounce of logic in this statement?
Dennis

 

Dennis,

Subjective - perhaps. Defeatest? I don't think so.

Like it or not we do not have any known or proven ways of capturing negative casts which are 'better' than our current practice. So for this reason, (or maybe even tradition or habit) we continue to mostly cast the foot in STJ neutral

Ian

 

Sam: Thank you for your pleasant posting.


Sam Stated:
I have seen quite a few patients that have limited calcaneal eversion (i.e. they cannot pass vertical), causing peroneus brevis insertional pain, due to the excessive strain the muscle is under to oppose inversion forces. Then after, as the forefoot loads, the leg internally rotates to compensate for the limited calcaneal eversion the foot pronates rapidly, this gives them plantar fasciitis, due to the speed and excessive forces involved in that pronation.

First, Sam, what is that pronation? RF Pronation? or somewhere else?

If you give them a STJ neutral cast with a varus post, you will make the peroneal pain worse.

Dennis Replies:

First, Sam: What is that pronation? RF Pronation? or somewhere else?

Next:
You are spot on to this thread.
Sam, your calcaneus with limited eversion is my rigid rearfoot type.
Furthermore, in your series, passing through midstance, the forefoot collapses at the medial column by first ray elevation (hypermobility, FHL, sagital plane pathology) and this is my flexible forefoot foot type and I think, "that pronation".
You are describing The Most Common Foot Type (see the thread of the same name), The Rigid Rearfoot, Flexible Forefoot Functional Foot Type.
If your numbers of “quite a few” are closer to “many or most” in your practice then we sing in the same choir.

A STJ Neutral cast of this foot type will “cast in” some forefoot collapse into your shell and place The Vault of the Foot low in closed chain. A shell that is “Optimally Vaulted” (Shavelson, Glaser) will perform better than the STJ Neutral shell, no matter what you do from there.
Next:
Your Rearfoot varus post is doing three things. It is slowing down compensatory motion available towards vertical (good), it is keeping the foot from functioning vertical (bad). It also reduces the leverage of peroneus longus and brevis, FHL and the core intrinsics (very bad).

Your forefoot varus post (1-5) has its highest point under the first ray, elevating it and adding to the forefoot hypermobility (very, very bad). That is the reason that for the Rigid/Flexible Foot Type, I recommend a 2-5 varus FF post with an aggressive first ray cutout.

In your example, the powerful, rigidly set rearfoot (relatively high CIA, NOT PRONATED) when countered in midstance by the flexible forefoot, causes unbelievable tissue stress (used the terminology properly?) in the medial band of the plantar fascia and depending on the patients weight, activity level, health state, etc) can produce the #1 complaint of feet, heel pain.
Common Foot Type, Common Complaint (can Robert help me explain that this is logical until proven otherwise?).

In addition:
Contrary to The Arena’s assumptions, by foot typing all feet I can focus individual care within each group, for each patient. Using the Rigid/Flex FFT as an example, because some are very rigid and not so flexible, some are not so rigid and very flexible, etc,), WITHIN that foot type, I must fine tune my casting and prescription for each patient within that type.
For instance, a patient with Rearfoot Perm of 6 varus needs some level of rearfoot varus posting (1-3 degrees) but the patient with a Rearfoot Perm of 1-2-3 or even 4 varus needs NO VARUS POSTING.

That leaves:
So if you reduce or eliminate rearfoot varus posting, how do you stop pathological rearfoot pronation without a rearfoot post?

A Medial Skive (Kirby)? A strut to The Vault (Shavelson, Glaser)? Both? Or something else?

One addition:
Dr. Root, although he is known for STJ Neutral Diagnosing and Casting, took into account the entire foot. The arch and forefoot and kinesiology was all included in his theory as I am positive Jeff Root will comfirm. We have modified his theory to suit our needs over time.

SAM, as I upgrade and expand on Root’s theory, I, like Root, have cherry picked all theories and included them in my treatment protocols, foot type-specific (this is where my theory dramatically differs from Glaser). So again, we sing in the same choir.
:drinks
Dennis

Final comment from Mr. Hyde:
If you read this posting, I wonder if anyone could translate it into “Kirbyese” and then tell me which of the two versions would be more understandable to a patient, a physician or dare I say it, to the podiatry masses.
You allow Kevin to coin lateral dorsal midfoot interosseous compression syndrome (lateral DMICS) on another thread but you mock my parents when I coin rigid rearfoot/flexible forefoot functional foot type.
And Kevin says that I have gone off my meds???
:bash:

 

GAAAAAAAAAAAAAAAAAAAAAAAAAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:bash::butcher::deadhorse::bash::bash:

I'll reply properly when I've calmed down.

Robert

 

Robert, I think the word you're looking for is twat.

 

1) "That Pronation" is "that patients" foot doing what "that foot" does.. No boxes.. it doesn't fit your system. It just is "that foot".

2) I think you are mixing calcaneal eversion with pronation. Two different things altogether.

In this type of foot there is no pathological pronation stemming from the rearfoot. Because it is a fixed varus deformity

If you put a varus post under a heel that has no calcaneal eversion and a peroneus brevis insertional pathology/enthesopathy/whateveropathy related to it's position you will make it worse. Guaranteed. I would put money on this everytime in this case. You increase the load on the peroneal insertion. You increase the pathological forces. You increase the level of pathology. Your patient hobbles off to see another clinician because you made him worse, you never see him again so you don't see that you have made someone worse....

Varus posting and medial skives placed under the heel are designed to reduce amount/speed/magnitude of calcaneal eversion, which is one of the three basic components of subtalarjoint pronation I was taught at uni.. can you tell me the other two??

3) The foot can pronate after at forefoot loading as the leg internally rotates to compensate for the fixed rearfoot varus deformity (not rigid rear foot) this can then cause pathology to the medial slip of the plantar fascia due to the amount and speed of the force applied to that structure because of this movement.

My treatment for a foot like this would be a 2-3 degree lateral post or lateral skive, to try to decrease the force needed by the per brevis to stop the patient getting an inversion injury/fall over sideways, and an insole that has a fairly high arch profile and is made out of something like 3mm polyprop depending on the size of the person, but something with a little flex to meet that arch of the foot and try to decelerate the speed of the pronation (but not stop) that is happening at forefoot loading.

This is the crux of the matter for me. It is not possible to type everybodies foot. I remember a post by Dr Kirby where he said something about the insoles that he made and if you put together all the variables with regards the different prescriptions he has given there are something like several million options.. This statement I make tentatively, from a memory I believe which is a year or two old and I would be grateful if Kevin would correct this..

If people follow your suggestions based on this model, they will make people with this condition more injured. Therefore, in my humble opinion, this proves the model is flawed.

I would like to think that we do not mock your model. We started this and other posts asking you to back up whatever claims you have made with either hard science or sound deductive reasoning. You have failed to do so, you started getting personal about other peoples clinical skills, you offended pretty much everybody, and then wonder why you are getting such a hard time...

DrSha, there are a few people here trying very hard to get inside the thinking behind your model, and the way they do it is to ask difficult questions. You have stated you do not know the terminology and that is ok.. so we need to find out what you are trying to say with the terminology you have invented to see if, underneath it all, the priniciple is the same.

I believe it has been nigh on impossible to find out exactly what you mean.

Regards,

Sam

 

Robert, Regarding the pronation comment I made.. I believe you are right.. Pronation happens at the subtalarjoint.. my comment was wrong and I hope I have explained myself a little better in my last post.

 

Singapore has been good for you my friend. Your thinking has opened wonderfully and you are producing some really excellant posts:drinks.

Right. I am once again an oasis of calm and peace.

Dennis.

The reason for my frustration was mainly this bit

We shall leave, for a second, the contention that the foot should "function vertical"

I might be dead wrong here but I think I may have spotted an area of miscommunication.

You refer to "rearfoot pronation" a bit here and there and as I have observed before that your model divides the foot into sections (which I feel leads to fuzzy thinking). The model, so far as I can make out, involves tayloring where the support in the insole is greatest to "where the pronation is happening".

My problem with this is that pronation / supination is a movement which happens at the STJ. Not the rearfoot, or the forefoot, but across that specific joint. The orientation of the axis will define how much movement takes place in the individual planes (for eg how much eversion per unit abduction) The amount of resistance (supination moments) the MTJ is able to offer by transfering inversion moments from GRF in the forefoot will contribute to the kinetics of the STJ. The amount of movement available in the sagital plane in the CCJ and the Met cuniform joint and the quality of this movement will have a huge effect on this and on the profile of the arch / vault of the foot. But these (and others) are all things which affect the STJ. There is no rearfoot / midfoot / forefoot pronation, just STJ pronation.

Following a minor epiphany I had whilst scraping poo off my youngest, I now present Dr Shavelsons FFT system as I think it might work. I might be barking up completely the wrong tree here.

Am I near what you are thinking with that Dennis? Or have I got the wrong end of the stick entirely.

Kind regards
Robert

The views expressed above are not those held by the author and are offered purely in the interest of interest. Yes I can see the problems with this line of logic as well .

 

The feet that we diagnose and treat have a million different unique biomechanical footprints, which like snowflakes, defy the use of rules and generalized care.

Questions exist as to whether to examine in open chain, in closed chain or in some combination of the two. Questions exist as to how to translate diagnostic information into effective treatment. Acceptable gold standards in all areas are being proven flawed and in need of expanding and upgrading.

All feet have three basic areas in common. They have a rearfoot that is impacted by GRF posteriorly, a forefoot that is impacted by GRF distally and connecting arches representing a non weighted area that connects the two.

All feet have a level of rearfoot pathology (pathological pronatory and supinatory moments), arch pathology (pathology measured by Navicular Sag) and forefoot pathology (FHL and pathologic dorsiflexion stiffness). Some feet dominate in the rearfoot, some in the arches and some in the forefoot.

For many years (The Rootian Years) the focus of diagnosis and treatment has dominated in the rearfoot by the vast majority of foot orthotic prescribers and laboratories. During this time additional paradigms have developed, with small yet passionate followings.

Some have focused on the rearfoot segment (SALRE, Inverted Casting, Pathology Specific Orthotics and the Ankle portion of Sagital Plane), some focus on the forefoot segment (Sagital Plane) and some focus on the connecting arches (MASS). Each has developed language and coined acronyms that replace or attempt to acculturate Rootian Biomechanics creating a veritable Tower of Biomechanical Bable.

Each paradigm dominates care in their respective segment (Medial skives, High Arches and Kinetic Wedges, respectively as examples) and fall short in feet whose dominant pathology is elsewhere (i.e. Kirby and Root in feet that need higher arches, Glaser in feet that need rearfoot or forefoot treatment and Dananberg in those that need care of another plane or segment).

Sadly, these new paradigms are evangelical and each wishes to replace the other rather than accept its own faults or incorporate the advances of others with an open mind.

What is needed in functional lower extremity biomechanics is a model that has:
1. A common universally understandable language that can unite the paradigms while allowing each to maintain its own branding and language.
2. A classification system that can subdivide the millions of different biomechanical types into subgroups sharing a set of similar characteristics so that a focused plan of care can be offered, subgroup specific that would reduce failures, improve outcomes of care and enable practitioners to discuss, monitor and research each subgroup while maintaining individual foot care.
3. The ability to incorporate varying percentages of diagnosis of treatment of the rearfoot, the connecting arches and the forefoot reflecting the level of diagnosed pathology that exists in each segment for each individual.
4. A unifying method of marketing and educating practitioners, the medical community and the foot suffering public as to the preventive, performance enhancement and treatment advantages of FLEB.

Such a model has yet to be inductively tested either with outcome studies or kinematic / kinetic trials, however I question whether there is a logically coherent argument for considering its development and testing?

Such as model, offers a potential method for explaining biomechanics to the world, uniting various paradigms of FLEB and optimising prescriptions to fit each patient’s unique mechanical characteristics.
:drinks
DrSha