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Student with questions on forefoot varus and supinatus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by blumley, Dec 13, 2011.

  1. blumley

    blumley Active Member

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    we have just had a lecture on this and im a little confused. We were told that supinatus is a soft tissue deformity and varus is an osseous deformity. What concerns me is that no further explanation of this was given, and when looking online the explanations seem a little vague. For example what tissues are involved in the supinatus and why does this happen?

    Also while im here, on rear foot varus we were told that most people who are fully compensated tend to actually over compensate leading to over pronation? why is this, is there a better explanation of this out there.

    I know these questions may be really dumb, but it is going to bug me not knowing why

    thanks for your help
  2. Admin2

    Admin2 Administrator Staff Member

  3. efuller

    efuller MVP

    It's good that you are asking these questions now. The king really isn't wearing any clothes. The "supinatus" problem is one of the reasons that forefoot to rearfoot measurment cannot be done accurately. I once had multiple practioners at a biomechanics conference measure the forefoot to rearfoot relationship of the same foot. There was a 10 degree range in values. This measurement is a terrible way to decice on what your othotic should look like. A forefoot valgus intrinsic post can add a lot to orthotic, but the decision of whether to add that modification should be based on measures other than forefoot to rearfoot relationship.

    An important concept to get from this discussion is that the STJ will tend to pronate until something stops it. Often it stops at the end of range of motion of the STJ. Sometimes, ground reaction force on the medial forefoot stops STJ ROM.

    Don't give up on biomechanics because of confusion caused in this area. There is something to it, but there are better explanations of how the foot works.

  4. blumley

    blumley Active Member

    Thanks eric,

    so for partially compensated rear foot varus, is this a case of the STJ ROM resisting further pronation before it reaches fully compensated?
  5. efuller

    efuller MVP

    Get your plastic bones out. With STJ supination the lateral process of the talus moves farther away from the floor of the sinus tarsi of the calcaneus. With STJ pronation the lateral process of the talus will slide along the posterior facet of the STJ until it hits the floor of the sinus tarsi. There is no more room for further motion. This is the end of range of motion of pronation. The medial forefoot may or may not be loaded when the STJ reaches this location.

    The difference between uncompensated varus and partly compensated varus is an odd bit of nomenclature. In uncompensated varus, there is no motion (joint fused) of the STJ and the medial forefoot is not loaded. In partially compensated varus there is range of motion of the STJ and it has reached its maximally pronated position of the STJ before there is medial forefoot loading. This is true for forefoot and rearfoot varus. In a compensated varus the medial forefoot does reach the ground. (This is a discussion of position, which is helpful to visualize, but understanding the forces involved is more important.)

    The thing to know about not fully compensated varus is that you need a forefoot varus wedge or extension. A traditional orthotic that ends behind the metatarsal heads is not going to "support" this deformity. My instructors kept insisting that it would. I ended up teaching biomechanics at the California College of Podiatric Medicine for over 10 years.

  6. RobinP

    RobinP Well-Known Member

    I've got to be honest and say that I still don't really understand what a rearfoot varus is. What is it varus in relationship to?
  7. blumley

    blumley Active Member

    thankyou for taking the time to explain this to me, it is greatly appreciated, I will do some more reading around the subject to try to gain a better understanding of this and hopefully see some patients with these types of deformities.
  8. As defined by Root et al, a rearfoot varus is an inverted calcaneal position (as determined by the calcaneal bisection relative to the ground) when the patient is positioned in the neutral calcaneal stance position in bipedal stance. Rearfoot varus may be due to a 1) subtalar varus, 2) a tibial varum or a combination of #1 and #2.

    I haven't taught this for over two decades but I still think I remember it correctly.
  9. Rob Kidd

    Rob Kidd Well-Known Member

    Dear Blumly

    I have written in the podiatric press about both - certainly controversially, and sometimes quite negatively. You may like to look at: Kidd(1984) The Pathomechanics of Forefoot Supinatus - The Chiropodist (UK); Kidd (1997) Forefoot Varus: Real or False, Fact or Fantasy? The Australasian Journal of Podiatric Medicine 31: 81-86; Kidd (2000) Forefoot Supinatus: Another Fictitious Pathology, or have we missed the point? Australasian Journal of Podiatric Medicine 34: 81-85. Some of these writing were quite inflamatory, though I stand by every word. Rather than inflame further, if you care to write to me privately, either on here or my private email (robertkidd5@bigpond.com), I will reply in detail. Cheers, Rob
  10. Nice.

    I would dispute this as a definition.
    My understanding is as follows.

    Root's original definition of FF varus is an embryological deformity in which the talar head fails to properly unwind. Look back to your skeleton foot and you'll notice that the medial column (mets 1-3, cuniforms and navicular) all attatch to the talus. Thus if you imagine the neck of the talus cut and rotated its easy to imagine an inverted forefoot.

    However. Feet with perfectly normal taluses (tali?) can also become inverted in the forefoot if ground reaction force pushes them into an inverted position. This could happen at the talar - nav joint, the nav cuniform joint, the cuniform - met joints, or more likely a combination of all of the above.

    Davis law and wolfs law will mean that over time this position will become firstly defined by soft tissue and then eventually bony remodeling may occur. So in fact a supinatus can be either a soft tissue OR a bony condition. The difference between Varus and supinatus is that varus is a deformity of the talus and supinatus in an aquired situation which may involve several joints.

    Hope this helps. If I've got this wrong i'm sure someone will correct me.

    Oh and
    The only dumb questions are the ones you don't ask.
  11. blumley

    blumley Active Member

    thank you robert,

    this explanation makes a bit more sense than what we have been told in class. Im hoping that after seeing some patients in our bio mechanics clinics this will be a bit easier to understand. I'm hoping to try and get some extra placements over summer to see if that will help with regards to understanding
  12. Rob:

    I don't think you need to worry about inflaming anyone here. This was old news here in California some time before you wrote your "inflamatory" papers. This idea that forefoot varus was caused somehow by "a lack of torsion of the talar head and neck" was never taught to us by John Weed or anyone else in the CCPM biomechanics department from 1979-1985, even though, I believe, it was listed in the Compendium. I think that by the time I became a podiatry student in 1979, no one believed this anymore within the department so they quit teaching it. I guess news traveled more slowly at that time across the oceans to our podiatric colleagues in other countries.
  13. Blumley:

    Root and Weed taught that a forefoot varus deformity was an inverted forefoot deformity that was structural in nature and a forefoot supinatus deformity was an inverted forefoot deformity that was a soft tissue contracture about the "longitudinal midtarsal joint axis" which, with proper orthosis correction, could be reduced to less of an inverted forefoot deformity.

    I remember specifically asking John Weed during my second year of podiatry school during one of his classes what he thought caused forefoot supinatus and whether this was due to specific shortening of some ligaments but he said he wasn't quite sure what caused it. All that he could say that in many children and adults that had previously measured to have a fairly large inverted forefoot deformity would over time with correction with a foot orthosis demonstrate a reduction in their inverted forefoot deformity.

    Toward the end of my student years and during my Biomechanics Fellowship in 1984-85, John Weed had started to advocate calling both forefoot varus and forefoot supinatus by the name of "inverted forefoot deformities" probably because this eliminated confusion as to what the true nature of the deformity was. I believe that this idea of soft tissue contracture is a very real phenomenon and that the forefoot to rearfoot relationship, as described by Root and Weed, can change over time depending on the prevailing external and internal subtalar pronation and supination moments acting on the foot during any time of that individual's life. I have written previously about this in one of my newsletter books but, for now, I got a schedule of 33 patients I had better start seeing.

    Back now from seeing my first patient. Here is an excerpt from the chapter I wrote along with Don Green. These were my thoughts on this subject in 1990 when I wrote this section of the chapter (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

  14. efuller

    efuller MVP

    This particular concept wont get any easier to understand. If you want a fun research project you should have several people measure the forefoot to rearfoot relationship of the same foot. You could even do that with people who claim that they are experienced at the measurement.

    On the other hand, more time spent in clinic asking instructors and yourself biomechanics questions will always be a good thing.

  15. Rob Kidd

    Rob Kidd Well-Known Member

    Kevin wrote (snipped)

    "An inverted position of the plane of the forefoot when compared to a bisection of the rearfoot while the subtalar joint is in the neutral position and the midtarsal joints are maximally pronated is commonly called either a forefoot varus or forefoot supinatus deformity.(39) A forefoot varus deformity is an osseous structural abnormality of the foot which causes a permanent inverted position of the forefoot to the rearfoot. A forefoot supinatus deformity is an inverted position of the forefoot to the rearfoot which is a purely positional deformity and which will partially reduce in degree with application of effective foot orthosis therapy.(38)"

    And therein lies the next rub of the "so-called" forefoot varus deformity. We clearly agree on the nonsense of its supposed etiology - talar head rotation is incredibly important, but nothing what so ever to do with forefoot-hindfoot relationship.

    Now let us look at the basis for diagnosis. A plane of the forefoot compared to a calcaneal bisection lines makes the implicit assumption that the plantar surface of the calcaneus is perpendicular to the calcaneal bisection line. No such relationship exists - and has been reported as such in JAPMA (among other places) for years - forgotten how many. I appreciate that you wrote this in 1990!

    Since we do not walk on the posterior surface of our calcaneus - but the plantar surface - we have involved a third, and probably spurious variable; what we should be doing is to look at the plantar surface of the forefoot and the plantar surface of the hindfoot - and comparing the two

    Proddingly - Rob Kidd
  16. Rob:

    Rather than look at the plantar surface of the calcaneus, we should all be looking at the talar head position since this more closely approximates the wide interindividual variation of subtalar joint axis spatial location that has such a large effect on STJ kinetics within the human population during weightbearing activities.
  17. Rob Kidd

    Rob Kidd Well-Known Member

    That as may be - and you may well be correct - but it not connected to the definition of "forefoot varus". Actually, with the exception of as a rare deformity, I would refute the existance of forefoot varus. This has always been a source of amusement to me, as when I was a "student" of biomechanics ('70's), forefoot varus was though to be as common as muck, and was a routine finding in student diagnoses. But then we looked but did not see..........
  18. So you are saying that forefoot varus doesn't exist? I have seen an inverted forefoot deformity many times during my practice career. How do you refute the existence of an entity that many podiatrists have seen numerous times? Maybe if you explained yourself more fully, I may better understand your logic.
  19. Jeff Root

    Jeff Root Well-Known Member

    Adult acquired flatfoot is an acquired condition that provides an excellent example of the development of a forefoot supinatus. These patients often report recognizing rapid and graphic changes in their feet, including increased eversion of their heel and relatively sudden collapse of the medial arch. This condition if often unilateral or significantly worse on one side.

    When you examine the effected foot and compare the plantar plane of the forefoot relative to the plantar plane of the rearfoot or if you compare the plantar plane of the forefoot to the sagittal plane bisection of the heel when the MTJ is full pronated and when the STJ is in the neutral position, you will see a marked increase in the inverted position of the forefoot on the effected side. You can’t always clinically differentiate a forefoot supinatus from a forefoot varus, but you can certainly see cases where forefoot supinatus has developed over a very short period of time.

    Jeff Root
  20. Jeff Root

    Jeff Root Well-Known Member

    You might want to read the following article by Douglas Richie, DPM to see how complex the development of ff supinatus can be and what structures might be invloved.

    Clearing Up The Confusion Over Posterior Tibial Tendon Dysfunction
  21. Rob Kidd

    Rob Kidd Well-Known Member

    Kevin, let us be careful not to mix issues. Issue 1) the basis for the diagnosis of forefoot varus. As outlined by your post above (admittedly quoting writing from many years ago) is, in the light of more recent publications - including in JAPMA - a nonsense. As I said above, several works have demonstrated that there is essentially NO relationship between the calcaneal bisection line and the plantar plane of the calcaneus. Thus, to use one as a proxy for the other is invalid. And in this context, invalid is to small a word. Issue 2) The very existance of forefoot varus. We have now (perhaps grudgingly), accepted that the etiology and the methodology of diagnosis of "forefoot varus" is spurious: how much further to we support this straw doll? I will concede and apologise to all and any, when you show me any valid diagnostic mechanism that demonstrates an osseous deformity that leads to an inverted forefoot compared to rearfoot as a relatively common disorder (that is, anything is possible as a 1/1*10^6).

    I am sorry to allude to this yet again, but we are seeing here the basis of a Nurenburg defence - "many podiatrists have seen numerous times" does not make it exist per se.

    The method of diagnosis as laid out in the early texts (enough slagging off individual authors) is so much a joke it is not funny - it is time for some science. None of my comments above relate at all to "forefoot supinatus" - whatever that is. That is also full of holes - but a different can of worms for a different occasion.

    As always, never personal, Rob
  22. Rob:

    Sounds like you are using a different definition for "forefoot varus" than did Root et al. If you change definitions for a term, then of course you can "disprove" that it exists. Root et al described forefoot varus as being when the forefoot is inverted on the rearfoot (Root ML, Orien WP, Weed JH, RJ Hughes: Biomechanical Examination of the Foot, Volume 1. Clinical Biomechanics Corporation, Los Angeles, 1971, p. 74). Are you saying you have never seen a foot where the forefoot is inverted to the calcaneal bisection line when the subtalar joint is in neutral position and the midtarsal joints are "maximally pronated" as described by Root et al? How are you bisecting the posterior surface of the calcaneus? Are you using the same methods as taught by Root et al or your own methods?

    And as far as the plantar aspect of the calcaneus, that bears little to no relation to the bisection of the posterior surface of the calcaneus, but it is of interest to me since I published a paper on this subject many years ago (Kirby KA, Loendorf AJ, Gregorio R: Anterior axial projection of the foot. JAPMA, 78: 159-170, 1988).

    Also, why are you interested in using the plantar aspect of the calcaneus as a reference plane? Does anyone use this clinically as a reference plane for measuring forefoot to rearfoot relationship?

    What is your definition, Rob, of a forefoot varus deformity or a forefoot valgus deformity in a living foot?
  23. Jeff Root

    Jeff Root Well-Known Member

    If you can't use a heel bisection to establish an inverted forefoot, then you can't use one to establish an everted forefoot either. Even given the heel bisection error factor reported in some studies, I would hope that all practitioners can use a heel bisection to recognize the extreme conditions that present with an inverted or everted forefoot, such as the cavus foot with a plantarflexed 1st ray resulting in an everted forefoot to rearfoot relationship or a forefoot supinatus associated with PTTD/adult acquired flatfoot.

    The term plantar plane of the rearfoot is really a misnomer since the plantar surface is typically convex. What we are really talking about is the line (or a plane) which is perpendicular to the bisection of the heel at the lowest point of heel of the non-weightbearing foot or a cast of the foot. It is extremely useful when working with a positive cast on a flat surface, since we can compare this plantar representation of the rearfoot or the heel bisection itself to the plane of the floor.

    There are cases in which subjects who excessively supinate and function with their heel inverted will demonstrate a very everted plantar heel surface because the rearfoot functions in an inverted manner which produces adaptation of the plantar fat pad. Conversely, we can see feet that function excessively everted in which the plantar surface of the heel appears much more inverted than average. These are relatively common adaptive changes seen in the lab (form follows function). In many of these cases, the plantar surface of the heel is typically much flatter in appearance or more plane like than it is in most feet. Again, this appears to be an adaptive change in the shape of plantar fat pad but there could be an osseous component as well.

  24. Jeff:

    I don't know why anyone would use the plantar plane of the rearfoot for any reference for the calcaneus since it is a highly variable surface, is rounded or flattened at different radii of curvature with its soft tissue,depending on the individual. In addition, the osseous structure of the plantar calcaneus, on average, is angulated 21 degrees from the weightbearing surface (Kirby KA, Loendorf AJ, Gregorio R: Anterior axial projection of the foot. JAPMA, 78: 159-170, 1988).

    Jeff, when Dr. Root defined "forefoot varus" initially, did he mean that the inverted forefoot relationship to the calcaneal bisection was structural in nature, meaning bones and ligaments, or osseous in nature, meaning bones only? Also, do you know when Drs. Root and Weed decided to change the terminology to inverted forefoot deformity versus forefoot varus or forefoot supinatus? I thought I remember this being discussed in one of the Root Seminars many years ago. Perhaps you can shed some light on this subject since it seems that Rob appears to be confused with what Drs. Root and Weed actually taught versus what he thinks they taught.:confused:
  25. efuller

    efuller MVP

    I agree with Jeff, that when you look at the extremes of forefoot to rearfoot realtionship, you will see a difference in many things, including types of pathology that the foot will present with. So, I believe that forefoot to rearfoot is a valid concept. It is one way to describe how feet differ from one another.

    I also agree with Rob Kidd in some aspects. There is no way that forefoot to rearfoot can be measured accurately across practioners. There is also a flaw in the logic used to alter the prescription of the foot orthosis based on this measurement. If you measure forefoot to rearfoot realtionship in neutral position and the measurement changes as move from neutral position (for the sake of this argument we'll assume that neutral exists and can be defined. A questionable assumption) to a more pronated position, the forefoot to rearfoot measurement will become more everted, then you will be treating an inaccurate measurement. Very few feet actually rest in neutral position.

    The use of an intrinsic post in orthoses was a great innovation that evolved from flawed logic. But, it is still a great innovation. We just need a better measurement (maximum eversion height) to decide how much intrinsic forefoot valgus post there should be.

  26. I'd go back a stage or two further... what exactly is it you are trying to achieve by adding a forefoot valgus (or varus post) to the orthoses?
  27. efuller

    efuller MVP

    The original logic was to prevent "compensation" for a deformity.

    I use it to alter load under the foot. Most commonly, with first ray realted symptoms (hallux limitus, hallux valgus, plantar fasciitis), I use a forefoot valgus post to decrease load under the first by increasing load under the lateral forefoot.

  28. And does it? If this is the rationale for their use there needs to be a clinical measurement which allows the prescribing clinician to correlate the degree of post (if we are still going to work in angles) with the change in loading under the first/ lateral forefoot.
  29. Just out of interest.

    Forefoot varus. :- an inverted position of the forefoot relative to the rearfoot.... due to inadequate frontal plane torsion of the head and neck of the Talus

    Is the definition in Valmassy...
  30. Show me the evidence...
  31. I never heard Ron Valmassy say that from what I remember, but I could be wrong. That was a long time ago. I think this is another one of those inaccuracies in podiatric biomechanics that I was talking about.

    My impression, during my student years and Biomechanics Fellowship year at CCPM (1979-1985) was that a structural forefoot varus was not just due to abnormailities in the rearfoot but also structural abnormalities (i.e. including osseous and ligamentous abnormalities) from the rearfoot distally. Most of us during that era didn't think that forefoot varus was all that common but that forefoot supinatus was fairly common. For every inverted forefoot deformity we saw about 10 everted forefoot deformities.

    Of course "forefoot to rearfoot relationship"depends on 1) how you find STJ neutral position, 2)how you bisect the calcaneus and 3) how firmly you load the 4th and 5th metatarsals from plantar during exam.

    Interesting discussion. Haven't talked this much about forefoot to rearfoot relationship for over 20 years!
  32. Rob Kidd

    Rob Kidd Well-Known Member

    Lets take each bit at a time.

    The whole process of involving the calcaneal bisection line is a Furphy - as we say in Australia. Since there is no predictive relationship between it and the plantar plane of the calcaneus - its use is not valid. It may well be a part of the original diagnostic protocol - but it was flawed. I looked at each of the flawed issues of forefoot varus, from its diagnosis, through its supposed aetiology, right through to why its myth persists in my 1998 paper in the Australian journal. Rather than repeat myself here, it may be best to read it and then we can further comment.

    I used the plantar plane simply because that it what we walk on - whether you wish to accept it or not - that is the very issue - the bisection line is simply an irrelevance. To use anything other than the plantar planes of the forefoot and reafoot is not looking at the true story.

    My definition of a FFVarus or Valgus is based upon the relationship of the plantar planes of the forefoot to the hindfoot while in neutral etc. The former would have an inversion, the latter and eversion. I do not wish to be drawn on supinatus in this debate - another story, another bag of flaws, another time.

  33. Jeff Root

    Jeff Root Well-Known Member


    To the best of my knowledge my father never changed the terminology that he used to describe inverted or everted forefoot conditions. As soon as he was able to recognize and classify the various types of inverted and everted forefoot conditions, I think he stayed true to that terminology. He described the following as inverted conditions (deformities) of the forefoot:
    1. Forefoot varus (a congenital condition in which all five mets are inverted in a common plane relative to the rearfoot)
    2. Forefoot supinatus (an acquired inverted condition of the forefoot)
    3. Metatarsus primus elevatus (because it creates an inverted relationship between the 1st and 5th met heads but it can also frequently involve some dorsiflexion of the 2nd in my experience)
    4. A plantarflexed 5th or plantarflexed 4th and 5th rays resulting in an inverted forefoot to rearfoot relationship.

    And he described the following as everted forefoot conditions (deformities) of the forefoot:
    1. Forefoot valgus (mets 1-5 in an everted plane)
    2. A congenital or an acquired plantarflexed 1st ray (Assuming the net position of the forefoot was everted to the rearfoot. You could have an inverted forefoot with a plantarflexed 1st that does not result in an everted forefoot to rearfoot relationship. He called it a forefoot varus with a plantarflexed 1st but technically that contradicts the strict definition of a true forefoot varus since all five met must be in a common plane.)
    3. A congenital plantarflexed 2nd ray resulting in an everted forefoot to rearfoot relationship. He did not believe that it was possible to have an acquired plantarflexed 2nd that would result in an everted forefoot to rearfoot relationship because he thought GRF would prevent this from ever happening.
    4. A dorsiflexed 5th or a dorsiflexed 4th and 5th met. resulting in an everted forefoot to rearfoot relationship.

    I remember my father being very careful and precise in his use of terminology. He did not use the terms forefoot varus or valgus to describe any of these other inverted and everted forefoot conditions that I described above. If he wasn’t attempting to be specific, he would just say “the patient has an inverted” or “the patient has an everted” forefoot deformity. I prefer the use of the term “condition” rather than my father’s term “deformity” to describe these foot types or foot conditions.

    All of the conditions I outlined above are determined when examining the foot in a non-weightbearing manner while the STJ is in neutral and while the MTJ is full pronated. I believe he was fairly clear to indicate which of these conditions might be congenital as opposed to acquired in nature. I know he also said there were times that you couldn’t determine if was congenital in origin, so he often look for symmetry in structure and ROM or ROM alone as an indicator. I think he looked at the foot as structural in nature (bone and soft tissue) but often attempted to describe the underlying osseous relationship individually.

  34. blumley

    blumley Active Member


    guys I really appreciate all the different opinions you have given so far, it gives me a lot to read on and hopefully come to my own conclusions. Is this area always one of controversy? with regards to understanding did you find a more practical approach (with patients) the best way to gain understanding in this area?
  35. Rob:

    So you are using the plantar plane of the soft tissue of the rearfoot in a weightbearing position to determine a forefoot to rearfoot relationship??? No wonder you think that you have "disproved" that a forefoot varus exists.

    It is really no use in discussing this further since you are not even using the same parameters defined by Root to "disprove" one of Root et al's ideas. I guess that is one way to think that you have proved your point.....you just redefine a measurement parameter to what you believe it should have been, then go on to claim that this disproves the existence of an entity defined by a completely different set of measurement parameters.

    Very convenient.
  36. Rob Kidd

    Rob Kidd Well-Known Member

    No I am not using the soft tissue - at least I try not to - I am using what I believe to be the bony structure underneath - nice introduction of a straw doll - by the way!

    You clearly have not read my paper of 1998 - I address the soft tissue "issue" in some detail. I will await further comment until you have read it.

  37. Rob:

    I don't know of anyone who has ever mentioned your 1998 article other than yourself. What was it about?

    Maybe you can send a copy my way so I can comment on it further. kevinakirby@comcast.net
  38. I've looked for it as Rob has mentioned it before - harder to find than a FF varus. Be good if Rob can post a copy on here then everyone can read it.
  39. Rob Kidd

    Rob Kidd Well-Known Member

    Sorry - 1997. Maybe you should read beyond JAPMA. A huge amount happens in feet in other journals.

    Kidd R.S. 1997. Forefoot Varus: real or false, fact or fantasy? The Australasian Journal of Podiatric Medicine 31: 81-86
  40. Being a bit silly Rob

    That journal and that paper is a far as I seen is not available so perhaps instead of making dumb comments you could post the PDF. Or you do not have one just say so.

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