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The Need For Orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by drsha, May 4, 2009.

  1. drsha

    drsha Banned


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    DrSha Position:

    10,000 years ago, a portion of mankind decided to become civilized. They paved the roads, built houses and communities and developed medical care that extended lifespan and quality of life.

    In these societies, the pull of gravity, the hard and unyielding ground, hard and unyielding shoe boxes and the existence of underlying inherited biomechanical pathology have combined to leave these unprotected feet unable to overcome the inherent stresses over ones lifetime and has left many members of society injured, with pain or disability or unable to perform.

    The diagnosis of foot pathology when coupled with advances in custom foot bed casting, prescribing and fabrication present a strong argument for most members of civilized society from school age up to have regular Podiatry care and monitoring including the use of custom foot orthotics.

    This will be added to their hairbrush, toothbrush, floride and regular medical and dental checkups and care as a quality of life issue.

    Summary: If left unprotected and unsupported foundationally, our feet and posture will develop pain and deformity as well as performance, shoe fit and quality of life issues. Foot Orthotics offer the best available protection from this inevitable downward spiral.

    Sam Randall Position:

    “Not all feet have some level of pathology.. only injured feet have some level of pathology. Unpathological feet have no level of pathology because they are unpathological” (and do not need Foot Orthotics).

    “It works very well for your system (and bank balance) to tell everyone that they have some level of pathology.. but the truth is they don't... not all feet become pathological.”

    In summary, to utilize Foot Orthotics in civilized society as a preventive, performance enhancement and quality of life instrument has only one purpose:
    To generate income!

    Any foot doctor utilizing foot orthotics before injury exists is guided by greed and not a desire to care for the feet and postural health and performance of his/her community.
     
  2. "For the words of the profits
    Are written on the studio [Arena] wall,
    Concert hall ---
    Echoes with the sounds...
    Of salesmen.
    Of salesmen!
    Salesmen!!!!!!!!!!!!!"

    Rush: The Spirit of Radio

    Here's a thought Dennis:
    "If you're in marketing, kill yourself"- Bill Hicks
    http://www.youtube.com/watch?v=gDW_Hj2K0wo
     
  3. Ian Linane

    Ian Linane Well-Known Member

    Hi Sam

    You suggest:
    ".... Any foot doctor utilizing foot orthotics before injury exists is guided by greed and not a desire to care for the feet and postural health and performance of his/her community."

    Leaving aside the context and frustration in which you said it, I would have to disagree with some of the above.

    Cheers
    Ian
     
  4. Ian,
    I agree that Sam has probably gone too far in this statement. However, I should be interested if you could point us towards some quality evidence that demonstrates the efficacy of prophylactic orthoses use.
     
  5. Ian Linane

    Ian Linane Well-Known Member

    Hi Simon

    Was not particularly looking to get into a debate with Sam (he's bigger than me even if he is in Singapore!) and approached it from very much a "broad sweeping statement" and the fact that I do not prescribe based only on injury but would not consider myself only in the business to make money. (Not that I took Sam's comment personally)

    I think it is exceedingly difficult to demonstrate quality research evidenced prophylactic efficacy (certainly my list of Refs would be hard pushed to come up with some - if at all.)

    Cheers
    Ian
     
  6. Ian, it's nothing personal toward you. The moot point is interesting though. In the absence of quality evidence does Sam make a reasonable assertion regarding treating the non-pathologic, albeit overstated in certain aspects? We may argue that we have evidence for certain kinetic and kinematic effects of foot orthoses, we may also argue theoretical pathological pathways, but ultimately how many studies demonstrate the prophylactic efficacy of foot orthoses? I'm not saying they cannot have a prophylactic influence, I'm just interested in exploring this.

    Question: How would you design a study to demonstrate whether or not foot orthoses have a prophylactic effect on a given pathology?

    I don't care how big either of you are BTW; there are always bigger fish ;).
     
  7. Here is a thought. We can make observations about the problems people develop WITHOUT orthotics by looking at people who have had no orthotics and develop pathology.

    What are our ideas regarding the problems people will develop WITH orthotics on a long time frame?

    Dennis raised an interesting view.

    We could make good arguments for and against this statement. We see lots of people with no orthotics develop problems. However...

    This is a presumption. Might be true, might not, but still a presumption.

    What if feet which ARE supported with orthotics which STILL go on to develop pan and deformity?! I've seen plenty of these!


    The (in)famous Tim Kilmartin study on Pediatric HAV springs to mind. Two groups of kids with HAV were split into 2 groups. One was given orthotics, the other not. After a few years the ones WITH orthotics had done slightly less well than those without!

    Many had assumed (still do) that orthotics would prevent these HAV's from deteriorating. They didn't. I believe Tim described it as a beautiful theory killed by an ugly fact.

    Its easy to boast prophylactic efficacy on that kind of timescale. Is it supported / justified?

    Regards
    Robert
    PS. I still sometimes issue orthotics to asymptomatic patients. ;)
     
  8. admin

    admin Administrator Staff Member

    There was this systematic review that looked at the evidence:
    As its a textbook chapter I don't have access to post the abstract.
     
    Last edited: May 4, 2009
  9. It would be interesting to see the results of that!

    However I think there is a distinction to be made between sports injury and long term degenerative process.

    Regards
    Robert
     
  10. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    My view is:
    1) Orthotics are used if patient is symptomatic and foot orthotics can alter the abnormal forces that are causing the symptoms
    2) Orthotics are indicated if the patient is asymptomatic and there are abnormal forces present that increase the risk of symptoms developing (and foot orthotics can alter those forces).

    The problem is we have good data to support (1) and not very good data to support (2).

    The real argument that has gone on about (2) is where to draw the line in the sand of risk. I don't have an answer and i don't think anyone else does yet either. We have a lot of good theory and that doesn't mean we won't have the good data on day.
     
  11. Sammo

    Sammo Active Member

    How about instead of looking at putting everyone in insoles we look at the development of the child and how best to protect their feet as they grow to avoid future pathology? May Non.. Mon dieu.. there isn't as much profit in that is there..

    (2) And you still haven't answered any questions. What about the STJ post when you were talking about putting people with an obvious injury to the peroneus brevis into a medial heel wedge.. Can you tell me why.. will you ever answer this question? I will start every post with this one question until you give me an answer.

    You have done wonderfully here by starting a new post.. You have deflected maginficintely from my previously asked questions and avoided having to make any real answers by picking up on a point i was making and trying to turn it into an inflammatory posting where you say "look everybody.. look at what sam randall wrote!!! Aren't I a clever boy for picking that up..!?!"

    I still don't recall you answering a single question in the last 4 months... You really have missed your calling as a politician!!

    Also, you paraphased me a little there and added a few things to my post for the sake of making yourself look better..

    Now.. to address this: I was arguing a point. The point being that NOT EVERYONE HAS SOME LEVEL OF PATHOLOGY!!!!! :bang:

    Some people have feet that we deem appear to be predisposed to pathology but not all of them become pathological.. Is it ethical to tell them they WILL get pathology when they may not..

    I see quite alot of children at the hospital that I work.. alot of them are brought in by worried parents, due to the fact they are deemed to have flat feet.. I spend alot of time on taking history and finding out if, amonst other things, the patients fall over too much, don't like sports, run around less than their peers, get tired faster than others, have trouble fitting into shoes.. I then make a judgement call on whether to treat..

    If I deem it appropriate I will say something along the lines of "your child has a foot type that may predispose the to X injury, although they are currently not suffering from any problems. I would prefer not to put them in insoles at the moment because there is the possibility that the insoles may mean that the foot muscles may not develop as well. What i would like to do is for you to watch out for signs of X, Y, Z and if you have any problems you can come in straight away to see me.. If not I will see you in six months to monitor your son/daughters progress."

    If they are pathological I will look at a combination of foot wear/insoles/exercises/physio referral and I might even call one of the Paeds specialist Professors/Drs I work with on occasion for their opinion.

    This idea works with adults too.. if they are not getting symptoms (and symptoms can consist of things as simple as a little back ache, tiredness not just foot specific pain) then I will educate them, ask them to monitor their condition, and try improve other aspects of their self care, foot wear, activity, training habits, shopping habits etc., to take a more holistic look at the patient.

    It is almost funny the amount of times I have casted someone for insoles and when they return in 3-4 weeks to pick up their insoles, they have an almost complete reduction in their symptoms just due to correction of poor training techniques or improve footwear.. Luckily I was working for the NHS then.. so they didn't have to pay for their insoles.

    But, at the end of the day I still prescribe alot of orthoses.. The point I am trying to make Dr Sha, is that insoles should not always be first line treatment for everything. And that not everyone should be placed immediately into insoles the second they walk through the door because they might get pathology. I might get struck dead by a falling dead pigeon, or a :pigs: but I don't wear a crash helmet to work every day.

    So, I look forward to you finding one sentence in there, turning it around on it's head, taking it out of context, adding a little bit, not answering any of mine, or anybody elses questions, and posting it in a fresh post so noone sees what started that topic in the first place. :craig:

    :drinks

    Sam
     
  12. Sammo

    Sammo Active Member

    Just to clear up a point.. I never said that. I feel the need to point out exactly what DrSha has done here..

    Sam Randall Position:

    “Not all feet have some level of pathology.. only injured feet have some level of pathology. Unpathological feet have no level of pathology because they are unpathological” Yes I said this and stand by it (and do not need Foot Orthotics). DrSha added this

    “It works very well for your system (and bank balance) to tell everyone that they have some level of pathology.. but the truth is they don't... not all feet become pathological.” This is also what I said.. please not the choice of terminology.. not all feet become pathological.. some do.. some don't it depends on a whole bunch of stuff.. and not just whether you get a pair of insoles.

    From this point down it is all DrSha.. I didn't say this, and for DrSha to suggest I meant this is absurd.. Shame on you. I take back the politician comment (and apologise to politicians).. You should work for the f*****g Daily Mail.

    In summary, to utilize Foot Orthotics in civilized society as a preventive, performance enhancement and quality of life instrument has only one purpose:
    To generate income!

    Any foot doctor utilizing foot orthotics before injury exists is guided by greed and not a desire to care for the feet and postural health and performance of his/her community.
     
  13. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I tend to disagree and it comes down to the poor understanding of the concept of risk within the profession.

    Dyslipidemia is a well documented risk factor for ischemic heart disease (note, you rarely see it stated it is a cause). The level of increased risk is well documented. Lipid lowering drugs have been well documented to lower that risk by well documented amounts. The purpose of using the lipid lowering drugs is to reduce the possibility of an adverse event (ie ischemic heart disease) from occurring. The purpose is not to line the pockets of the drug companies (though this is an obvious effect).

    Another eg is that there is a certain lifetime risk of developing a particular brain tumor (I can't recall which one) (for argument sake, lets say the risk is 1 in 250 000; (I can't recall the actual value). Some relatively weak data has shown that regular mobile phone use doubles that risk (so the chance of developing that brain tumor is now 2 in 250 000). That is still a very low risk, from a public health perspective it not worth doing anything about it. YET, the media will sensationalize this increased risk as "mobile phones cause cancer".

    The point I am making about these egs, is why is things so different in podiatry? Why are we still talking in terms of cause and not risk?

    It is obviously possible that certain foot types and/or characteristics can and do increase the risk for pathology down the track (eg a certain foot type may increase the risk for MTSS by 10; that does not mean that that foot type will cause MTSS in everyone with that foot type).

    If we want to be taken seriously, those foot types and the magnitudes of risk associated with them need to be documented. Then depending on the level of risk (and other factors) an ethical decision can be made to intervene or not.

    In the absence of that all we have is what I alluded to above as the 'line in the sand' and really what we are arguing about is where that line should be. I assume I am right in saying that Sam thinks it should be down one end of the scale and Dennis thinks its down the other end of the scale.

    Obviously the 'truth' will be somewhere between; those at higher risk of developing problems should be treated (ie the dyslipidemic end of the spectrum) and those at low or minimal risk should not be treated (ie the mobile phone use end of the spectrum).

    Until we have the data, then its has to be an ethical decision as to intervene or not --- and informed consent and understanding of the patient is large part of that. Also in the absence of the data I will have to somewhat agree with Sam, that the $ does unfortunately creep into the decision making (see the Parish and Bell thread!)

    I am not for one second, saying that we don't intervene to prevent problems. I am saying that if we do, then it has to done in the context of the understanding of risk, the lack of data either way, and informed decision making.
     
    Last edited: May 5, 2009
  14. Sammo

    Sammo Active Member

    :good:

    The only point I would like to discuss is that MTSS (and the vast majority of other conditions we see) can be treated very effectively, successfully and quickly and if it is not treated prophylactically it can be remedied very early on.. I would be uncomfortable selling a pair of insoles to a patient under the premise that they have a 50:50 or even 60:40 in favour chance that they are going to get pathology. Unless they new all the facts and wanted them anyway.. My position would be to educate the patient as to the first signs of pathology and then they come back straight away if that pathology happens.. intervene with orthoses, patient gets better, everybody happy.

    I feel I have been somewhat falsely positioned by DrSha in this debate (due to his misleading and somewhat slanderous posts) and hasten to point out that I sit closer to the treatment line in the sand than it may appear. I was being averse in previous posts to make a point..

    Kind Regards,

    Sam Randall
     
  15. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Probably not the best eg I could have used :craig:

    Its the same with lipid lowering drugs. All that you can be promised is that they will decrease by x% the possibility that you will have an ischemic heart event. No MD will promise that will prevent the event; and no MD would ignore the other interventions (lifestyle, dietary, exercie, etc).

    The difference between foot orthotics for prevention and lipid lowering for prevention, is that for the lipid lowering we know what 'x" is, so dec ision making is informed. For orthotics, the decision making is informed by theory and opinions.

    I am just arguing if we want to be taken seriously by the 'mainstream', then we have to change out understanding (move towards the concept of 'risk') and acknowledge the deficits in our understandings and data.
     
  16. Some good points here!

    I noticed this bit

    Which is certainly also true of my experience in practice. This ties into another of my pet peeves, the way people use the terms "biomechanics" and "orthotics" as synonymous.

    Others don't go quite that far, but still see the footwear / lifestyle / education bit as a pale adjunct to the real tangible meat of a pair of orthotics.

    Something which impresses me about you, Sam, when you worked with me was the amount of time and attention he spend on this side of patient care. I suspect in your case a goodly number of those who had improved by the fitting appointment were little to do with regression to the mean and a lot to do with the bio mechanical treatment you carried out with communication.

    This essential part of practice is easy to neglect in the sound and fury of a packed out list. Certainly I have to make conscious effort not to cut back on that side of things.

    Now THERE is an interesting study. Instead of comparing different types of insoles, compare people treated with non insole therapy (education, advice, stretches, exercise etc etc) with those who receive simply an orthotic. Or perhaps issue one group a pre fab in the post and another a pre fab in clinic along with the other bit.

    Of course, there's not much money in it...;)

    Regards
    Robert
     
  17. Indeed. This put me in mind of a rather splendid piece by Dr Ben goldacre, who's "bad science" website should be required reading for undergraduates IMVHO. Full link here
    http://www.badscience.net/2008/11/y...ur-head-if-you-wear-a-bicycle-helmet-all-day/


    Heuristics again ;).

    The sentence I picked out in bold is relevant as well. Has anyone else noticed that ANY MS injury or symptom suffered by a patient after orthotics have been issued are the fault of the orthotic? How often do we have a patient come in with the same pair of insoles they've had for 5 years convinced that the LBP they have had in the last month was "because the orthotics need adjusting". :craig:


    And, to be fair, we don't fully understand whether orthotics can have undesirable effects. Pronation, after all, is a MOVEMENT ;)with a purpose, shock absorption and adaption being the obvious ones. Yes it can malfunction as a mechanism and cause problems. But then the suspension on my car malfunctioned the other month, thats not to say its wise for me to shove wooden blocks in my suspension springs to prevent it going wrong again! It might reinforce the suspension but it might also shake the chassie to shreds!

    I'm not sure blanket use of orthotics for asymptomatic patients is so wise!

    Regards
    Robert
     
  18. Ian Linane

    Ian Linane Well-Known Member

    I wonder if others, like me, find the line in the sand alters intermittently.

    Things that alter it include:

    1 reading of any new research that addresses conditions and orthosis supply
    2 a swing back to days when such a pronated or supinated foot type automatically commanded an insert and you know from pt follow up that they benefited then and have continued to do so, so the might be good for someone else
    3 Your mood
    4 Having done your soft tissue work and joint mobs you still have an incling that some form of support may well benefit them
    5 then some more reseach comes along :craig:

    Strikes me that even more useful data, which we might want, we will still have to accept that the sand is there to allow a line to be drawn as it enables us to work with the variables that are presented by pts, for example, the ergonomics of their work and activities etc, etc.

    Simon: nothing personal was taken.

    Ian
     
  19. :good:

    Especially number 3!

    Robert
     
  20. drsha

    drsha Banned

    Sam Stated:

    Originally Posted by Ian Linane
    Hi Sam

    You suggest:
    ".... Any foot doctor utilizing foot orthotics before injury exists is guided by greed and not a desire to care for the feet and postural health and performance of his/her community."

    Leaving aside the context and frustration in which you said it, I would have to disagree with some of the above.

    Cheers
    Ian
    Just to clear up a point.. I never said that. I feel the need to point out exactly what DrSha has done here..

    Sam Randall Position:

    “Not all feet have some level of pathology.. only injured feet have some level of pathology. Unpathological feet have no level of pathology because they are unpathological” Yes I said this and stand by it (and do not need Foot Orthotics). DrSha added this

    “It works very well for your system (and bank balance) to tell everyone that they have some level of pathology.. but the truth is they don't... not all feet become pathological.” This is also what I said..
    From this point down it is all DrSha.. I didn't say this, and for DrSha to suggest I meant this is absurd.. Shame on you. I take back the politician comment (and apologise to politicians).. You should work for the f*****g Daily Mail.

    In summary, to utilize Foot Orthotics in civilized society as a preventive, performance enhancement and quality of life instrument has only one purpose:
    To generate income!
    Dennis Replies:
    1. I placed quotes around what you said and then without quotes, I summarized both of our thoughts with what I thought was your meaning without quotes.
    I thought this meant that I said that in a grammatical sense and not verbatum your words or thoughts.
    If not, Sam is perfectly correct and I "put my words in his mouth" but I still feel that my summary reflecting his bias and ager was accurate.
    2. I rarely use varus rearfoot posts. I reduce the posting to 1-2 or at most 3 degrees in cases of extreme uncompensated rearfoot varus and so I do not know where you got the notion that I would use a varus post in p. brevis complaints. Perhaps you could pull the posting and I can explain it or thank you for pointing out its error.
    3. I was under the impression that our language differences and the debate over terminology and translation and my lack of EB research eliminated my need to answer questions specifically as they do not hold water or they cannot be understood. I am not being evasive, I am looking for a way to communicate with The Arena more civilly.
    4. In your scenario of your Hospital Clinic experience, you are totally leaving out questioning the parents as to whether they and their relatives have foot, postural, performance issues that have kept them form full and productive lives.
    Sam: What would you do if the parents say they all have major bunions and lower back pain?
    Furthermore, since I don’t solicit for unhealthy patients and don;t do screenings anymore, I don’t see many that do not have complaints but there are certainly those whose complaints do not involve pain and discomfort.
    In addition, by working in the same community for many years and eliminating future bunions and postural complaints and improving the shoe purchasing abilities in my community, I am probably losing a great deal of income by divorcing these patients healthier in my orthotics instead of letting them get bunons that I can get rich on when I operate on them.
    Floride eliminated a great deal of income from dentistry.
    I have as a goal to eliminate much of the work currently performed by podiatrists and chiropractors in the future by preventing it.
    Sorry you remain inexperienced by youth, angry and biased.
    :empathy:
    Dennis
     
  21. :D

    Calm down Sam! Count to 10 slowly. I can see the look on your face from a few thousand miles away!

    Personally i'd say "there is not a shred of evidence, and only the shakiest of shaky rationales that orthotics prevent bunions". ;)

    I wonder how one knows if one has eliminated a future Bunion.:confused: I'm impressed! ;)

    Oh well. In that case I've had a few patients i've treated with orthotics who have NOT gone on to develop haemarroids. Perhaps I prevented them. :cool:

    Come to think of it, none of them have been eaten by bengal tigers either!:eek:

    Anyone else prevented anything bad happening with orthotics?

    Regards
    Robert
     
  22. Griff

    Griff Moderator

    Er... Do you wanna take this one Dr Spooner.... ;-)
     
  23. Sammo

    Sammo Active Member

    Ah, now you have me riled you play the reasonable one. Crafty..

    I apologise to the other members of the arena if i have risen to the bait somewhat. I have been following the debate over the last few months and see now that DrSha is doing to me what he has done to many others of you, some of who have reacted in much more dignified ways than I have.

    So, to finish off with.. I wrote "..I spend alot of time on taking history and finding out if, amonst other things.." fairly key part of the phrase the Amongst other things bit.... I wasn't about to list everything I did.

    And the question: I was trying to get you to answer how you would treat a foot with a fixed rearfoot varus deformity (where the calcaneum (calcaneus/heel bone) does not reach STJ Neutral, it remains in an inverted position, maybe only by a degree or two) where the patient is experiencing pain in the styloid process/peroneus brevis insertion/funny lump on the lateral border of the foot and the plantar fascia/aponeurosis/heel spur. I was also trying to find how that would fit into your paradigm/system/box of tricks/jiggerypokery. Does it have a box for a calcaneum which is fixed in an inverted position?

    Yours truly in my youthful, biased angst.

    S

    p.s. I'd be intruiged to see your technique for so clearly identifying the patients who will get HAV. Could you post it for me?



    Phew.. I should start a punk band or something.. T2 crowd can do Backing vocals.. "Some of them are hairy..."
     
  24. Griff

    Griff Moderator

    Not me mate, I totally lost my cool with the guy. Only way I can keep my blood pressure within reasonable limits is to try and not talk to him directly or reply to his posts (See - even now I'm talking about him in the third person...) I notice many members have adopted this approach and shouldnt think it will be long before he can't find anyone to talk to. Isaacs must have the patience of a saint ;-)

    Ian
     
  25. Robert does that sometimes if his own posts become irritating. He finds it helps!:D;)

    Regards
    Me
     
  26. Sammo

    Sammo Active Member

    :eek:
     
  27. drsha

    drsha Banned

    To The Arena:
    I have never shared or publicized the following until now as I hope it will explain some of my personal EBM.

    I retired from a charity clinic that I ran for almost 22 years where longitudinally, I treated a communal family of over 300 and their challanged "villagers" along with 3 physicians, virtually pro bono.
    In the Rudolph Steiner tradition, the anthroposophy belief of the physicians is that my orthotics "centered" the body and the spirit to the earth and most of the population was referred to me for orthotics at a young age.
    In addition, these folks work tirelessly 14 hours/seven day weeks and new arrivals often had foot and postural complaints which I resolved (or they left the community).
    This longitudinal population has served as my EBM for developing protocols for care and I owe them a huge debt for allowing me to be a part of their lives.

    I absorbed all costs for orthotics, dressings, equipment and supplies dispensed and never withheld care.

    Upon my retirement two years ago, I could not find a podiatrist willing to take over my position and "work for nothing on saturdays and evenings" and the practice has died.

    I never had an amputation, a foot related hospitalization and my elective surgical rate was much much lower than my NYC practice I believe in part, due to palliative care.

    It seems to me that your clinical practices in government supported facilities would welcome longitudinal studies to test out "palliative orthotics" and I would argue, that it would force you to develop a different set of standards for you to base orthotic performance upon rather than eliminating pain.
    :drinks
    Dr Sha
     
  28. Dennis.

    A graceful post considering mine, so I shall answer in kind.

    It strikes me that there are several things which set this group aside from your NYC practice. The lack of amputation and hospitalization is nothing particularly remarkable. It sounds like a small group (<1000). The elective surgical rate is interesting. You ascribe this, in part, to palliative care. What role would you say was played by demographics, the lifestyle of this group vs the New Yorkies, footwear etc. I doubt there were many heeled shoes on those 12 hour 7 days weeks. You mentioned earlier the hard and unyeilding ground, this sounds like a rural community to me, was the terrain different?

    The point I am trying to make is that assuming there was a better rate of foot health in that population there were several possible causes. Palliative care is one, but only one.

    How little you know the NHS!
    "I'd like to issue 500 patients with no pathology with expensive inserts which MAY cause complications and follow them for 10 years along with a control group with NO inserts to see if we prevent pathology.".

    Conservative estimate, £100 per pair orthotics, renew every year on average, 500 * 100 * 10 years = half a million pounds.

    My budget this year, £19.34, a stick, 3 pebbles and the used teabags from the mangement team meeting once a month. ;):sinking:

    Can't see them going for that. Could ask I guess...


    Regards
    Robert
     
  29. drsha

    drsha Banned

    It strikes me that there are several things which set this group aside from your NYC practice. The lack of amputation and hospitalization is nothing particularly remarkable. It sounds like a small group (<1000). The elective surgical rate is interesting. You ascribe this, in part, to palliative care. What role would you say was played by demographics, the lifestyle of this group vs the New Yorkies, footwear etc. I doubt there were many heeled shoes on those 12 hour 7 days weeks. You mentioned earlier the hard and unyeilding ground, this sounds like a rural community to me, was the terrain different?

    The point I am trying to make is that assuming there was a better rate of foot health in that population there were several possible causes. Palliative care is one, but only one.

    All accurate and true.
    DrSha
     
  30. Also your NYC clinic is made up of people who come to you with problems and return for the same reason. Your other was made up of healthy individuals who came to you to stay healthy. Not a surprise then that the latter group had fewer problems develop, they were healthy to start with!

    If you had an NYC caseload of patients with no pathology who came to you for preventative care (as did your volunteer clinic) it would be a better comparison.

    Regards
    Robert
     
  31. Not right now, Ian. Like Sam, I'm intrigued to learn the details of Dennis's predictive model for hallux valgus. Having spent 6 years on a PhD which was dedicated to this task, I could post the details of the predictive model that I built here, but at this stage I'd rather hear what the retired Dr Dennis has to say. I should be very interested to learn the details of the model Dennis developed for prediction of hallux valgus ............. Although, I will not hold me breath for fear of suffocation in the waiting for him to answer this question. As we all already know he won't answer any tricky questions put to him; yet he thinks he can say what he wants without challenge.

    Punk band, Sam? To quote Steve Jones of the Sex Pistols- "What a ****ing rotter" To quote Simon Spooner of various punk bands over the years: "What a twat you are, Dennis."
     
  32. I got one.

    If somebody DOES have orthotics and does NOT develop HAV it is retroactivly predictive that they WOULD have had they NOT had orthotics.

    Or something.

    Seriously, I'd like to see ANYONES models, Simons or Dennis' * for predicting HAV. Its a source of some irritation to me that I don't have one. Oh for the halycon days when HAV used to be caused by overpronation:boohoo:.

    Regards
    Robert

    *Although I suspect I would not understand either!:sinking: **
    **For somewhat different reasons.
     
  33. Just sending a PM to you with my model- no clues for Dennis ;)
     
  34. David Wedemeyer

    David Wedemeyer Well-Known Member

    Amen. Doesn't this incessant twaddle ever reach a climax with Dennis?

    Seriously Dennis you are an intelligent man but have zero research to support your profoundly anecdotal theories. Every thread you participate in is punctuated by a decrial of your detractors, many of whom have performed research and whose ideas are in wide usage in the podiatric community and you never, ever answer their queries with any reasonable evidence beyond your opinions.

    Please do us all a favor, engage in some research and gain a modicum of evidence and and some small body of proof for your theories and system and credibility and interest will follow. As of now all of your posts are argumentative and redundant. I am beginning to think you just like to argue and incite others rather than add anything remotely of value.

    I haven't posted in a while, actually haven't been reading many threads here because this entire campaign of Dennis's has become loathesome and absolutely pointless.

    Sorry Craig, I feel it needed to be said.:hammer:
     
  35. Like David, I have found myself tending to avoid the threads that Dennis Shavelson is contributing to since these threads invariably seem to end up with him:

    1) claiming that everyone on Podiatry Arena is against him,

    2) claiming that his method is superior to all others, without providing any evidence to support his claims, and

    3) claiming that other theories aren't as good as his theories, even though he also claims he hasn't read them and doesn't even understand the theories or the language used to describe the theories.

    I get the same feeling watching Dennis that I had while watching Ed Glaser pontificate for awhile here on Podiatry Arena. Here is what I see: lots of meaningless talk, lots of blame placed on others, lack of ability to answer simple biomechanical questions regarding their ideas, and absolutely no supporting evidence to show their ideas or orthoses are better than any others that they so freely criticize.

    After awhile it all gets very old, very predictable and very tiresome. As a result, I tend to end up not reading any of their posts since they just can't seem to see that they are continually beating the same horse to death in every thread they contribute to.:deadhorse:
     
    Last edited: May 6, 2009
  36. drsha

    drsha Banned

    First you say that in order to be in the Rothbart club I would eave the Arena to its members.
    Now, I am still in the club even though I haven't left?

    Please suggest an alternative method because all I really want to do at this point is be voted out of the Rothbart club.

    I won't stop until I am.

    and Kevin,
    all of us know you read every post that Dennis Shavelson makes!!!

    Mr Hyde
     
  37. Tough one. As Kevin points out the 3 major criteria are

    And you are still meeting these criteria:eek:.

    What happened to number 3 BTW Kevin;)

    I suppose the only way out of "the club", by these criteria is to

    1) accept that criticism of the model is not always down to personal vendetta's or dogmatic adherence to another model but might simply be an honest disagreement with your views.

    2) Quit claiming that your ways / insoles are better than everybody else’s unless / until you can support this claim with evidence.

    4) Learn how to use the language of biomechanics and physics then learn something about the other models so that you can critique them coherently and accurately rather than building horribly simplistic caricatures of them then pulling those caricatures apart. As you are acutly aware, nobody likes to have their work misrepresented.

    I'd add 5 (or possibly 3)

    Be conservative in your claims. Even if there is a nuggett of biomechanical gold in your model, and there may just be, people are turned off by exaggerated claims. If you went to the chemist (shemist?) with a headache what would you be more likely to buy, a pain killer you'd used before or a new wonder drug which would fix you headache, stop hair loss, build muscle tone and improve concentration.

    Regards
    Robert

    Robert is concerned that the referring to oneself in the third person is spreading!:eek:;)
     
  38. Griff

    Griff Moderator

    I'll take the second one please sir... ;)
     
  39. :rolleyes:

    There's always one!

    Hippy! ;)

    R
     
  40. drsha

    drsha Banned

    Simon Says:
    I should be very interested to learn the details of the model Dennis developed for prediction of hallux valgus .....

    Dennis States:
    I am so relieved now that I took the time to look up TWAT.
    n 1: a man who is a stupid incompetent fool [syn: fathead,
    goof, goofball, bozo, jackass, goose, cuckoo, zany]
    2: obscene terms for female genitals [syn: ****, puss,
    pussy, slit, snatch

    I grew up in Brooklyn, NY and in my neighborhood, the only definition for TWAT was #2.

    I can greatly reduce my ire towards Simon as I am comfortable being on his fathead, goof, goofball, bozo, jackass, goose, cuckoo, zany list but was very insulted being called a female genital.

    Sorry for my lack of british upbringing and class.

    Apology accepted?

    And now:
    To address Simon’s request.


    Preventing Bunions:

    An Apocryphal Biomechanical Fantasy by
    Dennis Shavelson, D.P.M.


    The pure Functional Foot Type that has a developmental relationship to the Hallux Abducto Valgus deformity (hereafter called a bunion) in The Functional Foot Typing System, is the Rigid Rearfoot, Flexible Forefoot Foot Type.
    In reality, there are three pure Rigid/Flexible FFT’s. One of them is unsupported and untrained, one is supported and untrained and one is supported and trained.

    In discussing support (to bear the weight of, especially from below, to hold in position so as to keep from falling, sinking, or slipping, to keep from weakening or failing, to strengthen) when it comes to the foot, it can come naturally, internally (as with fusion surgery) or externally in the form of a strut or Centring.

    In the untrained (not disciplined or conditioned or made adept by training; untrainable) Rigid/Flexible Foot Type, the lack of a supporting osseous Vault prevents the forefoot musculature from gaining enough mechanical advantage to overcome the ground reactive forces and function with power and perform work, in phase, in all of life’s activities (forward motion, stance, gait, lifting, pulling, side to side motion and backwards movement), not just forward motion.

    In the trained (to coach in or accustom to a mode of behavior or performance, to make proficient with specialized instruction and practice, to prepare physically, as with a regimen) Rigid/Flexible Foot Type, the osseous Vault supports the foot sufficiently to allow the forefoot musculature to gain enough mechanical advantage to overcome the ground reactive forces and have enough leverage and power left to function and perform work, in phase, in all of life’s activities, not just forward motion.

    An exact definition of the rigid rearfoot type is difficult because in some cases, this foot can be everted in closed chain due to superstructure influence or medial heel soft tissue collapse secondary to primary forefoot collapse after midstance. But as a starting definition, the pure Rigid/Flexible Functional Foot Type can be defined as a rearfoot that has a range of motion of inversion-eversion that places the calcaneus inverted to the ground in closed chain.

    The flexible forefoot type has a range of motion in open chain, when referenced to the fifth metatarsal, that exists from plantarflexed to the reference point when supinated to dorsiflexed to the reference point when pronated.
    This means that in closed chain, as the first ray begins to bear weight, it elevates before becoming stiff enough to prevent the foot from overcoming GRF and/or supporting the Vault. The end result is a collapsed Vault and pedal musculature that lacks mechanical advantage and leverage.

    The Rigid RF/Flexible FF FFT does not represent flat feet but instead, feet that flatten, with the pathology existing mostly in the forefoot. It does not represent feet whose dominant pathology is contact phase rearfoot pronation, it represents feet whose dominant pathology is first ray collapse in the forefoot after midstance.

    This story begins at about age eight (the age at which a future ballerina begins en pointe training), this foot type, in closed chain, allows the forefoot to lengthen and splay in addition to allowing the Vault of the Foot to collapse. Critical muscles involved in forefoot and vault support begin to lose mechanical advantage (Peroneus Longus, Flexor Hallucis Longus, Abductor Hallucis and other core intrinsics of the foot). They fail to engage the first ray in a leveraged position of fixed plantarflexion that should stabilize it against the first cuneiform proximally and the weightbearing surface of its head and the great toe, distally.

    At this critical time, this foot type either remains supported naturally or needs some form of additional support (Foot Surgery or a Centring). In addition, at this time, this foot type either naturally promotes muscular work to be performed or it needs additional training in order to promote a lifetime of normal function. In summary, in this fantasy, every one of these feet, in the civilized world, needs to be profiled and depending on its biomechanics, may benefit from some level of support or training.

    If unsupported and/or untrained at this moment, every step from that time on will stretch and loosen ligaments, maintain the collapsed Vault and habitualize muscles to not perform and in addition to poor performance and closed chain fatigue, over time and with activity (some with this foot type become lazy and inactive and the process occurs slower), the HAV angle will increase and the first ray will dorsiflex and the fore part of The Vault of The Foot will collapse followed by rearfoot and postural adaptation.

    One reason to diagnose and treat this FFT early is that at some point, different in all individuals, these closed chain events morph from being flexible events to being fixed in positions of deformity and poor function. This means that at some point in the lifetime of the unsupported and/or untrained Rigid/Flexible FFT, different for all individuals, surgery becomes the only means of improving support.

    The untrained Rigid/Flexible Foot will over time, allow the first ray to continue to splay medially and dorsally, without muscular support and leverage and will lead to 1st MP Joint dysfunction in the form of FHL, bunion and/or DJD formation, different for all feet. Every Rigid/Flexible FFT needs a foot stable enough and trained enough to support the foot and posture and accomplish a lifetime of work. If lacking support or training, early on, this foot type will fail to perform over a lifetime differently for each individual and eventually would become deformed like a bell with some individuals developing bunions.

    Let’s pretend to understand this untrained foot type in an 8-9 year old girl who wishes to be en points for ballet. She needs a foot stable enough to leverage the first metatarsal into fixed plantarflexion so that the great toe, supported by a ballet shoe can be trained to go en pointe. If this cannot be accomplished, this foot type will fail to perform at a high level when it comes to ballet and if ballet is persued, great toe joint pathology (by far the #1 location of injury and deformity in dance) is often inevitable.

    My goal in the unsupported Rigid/ Flexible FFT is to apply enough Centering under The Vault of the Foot by using a custom casted and prescribed Foot Centring to provide the support needed to the extrinsic and intrinsic muscles so that they can gain mechanical advantage and leverage and if too late to perform biomechanically oriented foot surgery to internal improve things.

    My goal in the untrained Rigid/Flexible FFT is to train the extrinsic and intrinsic musculature starting with Peroneus Longus to gain enough mechanical advantage and leverage to perform with power and in phase without compensatory deformity or breakdown over one’s lifetime.

    When utilized early and under the guidance of skilled professional minds and hands, this therapy may safely alter the structural and functional capabilities of the foot and in fact, prevent some bunions from blossoming.

    The perfect happy ending to the story, as with all apocryphal fantasies doesn’t come true for everyone due to the huge number of variables inherent in any biomechanics paradigms including The Foot Centering Theory of Biomechanics.
    :drinks:drinks:drinks:drinks
    The End
     
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