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The Tissue Stress approach to clinical biomechanics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Jan 22, 2006.

  1. admin

    admin Administrator Staff Member

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    I am grateful to Kevin Kirby and Precision Intricast for permission to reproduce this February 2002 Newsletter (you can buy the 2 books of newsletters off Precision Intricast):


    In last month’s newsletter, the subtalar joint neutral (SJN) approach to mechanical foot therapy was reviewed. To summarize, the SJN Theory is based on the premise that the structures of the foot and lower extremity can be accurately measured so that any deviation from an ideal or a “normal” structure would be considered to be a “deformity”. Using the SJN Theory as the basis for mechanical foot therapy, foot orthoses are designed to “prevent compensation for deformities” with the orthosis prescription being based on the “deformities” which are determined during the biomechanical examination of the patient. Proponents of the SJN Theory do not necessarily change the prescription variables of foot orthoses when different anatomical structures are injured or the mechanical nature of the pathological loading forces are different since it is assumed that by simply “preventing compensation for deformities”, more normal gait function will occur and the injured structure will eventually heal.​

    Within the podiatric biomechanics community during the past fifteen years, there has been a gradual shift away from using the SJN Theory as a theoretical basis for mechanical foot therapy. One of the reasons why many podiatrists have moved away from the SJN Theory is due to some of the inherent problems and inconsistencies with this theory of mechanical foot therapy. One large problem with the SJN Theory relates to the reliability of the measurement procedures used within the standard biomechanical examination techniques proposed by Root et al over thirty years ago (Root, M.L., W.P. Orien, J.H. Weed and R.J. Hughes: Biomechanical Examination of the Foot, Volume 1. Clinical Biomechanics Corporation, Los Angeles, 1971). These examination techniques have been found to have only fair to poor intertester reliability and, therefore, can not be considered reliable from one examiner to another (McPoil, T.G. and G.C. Hunt: Evaluation and management of foot and ankle disorders: Present problems and future directions. JOSPT, 21:381-388, 1995.)

    Another criticism of the SJN Theory is that the criteria for normalcy proposed by Root et al are not clinically practical since they are so restrictive that few individuals have “normal” foot and lower extremity structure (Root et al, 1971). In addition, the idea of Root et al that the subtalar joint should supinate through neutral position during the midstance phase of walking gait has been questioned by research by McPoil and Cornwall on 100 healthy, asymptomatic feet in which the subjects were more likely to have a rearfoot motion pattern which correlated to their resting calcaneal stance position than to their neutral calcaneal stance position (McPoil, T.G. and M.W. Cornwall: The relationship between subtalar joint neutral position and rearfoot motion during walking. Foot Ankle Intl., 15:141-145, 1994.) McPoil and Hunt have provided an excellent review of the problems associated with the SJN approach to mechanical foot therapy, including those listed above, and also have proposed a new model, the tissue stress model, for the approach to mechanical foot therapy (McPoil and Hunt, 1995).

    McPoil and Hunt have chosen to use the tissue stress model “as the basis for developing an examination and management paradigm for treating individuals with foot disorders”. They claimed that the tissue stress model is not a novel idea since it is based on the same ideas that are already in current use in the treatment of parts of the body other than the foot and lower extremity. In addition, one of the benefits claimed for the tissue stress model is that it doesn’t rely on the use of the “unreliable measurement techniques” currently in use within the podiatric profession (McPoil and Hunt, 1995).

    There have also been others that have also advocated the use of the tissue stress approach to mechanical foot therapy. Eric Fuller, DPM, has recently described the effects of rearfoot and forefoot wedging and how he uses the tissue stress approach in the clinical setting as a basis for mechanical foot therapy (Fuller, E.A.: Reinventing biomechanics. Podiatry Today, 13-3), December 2000). Dr. Fuller has also reviewed the concept of tissue stress and how computerized gait evaluation techniques along with the concept of modeling of the foot and lower extremity can help predict the stress in a specific anatomical structure (Fuller, E.A.: Computerized gait evaluation. pp. 179-205, in Valmassy, R.L. (editor), Clinical Biomechanics of the Lower Extremities, Mosby-Year Book, St. Louis, 1996). In addition, in two articles on future directions for podiatric biomechanics, I have also described the important concept of modeling of the foot and lower extremity and how modeling can be used to predict the loading forces, or stresses, which occur in the structural components of the foot and lower extremity during weightbearing activities (Menz, H.B. (moderator), Kirby, K., Cornwall, M., Rome, K., Tinley, P., Murphy, N., Keenan, A.: Clinical measurement of the lower extremity-where to from here? Australasian J. Pod. Med., 31 (3):95-99, 1997; Kirby, K. A.: What future direction should podiatric biomechanics take? Clinics in Podiatric Medicine and Surgery, 18 (4):719-723, October 2001).

    Previous to the time that I first heard the concept of the “tissue stress model” in a lecture given by Tom McPoil, PhD in 1997 at the American Academy of Podiatric Sports Medicine Annual Meeting in Bellevue, Washington, I had independently developed a similar thought process and approach to mechanical foot therapy that I called “thinking like an engineer” (Kirby, K.A.: Thinking like an engineer. March 1992 Precision Intricast Newsletter. In Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, pp. 267-268). In the newsletter, I described how it is more important for the podiatrist to focus on the internal loading forces, or stresses, which cause injury when treating mechanically related pathology than to just focus on determination of “deformities”. I also described how a structural engineer might use a similar approach when analyzing the stresses within the structural components of a building or bridge.

    The tissue stress model is another way of stating the idea that podiatrists would be more effective at treating their patients if they would only use some of the basic mechanical concepts that have already been used for decades by structural engineers. The model is based on the concept that any mechanical therapy designed for the patient should be based not only on the specific anatomical site of injury of the patient, but also on the nature of the pathological loading forces that are causing the injury and how to most effectively design a mechanical therapy program to reduce these pathological loading forces so that healing may be optimized. Podiatrists who use the more logical and biomechanically sound approach to mechanical foot therapy inherent in the tissue stress model are much more likely to efficiently and effectively heal the mechanically based pathology of their patients. The podiatrist that only uses the concepts advocated by the proponents of the SJN Theory, where treatment of externally apparent “deformities” guides the design of the mechanical foot therapy, likely will be less effective at treating the wide range of foot and lower extremity pathology that can be treated with foot orthoses.

    [Reprinted with permission from: Kirby KA.: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002, pp. 13-14.]
  2. How does a podiatrist use the tissue stress approach when seeing patients? Here is way it should be done:

    1. Accurately identify the anatomical structure which is injured or symptomatic.

    2. Determine the structural and functional characteristics of the individual's foot and lower extremity.

    3. Determine the most likely type of abnormal tissue stress which is causing the pathology within the injured anatomical structure (i.e. compression, tension or shearing stress).

    4. Design a treatment protocol to reduce the abnormal tissue stresses on the injured structure and reduce the local inflammatory response so that more normal gait and weightbearing function can occur.

    This is certainly very different from the way I was taught to treat patients with foot orthoses (i.e. STJ neutral theory) since this was based nearly solely on trying to get the patient to function in STJ neutral position, with little regard to the injured structure that was being treated.
  3. Craig Payne

    Craig Payne Moderator

    Forces damage tissue. Position and motion do not damage tissues. Treat the forces, not the motion and position .... (I have spent the last ~20 years treating motion and position becasue that what I thought we were supposed to do :eek: )
  4. It's interesting that podiatrists trained at the California College of Podiatric Medicine in the 1970's and 1980's (including myself) were dogmatically instructed that foot orthoses were meant to "prevent abnormal compensations", "make the subtalar joint function in neutral position", "lock the midtarsal joint" and "bring the calcaneus to vertical". All of these ideas are wrong and should be signficantly modified or discarded if one is striving to achieve the goals of foot orthosis therapy utilizing the tissue stress approach which are to:

    1. Decrease pathological loading forces on the injured structural components of the foot and lower extremity;
    2. Make the patient asymptomatic, and;
    3. Optimize their gait pattern.

    The theories promoted by my biomechanics instructors at CCPM taught us that "preventing abnormal compensations" was meant to include preventing abnormal compensation motions with no mention that compensation should also include preventing abnormal compensation moments. The idea that foot orthoses should attempt to prevent abnmormal compensation is not a bad one as long as it is understood that any abnormal compensation motions directly results from abnormal componsation moments.

    Since one can not have a change in rotational motion or have a change in rotational position in the foot and lower extremity without a change in moments, we should then rightly conclude that the term "compensation" does not need to include the concept of motion or position within its definition. Intead, the term "compensation", relative to foot and lower extremity function, should be defined as follows:

    "Compensation" is an alteration in moments acting across the joint axes of the foot and/or lower extremity that is caused by the mechanical interaction between the foot and the ground in a weightbearing environment and which may be modified by structural, positional or functional abnormalities of the foot and/or lower extremity. (Kirby KA: "The Biomechanics of Compensation for Foot Deformities", in Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002, pp. 33-36).
  5. Berms

    Berms Active Member

    Kevin has explained the tissue stress approach to managing foot pathology very well, and I agree that "position and motion" do not damage tissue, but rather forces do... However, if we were then going to treat the "abnormal forces" how would we go about it any differently than by attempting to alter the position and motion?
    The tissue stress model gives us a better understanding of foot pathology, but my real question is - how do we relate that to changing our biomechanical assessment and orthotic presciption? Wound't we still be doing the same assessment and prescription at the end of the day, just with a different understanding of what we were doing? :confused:

  6. Berms

    Berms Active Member

    tissue stress model

    Hi Kevin,
    The points you make above I believe are very valid, and we do need to shift away from the old Root version of "motion and position" when dealing with foot pathology and biomechanics. Points 1 & 2 above descibe the "biomechanical and clinical assessment" side of the equation, and point 4 the treatment. However, what I do not understand is point 3, how do we determine which type of force it is? and if it is a compression type force affecting certain structures due to end-range pronation for example. isn't the treatment protocol going to attemt to make a device which affects the "position and motion" of the STJ anyway so as end range compression forces do not occur? :confused:
    Apologies if I'm a little behind on this topic, but any of your thoughts may help me get a better grasp of the new model, and how to alter our clinical practice.
  7. Adam:

    We can best determine the most likely type of tissue stress (i.e. compression, tension, torsion, shearing) by knowing the function of that tissue, its anatomic location and how externally generated and internally generated forces are affecting it. For example, in a patient with plantar heel pain, which we commonly call plantar fasciitis, the pain can be caused by compression stress due to ground reaction force acting directly on the plantar medial calcaneal tubercle or due to tension stress from the fibers of the central component of the plantar aponeurosis on the medial calcaneal tubercle. If it is due to compression stress, then reducing the compression stress would be the most appropriate means of relieving pain. If it is due to tension stress, then reducing tension stress would be the most appropriate means of relieving pain. Of course, probably many cases of "plantar fasciitis" are caused by a combination of compression and tension stress so that therapy will need to include provisions for both.

    Another example is tenderness in the midsubstance of the central component of the plantar aponeurosis, which can be caused by both tension stress and compression stress. Tension stress would typically be caused by Achilles tendon tension during weightbearing activities and may respond to more arch support from an orthosis. Compression stress could be caused by a foot orthosis that is pressing too firmly on the medial arch of the foot during weightbearing activities and may respond to less arch support from an orthosis. Therefore treatments will vary, using the tissue stress approach, depending on the mechanical nature of the forces acting on the structural component in question.

  8. Kevin,
    So we've identified the tissue, lets take your example of a patient with plantar heel pain, due to tension stress from the fibers of the central component of the plantar aponeurosis on the medial calcaneal tubercle, how do I make an orthotic for this patient? How should I cast the foot? How should I balance the forefoot to rearfoot on the positive cast? What degree of rearfoot wedging should I add? In other words, how do I arrive at my orthotic prescription in the tissue stress paradigm? ;)

    Also, when I have dispensed the devices, how do I know whether I have altered the moments favourably? Now some bright spark is going to say, "because the patients symptoms improve". But we all know that this doesn't answer the question because symptoms can improve for a multitude of reasons, without necessarilly changing moments.

    Best wishes,
  9. Craig Payne

    Craig Payne Moderator

    You can still alter forces without changing position and motion. A change in position/motion of the rearfoot is not associated with outcomes (we have had a thread on this, but sorry I can not link to it as on a really slooooooow connection here at JFK and it will take forever to find it)
  10. Simon,

    The tissue stress theory of mechanical foot therapy is not comprehensive enough to provide an exact prescription protocol for all foot pathologies. However, it will allow guidance of the clinician toward an orthosis prescription that is quite likely to accomplish the goal of making the patient less symptomatic.

    For example, if it is determined by the clinician that the pain in the plantar heel is caused by increased tensile force within the medial fibers of the central component of the plantar aponeurosis pulling on its origin at the medial calcaneal tubercle, then I would design the orthosis with specific modifications that would tend to reduce the tensile force within the medial fibers of the central component of the plantar aponeurosis. This may include designing the foot orthosis with a 5 mm polypropylene shell, 4/4 degree rearfoto post, a 3-4 mm heel contact point thickness, 2 mm medial heel skive, 16 mm heel cup, minimal medial expansion thickness, a plantar fascial accommodation, and a 2-5 forefoot extension of 3 mm thick korex.

    To answer your other questions, the foot would be casted in STJ neutral position using neutral suspension casting technique described by Root et al. The forefoot to rearfoot of the positive cast would be balanced so that I am not creating either an excessive STJ supination or excessive STJ pronation moments with the orthosis. I don't use "rearfoot wedging" in the orthosis since all the correction is made into the orthosis....BTW, is "rearfoot wedging" some form of British podiatric orthosis therapy?? ;)

    If these specific modications then are shown at followup examination to have resulted in improvement of the condition (i.e. by increased subjective comfort and decreased tenderness on plantar heel), then one could logically conclude that the foot orthosis has reduced the tensile stress within the medial fibers of the central component of the plantar aponeurosis, which was the original mechanical etiology of the patient's complaints. Of course, other potential explanations are possible, but I think those questions are best left to the researchers who have the time to explore such ideas.

    By the way, the orthosis likely accomplishes the goal of reducing the tensile stress within the medial fibers of the central component of the plantar aponeurosis by decreasing the net forefoot dorsiflexion moment and decreasing the net first ray dorsiflexion moment since the function of the medial fibers of the central component of the plantar aponeurosis is to increase forefoot plantarflexion moment and increase the first ray plantarflexion moment.

    This tissue stress approach to mechanical therapy is all quite logical and mechanically coherent, as long as one understands the principles of modelling and free-body diagram analysis. I see that the biggest problem with many podiatrists using the tissue stress approach successfully is their relatively weak physics and biomechanics backgrounds. In other words, most podiatrists don't know the difference between a stress and a strain, a moment and a force and don't understand how modelling approaches may be used to determine internal forces within the foot using only a knowledge of the anatomy of the foot and the external forces being applied to the foot. The podiatrists who were engineers will be using the approach with no problem at all since it makes total sense to them. The podiatrists who struggle with basic mechanics concepts will never completely grasp these ideas so that they will likely achieve only mediocre results with their foot orthosis therapy.
  11. You've made a start within this reply Kevin, I'm sure all across the land patients will be receiving this prescription tomorrow;) Another way of looking at this is that perhaps the prescription does not need to be as exact as previously thought to achieve the desired outcome?

    Funnily enough I made a couple of pairs of these today ;) , except I used 3mm EVA for my forefoot extension and I didn't put in a plantar fascial accommodation as I haven't found them necessary in the past (I made these before I read your post-honest). Now back to playing Devil's advocate Kevin, why a 4/4 post and not a 5/4 post or 6/4 post? Why a 2mm heel skive (presumably inclined at 15 degrees?- Why 15 and not 10 or 12 or some other number of degrees?) Why a 16mm heel cup and not 15?

    Kevin, you know that you and I are pretty much on the same page when it comes to this stuff, but you must see it from the perspective of someone coming from the dogma of old, these are the things they want answering. I think, Howard (or maybe it was Craig) talked about viewing one model through the lens of another, and this is inevitably what is occurring, rightly or wrongly. Rootian mechanics gave a nice easy recipe to follow, and lets not forget, has helped a lot of people overcome their symptoms.

    I think the point is that if we did alter the prescription you gave above, lets say we did put a 10 degree, 3mm heel skive, we, changed the rearfoot posting angle by a few degrees +/-, it may not make a whole lot of difference to our outcome. I used to describe this to students as the "treatment envelope": we treat a patient with an orthotic device and they get better thus we know our prescription worked, but we don't know just how "accurate" the prescription was to the patients requirements, it could be that we could alter the prescription quite markedly and the patient would still get better, it could be that if we alter the slightest detail ,i.e. rearfoot post by 1 degree the prescription would have failed to alleviate the symptoms. Obviously this works vice versa, if a device fails to alleviate symptoms, we don't know how far away from the success zone we are, could be that 1 degree either way in the rearfoot post would have made all the difference.

    Just do a search in JAPMA, you'll find the term wedging is used frequently in papers published in American journals :rolleyes: How do you know when the forefoot to rearfoot of the positive cast is balanced so that excessive STJ supination or excessive STJ pronation moments are not created with the orthosis? OK I'll stop now :D

    Enjoying myself again in a podiatry chat-room :cool:

    Best wishes,
  12. You are absolutely correct. An exact orthosis prescription may not be necessary for a foot orthosis to be therapeutically effective since there are thousands of orthosis design permutations that may render a patient asymptomatic. The problem is that there are also probably a million or more orthosis design permutations that will cause little therapeutic benefit and may, in fact, cause other injuries to occur. The basic idea, therefore, is to get close to the correct prescription that accomplishes the goals of orthosis therapy (i.e. get patient better, improve their gait and cause no other pathology or symptoms).

    These are good questions because they point to the idea that orthosis prescription does not need to be exact in order for patients to improve and derive benefit from them. This is an important point that I try to make when training podiatrists, podiatry residents and students. I teach them that as long as they are headed in the right direction with orthosis design, they are more likely to achieve therapeutic success with the orthosis and there isn't one "magic" orthosis prescription that will work for each patient....there are multiple orthoses that may work for them.

    Some pathologies require very precise orthosis design to make the patient better and not cause other pathologies, whereas other pathologies will respond well to widely varying orthosis designs. Some of this is also patient dependent. The patients that can feel the slightest orthosis adjustment and then get pain as a result of this slight adjustment I call my "Princess and the Pea Patients". They are commonly the same patients that will wear their socks inside-out to avoid irritation to their toes from the seam at the dorsal digits.

    This is very similar to the way I view it. However, the clinician does need a treatment model by which to make specific treatment decisions. The better the treatment model, the better it will be at allowing a high percentage of clinicians to have a high percentage of treatment success with their foot orthoses. When it comes to the treatment models, I don't think any of them (sagittal plane facilitation, STJ neutral, etc) even come close to the tissue stress and STJ axis equilibrium model in being able to design foot orthoses that can treat the widest range of foot and lower extremity pathologies. However, for me to be chumming the waters now for further discussions in this regard may not be the wisest choice, but the bad boy in me just couldn't resist the temptation.

    If the patient complains that they are having supination related symptoms (e.g. feel like their ankle is going to roll into inversion or walking on the lateral side of their foot) or pronation related symptoms (e.g. sinus tarsi pain or PT tendinitis) then one knows that the orthosis has created excessive STJ supination or excessive STJ pronation moments. There are other factors for determining proper forefoot to rearfoot "posting" in the orthosis, but this topic is far beyond the scope of this discussion.

    Good discussion Simon. By the way, I feel sorry for your former instructors....hope they didn't run away from you like they ran away from me during my podiatry student days when they saw me walking toward them with a list of questions. ;)
  13. Berms

    Berms Active Member

    Hi Craig,
    I understand that a change in position/motion of the rearfoot is not necessarily associated with outcomes... However, my question still remains - If we were then going to treat the "abnormal forces" how would we go about it any differently than by attempting to alter the position and motion of the foot with orthoses?
    (ie wound't we still be doing the same assessment and prescription at the end of the day, just thinking about it in a different way?) BTW I would like to read the thread you mentioned on this topic in your last reply if you have time to provide me with a link.

    Thanks again,

  14. Craig Payne

    Craig Payne Moderator

    Its now 2.00AM and I made it to LAX ... still have another day of work tomorrow before heading back ... just come from the 5 degrees below and snow of Montreal .... I guess that better than the 42 degrees in Melbourne :p

    The thread is Kinematic change and foot orthoses outcomes.
  15. DaFlip

    DaFlip Active Member

    Sorry Kevin,
    no entry into the bad boy club until you are mad as well as bad.
  16. drsha

    drsha Banned

    Here is a 2002 example of a totally unproven (to this day) piece of self proclaimed expert opinion by Kevin Kirby DPM quoted from his self published work.
    Jeff Root's Rules #4

    This has been promated by Dr. Kirby and his followers for these eight years and I am sure that, like the Rootians, it has become accepted as fact or proven by its faithful like Jeff Root and his followers are to The Rootian paradigm.
    This is known as BIAS.

    Could any of you give proper evidence that my clinical outcomes, or those of any other practicing Biomechanist are "less effective" than anothers or even better could you give evidence that you are "much more likely" to have better clinical outcomes as Kevin opines?
    Dr Sha
  17. Actually, I hate to say it (really, really hate to say it), but I'm with Dennis here. :eek:

    I think the tissue stress approach is the most logical and best one. I think it is the only one which will grow with our increasing understanding and I think it provides the best clinical outcomes. But I will freely admit that these are only my opinions. I have no evidence that TS performs better clinically than STN, pre fabs or any other model.

    If we would hold others to task for the substance of their claims (and I think we should) it behooves us to hold ourselves to the same standards. Expert opinion, and I can think of none more expert than Kevin, is valid and valuable, but it remains only opinion and should be stated as such.

    That said, this newsletter was a "lightbulb moment" for me a few years back and I remain very grateful that it was penned and placed in the public domain.
  18. efuller

    efuller MVP

    The reason that we cannot give proper evidence that the methods you use create worse clinical outcomes is that we don't know the methods you use. You have yet to fully describe them. That's why I've been asking you to explain how you modify an orthosis for the different foot types. Yes, you did post something, but it was something like for this foot type I use the forefoot centering technique. But you did not describe the technique. If you can't describe the technique you cannot test it against another technique.

    It would also be helpful if you would explain the logic of why you think this modification would work. The tissue stress approach provides very good logic as to why a certain prescription should work. There is published proof about how lateral wedging can relieve medial knee pain and this well explained and predicted by examining moments at the knee. I would agree that very few other things have been proven about the tissue stress approach, but you can't say there is no evidence.

    Dennis, part of your technique relies on the standard Root (neutral position) technique. There are logical flaws in the Root technique. For example, the neutral position theory isn't quite clear on how the orthotic is supposed to work. One proposed mechanism is that the orthotic supports the "deformity." However this deformity is measured in STJ neutral position non weight bearing and the vast majority of feet don't stand in neutral position. If you were going to support the forefoot to rearfoot deformity, shouldn't you support the forefoot to rearfoot deformity that exists in the position of stance. (As the STJ pronates from neutral, the range of motion of the STJ increases thus increasing the amount of forefoot valgus that would be measured in the more pronated position of the STJ.) This is flawed logic for both centering and neutral position paradigms.

    So, Dennis, the part of your paradigm that we know well has faulty logic. I suspect that the part we don't know so well has faulty logic as well. You could prove me wrong if you would explain it. Your reluctance to explain it tells me that you have either not thought it through or that you just made something up that sounded good and you don't really believe it. That is the logical conclusion that many on the arena have come to. You can call that bias if you like, but there is some logic to that bias.

    The lowest level of evidence based practice is that in the absence of evidence you use treatments based on logic and the available science. Mechanical engineering is well established science. This is why I feel that people should choose the tissue stress approach over other treatment paradigms. Dennis, why should we choose your paradigm? What is your paradigm?

  19. Just for fun. Tonight Matthew, I will be, Dr Sha.


    So, to recap, the advantage of tissue stress (TS) over Neoteric (NT) biomechanics and Root (STN) biomechanics, is that whilst neither can claim inductive outcome evidence, TS has a rationale based on known variables and physics.

    In dispute I would offer the following.

    There are, as you say, potential logical flaws in the standard Root method. However notwithstanding this, it works. There is abundant outcome evidence, kinematic data and patient satisfaction data which shows positive outcomes when using STN protocol.

    By the purist approach, this would seem to indicate that notwithstanding its potential lack of theoretical consistancy, it can acheive positive clinical outcomes. This makes an interesting inference.

    Now you might argue that the successes of STN are based on those areas where it crosses over TS. In other words, where STN produces a similar prescription to TS it will be effective. However this is speculation on your part. I might claim the same.

    The problem with the TS theoretical consistancy is the degree to which it relies on A: Itself, and B: bench data. Brian Rothbart claims similar "rationale" for his model. If the foot moves the leg, the leg moves the pelvis, accepted link between pevic anteversion and the isthmus block THEREFORE insoles help fertility. This is the gulf between theorising and clinical reality. The data does not presently exist to bridge this gap for either tissue stress OR PCI's.

    To mangle an expression, a good theoretical model and $1 will buy you a coffee. The clinicians following these threads are interested in theory, but also in practice.

    NT biomechanics is a "formula" model of biomechanics. The cookbook approach as it is derisively called sometimes. This means there ARE comprimises in the model to make it accessible for people who do not have higher qualifications or knowledge of biomechanics. At base it is like root in that it is a straightforward "in the trenches" model. Cookbooks are not bad things. Who cooks a complex dish without a receipe? Expert accomplished chefs perhaps, but most of us can't.

    Empirically what most clinicans know, but won't admit, is that when they have someone come back with an insole which has not had the desired effect, they add a bit. More RF post or a higher arch. NT biomechanics STARTS with the higher arch and equips the podiatrist with a convenient and neat way to make the modifications. The theoretical model aside, this is simply an enhanced version of what most people already do when the root device is inadequate. Its simple, accessable, easy to use and formalises what empiricism has shown us over 40 years of using root type devices.

    Whilst the theorists may argue, and produce complex models, in clinic experience is king. If people take time to examine NT biomechanics they may find it actually dovvetails with what many clinicians already know. That when a lower arch, less posted device fails, a higher arch device with more wedging succeeds.

    I Know I will never convince the theorists, but then I'm not seeking to. But if those people who follow these threads without pitching in, who are not interested in the high level theory that only a few dozen people in the world understand but who ARE interested in a hands on clinical approach which gives great outcomes and more clinical freedom than the root approach, are interested they may get something from this.

    Dr Sha.

    The views expresses in this post are NOT those of the author and are expressed purely to stir the pot somewhat and add variety to what threatens to be a thread identical to all the OTHER threads.

  20. So Bob Sha ( so I can tell who I´m addressing)

    If the tissue stress approach is too hard to understand, you must be able to understand Dennis FFT approach maybe you can answer the question which Eric, Jeff Root have asked in the last month. I found some more which Davis Smith and Ian asked in 2008 today that never got answer.

    How can you begin to understand anything if not 1 question gets a direct answer ?

    I don´t really think the tissue stress approach is that hard to get you head around, as in all things it can get high brow, but saying it´s too hard so I will dismiss it is just lazy in my option- this does not mean you have to use it, but to say you will or you want you have to look at it.
  21. Hey Michael-san ;)

    You'll have to jog my memory on the questions....

    But regarding tissue stress (which is of course the topic of THIS thread, keep on topic you BAD man.)

    Its a simple concept in the same way as the ideal technique for bowling is "hit the middle". But there is a million miles from that to being a simple thing to execute clinically.

    Root is based in part on rearfoot measurements and much criticism has been leveled at this due to the inaccuracies of rearfoot measurement.

    Tissue stress, as described below, has little such measurement. However there is a MASSIVE presumption in the steps kevin describes.

    Answer me this. How "repeatable" or "accurate" is the average Podiatrist at

    "Accurately identifyingthe anatomical structure which is injured or symptomatic."

    Hmmm? Any tests been done on this? How many times have you seen a patient diagnosed with condition X when you think they have condition Y? Plenty if you are like me.

    Now the whole logical basis for the TS model is step 1. If this is not 100% (and I doubt anyone will claim it is) then the rest of the process is only as good as the initial step.

    And UNLIKE STN or NT biomechanics, the treatment can be radically variable based on the diagnosis of affected structure.

    So if we are going to be fair, and not biased, perhaps we should recognise this rather large source of potential error in the TS model (since we look for them in other models) and accept that it renders the model dependant on the podiatrists diagnostic skill to a much higher degree than root or STN. If the first step of TS was reliable then the rest of it is indeed logically sound, but lets not lose sight of the fact that we have no real idea what degree of inter tester repeatability there is on the identification of injured tissue.

    So, some questions for YOU about TS

    1. Do you accept that the subsequent steps of the model all rely on step 1 being accurate?

    2. Do you accept that podiatrists, being fallible, will get this step wrong from time to time.

    3. Do you accept that we will never really know how MUCH of the time this is.

    4. Do you therefore accept that the "logical consistancy" of the TS model is based on the accuracy of a completely untested measurement?

    5. Do you accept that an incorrect diagnosis of compressive vs tensile knee pathology will have the following effects based on the model

    STN, No difference to treatment if you get it wrong
    NT No difference to treatment if you get it wrong
    TS Potential to treat a tensile medial knee complaint with a lateral wedge which will increase abduction moment in the knee, amplify pronatory moment and generally "do harm"

    Bob sha

    The views expresses in this post are REALLY REALLY NOT those of the author and are expressed purely to stir the pot somewhat and add variety to what threatens to be a thread identical to all the OTHER threads. Honestly, just playing Shavelsons advocate.
  22. Notsure about massive presumption as tissue stress is just using what I like to think of as the laws of nature, or physics in relation to the foot and leg. It´s almost more of a presumption not to implement these laws.

    Abit hard to say, but I will say this we should all be better. I will say this thats it´s probably not at the level it should be.

    it maybe but thats how the rest of medicine works. We come up with a list of possible diagnosis and then through means such as palpation, x-ray, MRI,blood tests etc reduce that this until we get left with 1 and then treatment begins. Possibly one of the mistakes people make is that they beleive they must make a diagnosis at the 1st appointment.

    So, some questions for YOU about TS

    I do to a point, take "plantar related foot pain, 99% of the time a diagnosis of plantarfasciitis is made, but if the pain is in the intrinsics and the cause is tension the treatment may well be the same a positive results be had.

    So does everyone in the medicial world, but with technology such as ultrasound it should hopefully be less in the future.


    not sure I get you here, diagnosis is well diagnosis not a measurement. ??

    By using a lateral wedge and adjusting the COP of the knee, you may well cause harm just as you may with STN or NT you just could not prove that you did. But it my experience lateral wedge has such fantastic results, which may improve peoples quality of life that In my option you would be silly not to try. Also people seem to forget that if the patient says " my knee is great but Ive got pain here" and you can contribute that to your device, change the device. Remaking a device does not mean your a crap podiatrist in my world.

    Ive 2 brothers would Ive put off till a later date their knee replacement surg - Ive made adjustments.

    ps while we are making disclaimers, I seem to be having a bad English day so my spelling and expression is worse than normal if thats possible
  23. Michael San (this is really giving me a headache. Its so very Screwtape.)

    The presumption is in the first step. For sure you cannot change the laws of physics, but this is a CLINICAL model and you can misapply them. The presumption when talking TS is that the Diagnosis is correct.

    So you accept that ALL of us are prone to error in diagnosis the. By inference of this, all of you TS'ers are following erroneus treatment plans at least some of the time. Thankyou.

    Ah, so you're saying that a Tissue stress treatment plan can often not be initiated in the first appointment. Diagnosis is, after all, step one and you now say a diagnosis may not be made in the first appointment. What treatment model do you use before a diagnosis is made then? And is this a separate part of the TS model outwith Kevins description or have you expanded on his work? What do you do before your Diagnosis Mike? WHAT DO YOU DO!?!?!?! (sorry, getting carried away with method acting)

    And with respect, this is NOT how the rest of medicine works. In reality most medicine works on symptom set not diagnosis. Headaches get painkillers, lifestyle advice etc before referral. Neither you nor your GP is fussed about whether it is a tension headache, a migraine or a cluster until the phase 1 treatment has failed. Mysterious fevers get antibiotics without swabs. Suspected MI's are treated AS MI's until proven otherwise. That is the reality of coal face medicine.

    Ah, so you ARE treating symptom sets, not specific diagnoses then. And, whats more it does'nt matter because positive results can be had.

    Bit inconsistant with the model there. Seems to me we are BOTH treating symptom sets and foot types and we agree that this can still produce good outcomes. Seems a bit disingenuous to conceed this but to insist that you are making a firm TS diagnosis based treatment plan. Is the difference between us in what we do or why we claim we do it I wonder?

    What % of podiatrists have ROUTINE access to ultrasound do you think.
    Ah so its a model based on an untestable premise then. Puts one in mind of the homeopaths an other alternative medics who claim their "science" is "untestable". If its untestable, its not science really is it?

    Sorry, slip of the pen. I was thinking of how alike STN (based on an unrepeatable measurement) is to TS (based on an untestable diagnosis).

    Surely not! After all the times I've been flamed for begging people to try NT biomechanics because I get fantastic results, you say it would be SILLY not to try this on the same basis?! Double standard alert!!!

    Bob Sha

    The views expresses in this post are REALLY REALLY NOT those of the author and are expressed purely to stir the pot somewhat and add variety to what threatens to be a thread identical to all the OTHER threads. Honestly, just playing Shavelsons advocate. And its causing me a massive cognative dissonance headache to argue something I don't believe by the way. But Its worth being as brutal to ourselves as we are to others. Mike, you know what I really think and that I love you so please don't take this personal. Its just sparring.
  24. if you show me one clinical approach that give 100% results I´m in except for shooting people 100% effective but would not go over so well.

    I don´t want to be seen speaking for anyone but myself - unless you can get x-rays etc in 10 min ( why do people complain about the NHS) sometimes a diagnosis takes time.

    BUT that could be a money issue rather than good medicine

    I still don´t have much idea what "you do" as there is no peer review stuff to read, so I can´t decide what you do or don´t or if it´s something for me to look into to expaid my practice set with.

    but there is evidence for this treatment of lateral wedges , where is "your" evidence for your results in " your" EBM practice. There is even good mechanical theory of how and why it works. so not a dbl standard evidence v´s none.

    As for ultrasound I think in 5-10 years alot of Pods will have one to speed up the diagnosis process.
    No stress here Bob :drinks
  25. drsha

    drsha Banned

    The Tissue Stress Paradigm takes underlying infallable facts (TST) and then makes expert assumptions that are not proven as fact and using the facts developes a following.

    The fact is that tissues when put under stress beyond a certain point get injured or develop pain.

    The thought that engineering and Newton;s Laws (ORF) is the seemingly only way to the cure is expert opinion.

    In fact, the way we stregthen ourselves and grow and get stronger and improve our performance is by stressing the tissues.
    To eliminate stress into tissues would eventually lead to atrophy, disuse and poor performance.

    Mueller's PST Article in:physical Therapy, April 2002
    The PST focuses on the physical stresses that influence all biological tissues.

    Tissues are formed from groups of similarly specialized cells that cooperate to perform one or more functions within the body. The 4 fundamental types of tissue are: (1) epithelial tissue, which covers internal and external surfaces of the body and forms glands, (2) connective tissue, which provides structural and functional support to other tissues of the body, (3) muscular tissue, which has specialized contractile properties for producing movement, and (4) nervous tissue, which collects, transmits, and integrates stimuli to control the functions of the body.
    The PST does not address molecular or cellular mechanisms of adaptation.

    Rather, the PST identifies common principles from the literature that we suggest may be used to predict adaptive tissue changes that occur in response to physical stress.

    PST presents

    They Are:


    Muscle performance (force generation, muscle length) is a critical aspect of movement that can influence tissue stress. Muscles are highly adaptable. They generate movement and, hence, forces that place stress on tissues. Muscle also is an important "shock absorber," and muscle contraction is well recognized for its ability to protect bones, cartilage, and ligaments from excessive stress.23 As a general theory, the PST can be used in combination with other theories and approaches that provide a more detailed analysis of the mechanisms by which muscle performance contributes to stress on tissues of the body.24–30


    Motor control has been defined as the study of the nature and cause of movement,31 and it, therefore, represents a major component of physical therapists' expertise.21 Evaluation of the ways in which people control their movements to accomplish tasks provides physical therapists with insight into how stresses are applied to tissues of the body during movement. For example, Maluf et al32 have proposed that the daily repetition of similar movements and postures may result in excessive stress on tissues of the low back. These authors suggest that physical therapists can identify and modify motor recruitment patterns which potentially contribute to patients' low back pain during the performance of daily activities. Maluf et al32 contend that an important role of physical therapists is to identify patterns of movement that contribute to excessive tissue stress and to teach patient-appropriate movement strategies to prevent tissue injury and pain.


    Kendall et al25 have emphasized the relationship between posture, impairments, and pain. The Kendalls' basic premise, based on their clinical observations, is that there is a standard or "ideal" posture and that deviations from this ideal posture lead to characteristic patterns of musculoskeletal impairments and pain.25(p5) For example, the Kendalls predict that a person with excessive lumbar lordosis would have weak abdominal and hamstring muscles, with short, strong low-back and hip flexor muscles.25(p126)
    Some studies33–37 have questioned, and even refuted, a large relationship between these variables in people with and without back pain. Rather than emphasizing an ideal standard of posture and hypothesizing that there is a large relationship among specific postures, impairments, and pain patterns, the PST proposes that pain is caused by excessive tissue stress and that postural deviations are one of many potential variables that contribute to the excessive stress levels that result in pain. We commonly observe people with "poor" posture who are pain-free and other people with "good" posture who have pain. The types of activities performed by people varies widely, resulting in different stress demands on tissues of the body.
    The PST predicts that no one ideal posture exists for all people because tissues will adapt to meet the unique stress demands of each person. Injury occurs when tissues are unable to adapt to meet the demands of a given posture or task. Therefore, rather than comparing a person's posture to an ideal standard, the therapist's examination should focus on the postures or movements that cause pain.26,32,38,39 Within this context, postural deviations become one of many potential factors that may place stress on injured tissues. In some people, the postural deviation may be the primary factor contributing to excessive tissue stress (see "Implications for Physical Therapist Practice" and "Implications for Research" sections). In our view, the PST expands upon the Kendalls' theory by proposing that postural deviations are one important component of musculoskeletal pain; however, pain patterns should be evaluated in a broader context that considers other potential sources of tissue stress.


    Physical activity is another component of movement that results in tissue stress. The US Department of Health and Human Services and the American College of Sports Medicine have adopted the definition of physical activity as "bodily movement that is produced by the contraction of skeletal muscle and that substantially increases energy expenditure."40(p4) Physical activity may be divided into the specific subcategories of occupational, leisure, and self-care activities. The PST predicts that physical activity improves health because it increases stress on a broad range of tissues, making the tissues more tolerant of subsequent physical activity. Because the tissues are more tolerant of physical stress, they are less likely to be injured. This reduction in the likelihood of injury occurs regardless of whether the tissue is part of the cardiovascular/pulmonary, integumentary, musculoskeletal, or neuromuscular system. Increased physical activity has been linked to many positive health benefits, including lower risk for non-insulin-dependent diabetes mellitus,41 stroke,42 and obesity.43 The federal government, in Healthy People 2010, has set a number of goals to increase physical activity (Objective 22; Physical Activity and Fitness) in people who are otherwise healthy. We believe that physical therapists should use their expertise to provide instruction on how people can increase overall physical activity without injuring specific structures (ie, back or knee).

    It further states:

    Orthotic devices can be used to modify physical stress on biological tissues and can be used as an adjunct to other interventions in several phases of tissue adaptation. An orthotic device can be used to relieve stress from injured tissue (eg, a resting hand splint for patients with carpal tunnel syndrome, a lumbosacral corset for a person with low back pain). An orthotic device also can be used to apply stress to tissue to cause a change in the tissue (eg, orthotic devices that apply low loads for prolonged periods to increase muscle length and joint range of motion at the elbow).44 According to the PST, orthotic devices are an appropriate adjunct to treatment when other means of movement can not adequately control stress on the tissue to meet desired guidelines. We contend that components of the orthotic device should be chosen for their ability to achieve a desired stress level on the tissue. Likewise, taping45,46 and assistive devices (eg, crutches, walkers, canes) may be effective adjuncts to help modify stress on injured tissues.

    What gives the Tissue Stress Paradigmers the ability to say that all treatment can be delivered by manipulatiNG the ORF using newton's Laws (#3, #4)?

    In Fact:

    Stress levels that are higher than the maintenance stress range, yet are lower than the threshold value for injury, can have positive effects on tissue adaptation. Based on Principle E of the PST, musculoskeletal tissues subjected to levels of stress that are higher than normal become more tolerant to subsequent physical stresses and are more resistant to injury (ie, tissues become stronger). Principle I suggests that this type of adaptation occurs only when tissues are able to recover and adapt to previous bouts of physical stress. Controlled increases in physical stress through progressive resistive exercise cause muscle fibers to hypertrophy and become capable of generating greater force. Likewise, higher-than-normal levels of physical stress can promote remodeling in bone. Wolff's Law provides an excellent example of how one specific biological tissue, bone, responds to physical stress by remodeling. Wolff's Law states that the thickness, number, and orientation of trabeculae will correspond to the distribution of mechanical stresses on bone. A consequence of stress-induced bone remodeling is that the strength of bone is greatest in the direction in which loads are most commonly imposed. For example, the maximum stress tolerated by bone just prior to failure has been found to be higher for compressive loads than for tensile or shear loads, reflecting the predominantly compressive loads experienced by bone during weight bearing. Runners with a documented increase in bone mineral density (BMD) in the leg, but not arm, compared with nonathletes provide one example of mechanically induced adaptations in bone.51 Similarly, contralateral differences in arm BMD have been observed in volleyball, basketball, and tennis players, but not in swimmers.

    This is my sense of the proven lateral wedge cures medial knee pain level 5 evidence:

    I believe (Jeff Root's Rules #4) that the compensatory atrophy and performance reduction that lateral wedges can and do cause, foot type-specific far outweigh their proven positives and so I don;t include that evidence as valid to incorporate in my EBP.

    McPoil TG, Hunt GC. Evaluation and management of foot and ankle disorders: present problems and future directions. J Orthop Sports Phys Ther.1995; 21:381–388
    McPoil and Hunt27 also have recognized the importance of mechanical stress in the management of foot and ankle injuries. These authors have described a treatment approach based on a "Tissue Stress Model." This approach proposes that clinicians focus on reducing excessive mechanical stress from injured tissues in the foot and ankle rather than attempting to place the foot in an ideal posture, or subtalar joint neutral position, as advocated by the Root Theory

    That addresses mechanics alone.

    What about a systemativc approach to motor control, manual therapy, phgysical activity, etc that may be exposed or enhanced by using ORF to position a patients feet where these modalities and activites respond favorably instead of injuriously.

    1. We are all working clinically using a version of the tissue stress theory trying to work with presenting injury and complaint. That is fact.

    2. That TSP does (or eventually will) provide all the answers to treat based on the fact that tissue will injure when stressed is an intellectual dishonest debate
    #4 violation.

    Dr Sha
  26. efuller

    efuller MVP

    You left out step 5 that I know Kevin and I have both included at various times in discussing tissue stress.

    5. Alter treatment based on the patient's response to the initial treatment.

    There is an inherent admission that we don't always get it right the first time.

    Good point. Diagnosis can be quite frustrating, especially when the patient changes their story or can't tell you exactly where it hurts. You just have to admit that you are x% sure that your diagnosis is correct and proceed from there. Or you are left just throwing an orthotic at the problem as you are with other paradigms.

    When you add in step 5 it helps negate the effects of diagnosis error. Additionally, it gives you permission to alter the recipe. When I was a student, there were times when a patient came back when the orthotic didn't work. We were a teaching clinic where we could make another pair quite easily. So, we would make another one using the same protocol. Sometimes, we would look for the error in casting or some other part of the process. Other times we just made a new orthotic without looking for the error. But, we used the same recipe and never questioned the paradigm.

    Often podiatrists, and other people, are fallible in that they won't admit that they made a mistake and don't reexamine their assumptions/diagnoses.

    When I dispense a medial heel skive device in a patient with significant genu varum, I will warn the patient that they experience medial knee pain and if they do they need to come back and get the orthotic modified.

    The nice part about tissue stress approach is that it can give you an idea of how a device should be modified. You have posterior tibial dysfunction that still hurts after orthotic therapy. Add more varus wedge in the heel. Or, in that same patient, medial knee pain develops, but the tendon is improved, you grind a little off of the medial underside of the rearfoot post.

    True, some of the time, you will give a patient an orthotic and they will get better just because time has passed. But that is true for all paradigms. We all like taking credit for that. Sometimes all the foot needs is an arch support. There are some studies that show that OTC devices are as effective as custom. If we are going to make a custom device we should be able to describe why the shape of the custom device is better than an OTC device.


  27. Robert:

    I have found your attempted "joining of forces" with Dennis Shavelson quite entertaining. However, here are a few observations:

    1. I can understand and follow your logic in your postings, but can't say that I have ever quite understood the postings of Dennis.

    2. You can make a good argument against Tissue Stress Theory and you don't even believe what you are saying. On the other hand, Dennis can't make a good argument against Tissue Stress Theory and he does believe what he is saying.

    3. You don't have a financial interest in seeing that Neoteric Biomechanics, Foot Centrings and Wellness Biomechanics are promoted. On the other hand, Dennis has a patent pending on the term "Neoteric Biomechanics", has a trademark on his "Foot Centrings" and as a trademark on his term "Wellness Biomechanics" that his website proclaims is "a new paradigm of podiatry practice that not only addresses foot and postural pain and deformity, it addresses prevention, performance enhancement and quality of life issues for current and future foot and postural sufferers like no other paradigm of Biomechanics does." His website reminds me very much of the websites that Brian Rothbart has created, complete with testimonials, outlanding claims, etc.


    My question to you, Robert, do you really want that much to be associated with "Neoteric Biomechanis", "Foot Centrings", "Wellness Biomechanics" and ....... with Dennis Shavelson??
  28. Oh I don't! I'm just taking a position diametrically opposed to what I believe for the intellectual stimulation. And because it does one good to be critical of oneself from time to time. I can't generally follow Dennis's arguments either (especially when you find an article and do a "cut and shut" dennis), so I thought I'd have a shot at providing some more substantial criticism of what I believe.

    It really is an odd feeling to be looking for weaknesses in what one does every day!

    I can only really do the criticism bit of dennis. Can't do much on the pro side. I may try though.
  29. Hope the headache is getting better Robert.

    two things I would like to highlight from yesterdays discussion.

    1 - All tissues require stress, thats how they stay strong. The tissue stress approach is dealing with tissue that has due to forces acting on them has become pathological.

    2 The tissue stress approach is the most flexiable approach as I suggested and Eric high- lighted, we can adjust the treatment plans according to what results we have with the intial treatment plan. Where as those who begin with measurments, unless the foot changes if the measurments we taken well and the cast taken well and the device made well, The orthtoic provided will be the same everytime.

    And one other thing I would like to highlight.

    The tissue stress approach does not just mean orthotic intervention.

    once the stressed tissue has been found the forces on that tissue can be reduced the best way, that maybe with an orthtoic that maybe with modified training etc, but I beleive still fits with the tissue stress approach.
  30. drsha

    drsha Banned

    Kevin: Rather than change the subject and IDD, if you understand Robert's logical arguments, why don't you simply respond to them?

    As far as your posting and its dishonest debating tactics, here are my responses in trying to keep to the thread:


    I have found your attempted "joining of forces" with Dennis Shavelson quite entertaining. However, here are a few observations:

    #23. Argument by Intimidation. #3. Questioning the motives

    1. I can understand and follow your logic in your postings, but can't say that I have ever quite understood the postings of Dennis.

    #7 Unqualitified Expert Opinion, #8 Motivation end justifies dishonest means.

    2. You can make a good argument against Tissue Stress Theory and you don't even believe what you are saying. On the other hand, Dennis can't make a good argument against Tissue Stress Theory and he does believe what he is saying.

    #5 False Premise, #2 Changing the subject, #12. Playing on widely held fantasies,

    3. You don't have a financial interest in seeing that Neoteric Biomechanics, Foot Centrings and Wellness Biomechanics are promoted. On the other hand, Dennis has a patent pending on the term "Neoteric Biomechanics", has a trademark on his "Foot Centrings" and as a trademark on his term "Wellness Biomechanics" that his website proclaims is "a new paradigm of podiatry practice that not only addresses foot and postural pain and deformity, it addresses prevention, performance enhancement and quality of life issues for current and future foot and postural sufferers like no other paradigm of Biomechanics does." His website reminds me very much of the websites that Brian Rothbart has created, complete with testimonials, outlanding claims, etc.

    #2 Changing the subject, #10 Cult of personality, #12 Playing on widely held fantasies, #14 Stereotyping, #15 Scapegoating

    My question to you, Robert, do you really want that much to be associated with "Neoteric Biomechanis", "Foot Centrings", "Wellness Biomechanics" and ....... with Dennis Shavelson??
    #23 Argument by intimidation ---Big Time---,

    Please try to stay on thread and support your paradigm instead of changing the subject to how you don't support mine which is evidenced in other threads.
    Dr Sha
  31. Here's the comedy, Dennis. You have taken a posting that Jeff put up here which was taken from somewhere else and decided that we should all obey these rules. Here's the fact's, Dennis (not that you've ever let the facts get in your way):

    a) The validity of the "rules" is highly questionable. To put this into a perspective you don't understand but insist on talking about- what level of evidence is there for these "rules"?
    b) No-one has signed up to these rules, other than you.

    Shall we list Spooner's rules for the "Arena" and have everyone apply them to all of your posting's, Dennis? Why should the rules you've adopted be any more valid than the rules I choose to adopt?

    Rule number 1. Rules are made to be broken....

    Rule number 2. Read rule number 1, knob head.
  32. Always happy to entertain :drinks.

    Ah, but there is the rub. Is our ability to accurately discover the stressed tissue reliable enough to base a treatment plan on?

    I move that this was not included in Kevins list earlier in the thread and is as such inadmissable.

    Bob Sha.
  33. Can I have an arbitary set of rules as well please?
  34. If in doubt request further studies until you have your target tissue isolated.
  35. I suspect you already have.
  36. drsha

    drsha Banned

    I find using these rules keeps me more on thread, more even keeled and better understood. That is why I am using them. They are Jeff’s rules not mine. They work for me so far.
    They seem pretty valid and reasonable from my perspective.

    Here's the comedy, Dennis. You have taken a posting that Jeff put up here which was take from somewhere else and decided that we should all obey these rules. Here's the fact's, Dennis (not that you've ever let the facts get in your way):
    Jeff’s Rules #1 Name Calling, #25 Innuendo, #3 questioning the motives of the individual, #2 changing the subject

    a) The validity of the "rules" is highly questionable. To put this into a perspective you don't understand but insist on talking about- what level of evidence is there for these "rules"?
    #7 unqualified expert opinion,

    b) No-one has signed up to these rules, other than you.
    #11 Vagueness, #4 Citing irrelevant facts or logic, #5 False premise

    #1 Name calling ---big time---
    Dr Sha
  37. I am glad your rules help you. After all it's no secret that you have found it very difficult in the past to debate with those more experienced and successful than yourself upon this forum. Indeed, you appear to have found it near impossible to answer a direct question. I can only hope that now you have your own rules you might find it easier when asked a direct question to answer it with a direct answer. For example, would you like me to go to the archive and pick any number of the numerous direct questions that have previously been asked of you and post them here now so that you don't have to break your own rules? Indeed, a quick glance from recent postings suggests that you are still incapable of answering Eric's direct questions, I note. To reiterate, they are not Jeff's rules, he has already pointed this out to you, yet you persist in this callow manner.

    This is the type of statement a narcissist or dictator might make. Exactly who else have you gathered the views from upon this issue? I believe that's a no. 7 in your rule system as your are clearly no expert on academic debate. Direct question again, Dennis. Moreover, who are you to make the rules here? (there's another) You are a relative newcomer and you certainly don't own the site. Why should your views be more important than mine or anyone elses? (There's another).

    You've mistaken me for someone who has signed up to your rules. Not playing Dennis, and what you going to do about it? ---big time---

    Spooner's rule No. 1.

    So, one more direct question Dennis, how do foot orthosis work within your paradigm and what evidence do you have to support any conjectures you ever make?

    Here's Spooner's prediction, you'll persist with no. 3, and nobody will even bother to talk with you here Dennis. Carry on....
  38. Avoiding a direct question, no. ????

    To reiterate: who says the rules that you, and only you, have signed up to are valid? What level of evidence do you have to support these rules? "I like them" doesn't cut the mustard, Dennis?? Your evidence please...

    Or, are you unqualified to provide expert opinion on these "rules"? I suspect you are: would that be a number 7? I'm off for a number 2.
  39. drsha

    drsha Banned

  40. OK
    Not answering the question no. 12t

    selective editing to avoid questions rule no. 17 subsection

    Whether you offer a money back guarantee is neither here nor there to the question you were asked. Just answer the question.

    So the orthoses you are selling have only the evidence of the person who is selling them.

    I suspect that the orthoses I prescribe have direct and indirect biomechanical effects, we can go into those later, I've published limited research on this in peer reviewed journals, I can pick out other research which supports my actions- you? They may also work via placebo and Hawthorne effects. But anyway, you are attempting to avoid the original question, which was posed to you, not me. How do your foot orthoses work within your paradigm? Lets take each foot-type within your paradigm and look at the exact prescription variables for each foot type and explore how you believe they work for each foot-type.

    Lets start with, your choice.. or I can go to your web site and pick one....

    Then lets pick up the other questions posed to you in post no. 37


    What's good for the gander, Dennis.

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