The Tissue Stress approach to clinical biomechanics

P.S. where did I call you a name in that post?

Here it is again for you to evidence that statement:

"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.


Quote:
Originally Posted by drsha
They seem pretty valid and reasonable from my perspective.
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).


Quote:
Originally Posted by drsha
#1 Name calling ---big time---
Dr Sha
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...."


EXACTLY WHERE IN THAT ARE YOU ACCUSING ME OF NAME CALLING, Knob-head?

 

My opinion is that you research is low level and has not received general acceptance or validity and has not been entered into my practice or those of many dpm's such as your subtalar axis measuring device. #4.

You ask for exact parameters and like you (I assume), I have none #4. Foot typing gives direction and nothing exact as the clinician must artistically decide on the exact casting and prescription.

and rather than state that when it comes to your treatment of feet, "lets go into that later", I suggest that we work simultaneously on the same hypothetical foot.

I suggest that we pick a hypothetical painful foot with a set of hypothetical matching variables, lets say given subtalar joint axis and dorsiflectory stiffness variables as possibilities.

We could then diagnose that foot, you to your paradigm and me to mine.

Then we could suggest orthotic casting and prescribing variables for that foot simultaneously.

This will include a discussion of motor control, manual therapy, shoes variables and potential gait and activity modifications.

That way, placebo and Hawthorne effects will be held to a minimum and we can let The Arena be the judges
as I feel that you have huge inherent bias. #7

Please alter the rules until we can agree at a starting point but this way, the rules hold for us both and neither you or I are the final judges.

Are you game?

Dr Sha

 

Tissue Stress Debate

Simon Spooner vs. Dennis Shavelson

reminds me of.......

Mohammed Ali vs. PeeWee Herman?

Any better analogies??

 

Not answering the questions, changing the subject, being a twat etc etc.....:dizzy:

The answers to those questions Dennis! Start with post 37 and whenever you see a question mark, answer the question. It's very simple.

 

...and pee wee herman is staggering against the ropes!

 

I got one.

Roger federar vs tiger woods.

Their playing different games and arguing about the rules a lot. Roger thinks tiger woods is crap because he never returns the volley and tiger is arguing that roger is doing it all wrong.

 

The funny thing about all this is that if Dennis answered question with direct answer - even if was " I don´t know" none of this would have turned out this way. Ive looked at the 1st thread that Dennis joined the other day, there are still lots of questions still not answered in that.

 

I thought something more graphic might be a little more representative:

 

So Simon, does that mean you're not game?

 

I'm gonna hop back onto my usual side of the fence for a bit. Just to be clear, this is now Robert again, rather than Bob-sha (or indeed guru bob).

Here is the thing. Such an exercise as you descibe would be jolly tricky because you are talking about diagnosing a FOOT.

Mostly, when we are talking about diagnosing we're talking about diagnosing a pathology. This is where TS differs from NT. TS is about identifying and treating specific pathology whereas NT seems to be about identifying mechanical patterns which are expected to lead to pathology.

So comparing approaches might be tricky. A TS diagnosis and an NT diagnosis mean something quite different.

Oh and if we ARE talking boxers, I think Simon is more Mike Tyson than Mohammed Ali.

 

Dennis, I'll try to identify the criticisms of tissue stress in your post and remove some of the other material.

This is the straw man argument. You are describing the tissue stress paradigm as something that it is not. (I'm assuming that by ORF you mean orthotic reactive force. The use of crutches is a method by which you can reduce stress on anatomical structures of the foot. Of course it will increase strress on the arms and shoulders.

In the book the peter principle there is a section on ways people have risen to their level of incompetence. One method is make the reader, opposing debater is the over reliance on acronyms and abbreviations. I'm all for the use of well defined abbreviations, but they do need to be well defined.

Perhaps, we should stress more that we are talking about mechanically induced pain. I'm not going to claim that orthotics are going to work for complex regional pain syndrome CRPS)

This can easily be taken into account in the tissue stress paradigm. Take a commonly seen foot pathology, the second metatarsal stress fracture. (Dudley?) Morton described the short first metatarsal would tend to lead to excessive stress on the second. Sometimes you got 2nd met stress fractures sometimes you got massive second metatarsals. The different outcome is dependent upon how quickly the increase in loading occurred. Think about the classic "march fracture" of boot camp. It is possible to have enough stress on a structure to injure it. It is also possible to have a slow increase in stress that will lead to a physiologic response that will lead to an increase strength of structure. This argument does not refute the paradigm.

Additionally, what treatment do you think would work better for treating a 2nd metatarsal stress fracture? A centering orthotic that ended behind the metatarsal heads or a neutral position device that had a top cover and extension sub 1st and 3-5 metatarsal heads?

All of the above items can be incorporated into tissue stress. For example, posterior tibial tendon pathology. Take a foot with a medially deviated STJ axis and compare it to a foot an average location of the STJ axis. The theory can take into account MUSCLE PERFORMANCE, MOTOR CONTROL, POSTURE AND ALIGNMENT, and PHYSICAL ACTIVITY. Then tendon will becomes stressed only when there is muscle activity. In fact the theory predicts that the muscle will have to be more active (have more tension) in a medially deviated axis foot to produce the same amount of motion that a tendon in a foot with an average axis would produce. This increase in activity, to produce the same motion, is brought about by increased stimulation from the motor control centers. The comparison of STJ axis position is a good explanation of why posture and alignment is important. Obviously, there will be more stress in the foot that is more physically active.

Straw man argument. See above. Crutches and braces can be used to manipulate the forces acting on a particular anatomical structure. Dennis are you referring to Newton's laws? There are only 3 laws. Inertia, F = ma, and equal and opposite reaction. If you were referring to the points from the article that Jeff quoted it would be helpful to give a brief description of that point. For example, my use of the straw man argument. There was also that time where you just threw out a number and I looked it up and it did not apply. Dennis, you have created your reputation here on the arena by actions like this. I'm not going to bother to look up the article and just assume you got it wrong.

Dennis the study is not saying that a lateral wedge is good for all feet. It is saying that it good for knee pain in knees with genu varum. If the patient comes to you complaining of knee pain are you going to treat their foot or their knee? When I treat their knee with a valgus wedge, I will certainly warn them that they may have pronation related problems in the foot. This is the essence of the tissue stress approach. You design the treatment for the specific pathology. You don't do the same treatment for everyone or even the same treatment for one foot type.

A better sentence structure for your last comment would be "It is an intellectually dishonest debate to say...." However, I'm not quite sure what you are saying. I may have addressed this point above with the discussion of 2nd met stress fractures.

I challenge your point #1. I don't understand how foot typing is trying to address the presenting injury and complaint. If you think foot typing is addressing the presenting injury, could you give an example of how it does. If you want to stay on topic, you could start another thread.

Eric

 

So Dennis, does that mean you are still incapable of answering direct questions and intent on changing the subject? Here's what I'm game for, reading your responses to my questions, just for once.... not holding my breath.

 

I've put my tin helmet on and am vigorously waving my white flag and gingerly putting my head above the parapet. If there is a bit of residual quaver in my voice forgive me but at least as long as it's only my head that's showing you won't see the damp patch spreading across the front of my trousers. Apart from that if you bite my head off I won't have lost anything that vital.

In this thread the phrase 'tissue stress' has been variously associated with 'approach', 'model', 'theory', 'concept', 'paradigm'.

I would like to associate it with the word 'axiom' which I will narrowly define as a self evident truth. It (tissue stress) is a self evident truth that needed to be shouted out loud on a few occasions to get it to the forefront of interested parties minds but axiomatic in esence is what it is.

I would imagine that when you were a student being feed the ideas of the time your head was always asking why? I wouldn't imagine that it took you too long to come to the conclusion that biomechanics of that time was, in a rather blind, possibly deluded, undoubtedly erroneous way, trying to reduce the stresses on traumatised or painful tissues. The therapeutic prescription never knowingly included a fairy dust sprinkler.

My sense is that if tissue stress wasn't mentioned at the time it's because it was axiomatic?

Duck!

Bill

 

Bill:

I don't know what your experience was, but at the California College of Podiatric Medicine, studying with the people who created Root's subtalar joint neutral theory, I can tell you for a fact that orthosis prescription was based on what "deformity" was measured, not necessarily what specific structure was injured. In other words, whether the patient had plantar fasciitis, peroneal tendinitis or posterior tibial tendinitis, a patient with a "fully compensated rearfoot varus deformity" and "3 degrees forefoot valgus deformity" always got a vertically balanced Rohadur orthosis without a forefoot extension. I not only was taught this approach as a student, but this STJ neutral approach was something I taught to podiatry students as a Biomechanics Fellow at CCPM.

Please tell me how this above approach indicates that the design of the orthosis was based on the axiom of reducing tissue stress and not reducing "compensations" for deformities?

 

When I was about two years old I fell on my face grazed my knee and bled my nose. From then on I understood that some parts of my body (soles of my feet) could fall on the ground time after time with no apparent injury and that for other parts, eg knees and noses, ground contact was a bad idea. Sortly after that I got a splinter in my finger and learned that injuries could take different forms. Then a friends older brother was run over by the school bus, which broke his leg. By the time I was five I had well and truly grasped the concept of tissue stress and realised that avoiding or minimising tissue stress eliminated the risk of injury. I don't think I was a particularly quick learner. I would imagine everyone had put the tissue stress concept together pretty well by five years of age?

Sometime shortly after I fell for the first time I saw an older woman (probably about 70 years old) stumble and fall but in a far less spectacular way than I had fallen, ie she wasn't running and she didn't roll forward so that all of her weight was taken on the point of her nose. However her injuries included a fractured femur, a fractured cheek and various extensive contusions plus concusion.

My conclusion was that the risk of injury from the application of similar or lesser forces depended upon the age or health of the tissues.

Before I got to podiatry college I had grasped the idea that, in physical terms, what I would be dealing with was largely the effects of the application of forces to tissues against a background of tissue vitality. I don't think that I was unusual in that.

Therefore biomechanics, even if it was unstated, could deal with nothing other than this.

After that I could misunderstand the physics, the kinetics, etc along with the best of them but at that stage I assumed that this single therapy reduced/optimsed the forces in all of the tissues, including the injured tissue. I think it was an acceptable starting point?

At that stage I quite happily used the phrase 'compensation for deformities' while tacitly understanding that these 'deformities' were only significant if they generated traumatic stresses in tissues.

I still think that although in terms of biomechanics I was a man of my time I along with a few billion others had and have a pretty good grasp of the tissue stress concept.

best wishes,

Bill.

 

Bill:

The point is that Root and coworkers were, of course, hoping that their orthoses would heal the patient's injuries and implicitly assumed they were doing so by designing their orthoses to "prevent abnormal compensatory motions" of the foot during weightbearing activiies" and relieve abnormal forces on the injured tissues. No is saying that all of us who taught the neutral position theories of Root and coworkers didn't implicitly understand that the purpose for the orthosis was to heal injury to tissues.

The term "Tissue Stress Theory" does not assume that other fine physicians who have different theories of orthosis design do not understand the concept that abnormal tissue stress is the cause of tissue injury.

Rather, the term "Tissue Stress Theory" does mean that specific "structural deformities of the foot and lower extremity" do not necessarily need to be measured or evaluated in order to optimize orthosis design for the patient.

"Tissue Stress Theory" does mean that one doesn't necessarily need to find subtalar neutral, the forefoot to rearfoot relationship, the calcaneal bisection or the degree of rearfoot varus/valgus deformity in order to design the optimal orthosis for a patient.

"Tissue Stress Theory" does mean that "placing the foot in subtalar joint neutral" or "realigning the calcaneus to vertical" or "locking the midtarsal joint" is not a goal of foot orthosis therapy.

"Tissue Stress Theory" does mean that as long as the clinician understands the biomechanics of how the internal forces and moments are generated within the foot and lower extremity and how altering the point of application, temporal patterns and magnitudes of ground reaction forces on the plantar foot mechanically affects these internal forces and moments, that effective foot orthosis designs will result from proper use of that knowledge.

"Tissue Stress Theory" does mean that in order to optimize orthosis design for the patient that the following three things are of highest priority:

1. Determine the structural component within the foot and lower extremity that is injured.

2. Determine the structural and/or functional variables that may be the source of the pathological forces on the injured structure.

3. Formulate a mechanical and therapeutic treatment plan that will be most effective at accomplishing the following goals of treatment for each patient:

A. Reduce the pathological loading forces on the injured structural components.
B. Optimize overall gait function.
C. Prevent any other pathologies or symptoms from occurring.

Now, Bill, if you still believe that other theories of foot orthosis design used these same ideas prior to 1995, then I will be happy if you could provide these references to me and to the rest of those following along.

I won't hold my breath.

 

You do have an intuitive grasp of tissue stress. But, when you think of supporting the deformity, you don't have a complete grasp of how orthotics work. Sure, if the pain stopped after wearing the orthotics then you reduced the stress on the structure that hurt. However, the explanation of how the pain stopped is better understood through analysis of tissue stress.

We've got a couple of questions. Do orthotics work? If they do work, how do they work? When I go without my orthotics I have to walk a lot more gingerly or my feet will hurt. I'm convinced that they do work. There are many explanations of how they work. Howevr, if all the explanations, at some level, claim that they reduce tissue stress, then we eventually have to examine stress on anatomical structures to explain or show how they work. So, we can skip over some of the parts of other explanations and go right to tissue stress.

In some cases the explanation of supporting the deformity works quite well. For example, a person with a partially compensated varus (forefoot or rearfoot) with sinus tarsi pain. Adding a forefoot varus wedge, to support the deformity, will also tend to reduce pronation moment from the ground that is causing the compressive force in the sinus tarsi. So, you can say that supporting the deformity stopped the pain or you can say that reducing the compressive force in the sinus tarsi stopped the pain. Which one is a more complete explanation? Which one is a more simple explanation? (You don't need to define the problem in terms of neutral position of the STJ.)

The above example was nice in that the support the deformity treatment was the same as the tissue stress treatment. Now suppose you measure a forefoot varus and the problem is a painful 1st MPJ.... (can of worms)

Eric

 

If you review the literature, you can see that prior to the "Root invasion" of the UK, people like William Sayle-Creer and Swallow (Arthur?) were actually quite well along with a tissue stress approach here in the UK. I haven't looked at Swallow's papers for years, nor do I own any copies these today, but I do recall reading these 10 or so years ago and thinking we'd pretty much got it sussed here in the UK until Root came along and screwed it all up. I tried to say this in diluted form in Belgium, Kevin. Perhaps Eric Lee can provide more background.

This is a discussion of Wiliam Sayle-Creer's work from the 1930's contained within Leslie Smart's book "Foot Mechanics" Bailliere, Tindall and Cox 1950: “By wedging the inner border of the heel and thus inverting it, the tibials are relieved. By wedging the outer side of the sole, the foot is everted and the strain on the peroneus longus is removed. Clinical practice shows that the degree of wedging must be determined for each individual case.”

Like I said in Belgium, here in the UK at least, we were moving along quite nicely thank you very much for asking, until Merton Root came along and put us backward for 30 odd years. IMHO.

 

Agreed, that we have been calling our approach many things. Mainly, I have been using the term theory because it has not been fully proven. However, I beleive that it can be proven. I believe that we can predict which anatomical structures will be injured with some measurements. That we can predict which treatments will reduce stress on structures, that the stress will in fact be reduced and that symptoms will resolve when they are reduced. Maybe not for all diagnoses. The research has yet to be done. The other nice thing about tissue stress is that you can develop research questions that can be tested. You can't test neutral position measurements because they cannot be done accurately across practioners (heel bisection, leg bisection, etc.)

They didn't know they were including a fairy dust, but there are some gaps in logic. "Lock the midtarsal joint" looks a little bit like fairy dust. Especially if you start to believe that imaginary lines alligning, or not alligning, control the motion of the midtarsal joint.


Eric

 

Simon:

It would be great to get copies of those references from William Sayle-Creer. Whitman also used some tissue stress terminology back in the late 1800s.

 

Strangely, while Leslie Smart's book states: "In 1937, Mr. W. Sayle Creer, M.Ch.Orth., F.R.C.S. demonstrated that bringing the calcaneus into normal alignment with the talus and tibia depressing the head of the first metatarsal re-formed the inner longitudinal arch. He achieved this correction mechanically without the use of arch supports by prescribing an inside heel wedge and an outside sole wedge. Mr Creer's principle has been carried out at the East Lancashire Foot Hospital during the last ten years with conspicuous success"... and goes on to devote the rest of the page to Sayle-Creer and includes the quote I gave before, Smart does not list any publication by Sayle-Creer in the bibliography.

I did google this some time ago and could not find anything by Sayle-Creer from 1937, but did find these references from around that time:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1035558/pdf/brjindmed00269-0058.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2209926/pdf/brmedj04204-0033.pdf

While the former talks about wedging position, neither goes so far as to name the tissues that such wedging should reduce the stresses upon; Smart's book does. Perhaps Leslie Smart should be given the credit for this unless someone can identify the 1937 work which Smart referred to?

 

To me, this quote highlights the important role of the pain in the "economy" of the tissue stress theory

How can we use the tissue stress theory when we have to determine the structural component within the foot that will be injured in the absence of preventive actions ? Especially in the diabetic foot where the pain [thinking at the first quote] sometimes can't help us too much ?

Thanks,
Daniel

 

Pressure mats and/or pressure-sensing insoles (i.e. FScan) can detect high pressure areas in the absence of normal plantar sensory function.

 

In response to Simon above, Sayle Creer was a major influence on the Salford School of Chiropody and this led to an insole known as the "contralateral wedge" which I think is what you have described. This was still taught in my student days - grad 1975, but by the time I joined the staff there in 1980 was being ridiculed as "breaking all the laws of biomechanics", to quote one now retired member of staff. There is always a danger of throwing the baby out with the bath water; perhaps it is time to revisit some the old names such as Lake, H P DuGillet (sp?) - maybe they had a point. Certainly DuGillet (whom I had the honour of speaking with at the Glasgow conference in 1997, not long before his death), was severely ourt of favour with his phylogenetic theory of HAV (he advocated an atavsitic origin); now I am not so sure. Rob

 

STJ axis position. Those with highly medially positioned axes should get varus heel wedges. Those with more lateral axis lateral forefoot wedges, if they have adequate range of motion.

Those pressure mats are just machines that tell us where the calluses are. We can always "read" the foot and the shoe.

Eric

 

But ultimately putting the past in order should be the domain of the professions historians and sociologists. Where are they? Why are they sitting on their hands?

The job of the pioneer/innovator is to forge ahead so readjust your gaze and keep em doggies rollin.

Bill

 

I agree.

Bill

 

According with the references, the location and peak internal stresses [as risk factor for ulcer development] can't be accurately predicted by interface pressure measured with pressure mats. Also, acommodative treatment doesn't decrease the pathological internal stresses !! How can be applied tissue stress theory in these situations ? Based, mainly on clinical tests [STJ position, Lunge test, Jack's test,...]?

Thanks,
Daniel

 

Ditto!

But Bill. At the level of being an innovator and pioneer, one uses new terms, new ideas, new innuendos. One massages the historical past without the benefit of evidence or proof and one deserves to be visited honestly, fairly and openly by his/her colleagues. One depends on expert opinion, anecdotes and experiential input to grow the invention to the level where it actually is researched.

MTTS, Midtarsal joint dorsiflectory stiffness syndrome, functional foot typing, SALRE, etc.

Why can't we keep those doggies rollin instead of putting in so much effort to eliminate or even worse, vilify other innovators and pioneers?

Dennis

 

Absolutely - and if it weren't for good teachers like Bill who taught us to question and test everything, especially that which was taken as read, I fear the dogma and confusion may have inhibited progress even more. It may just be interpretation and the way we think about things - in the same way that we are seperated by a common language elsewhere.

 

Tissue stress is certainly not fairy dust. It has a strong place in the future of biomechanics. However, as Tiisue Stress, by your own pen is not fully proven, not researched, based on belief and prediction, what gives you the right or ability to posture as if other theories that are parallel to yours that you don't agree with should be deemed less valuable than yours?

Dennis

 

If you are going to proactively treat internal stresses then you are going to need findings that will be predictive of high internal stress. For example, a medially positioned STJ axis is highly likely to be related to stress in structures that create internal supination moment.

I would agree that high plantar pressures may not be predictive of some stresses. However, a high pressure area in a person with neuroopathy has a really good case for being treated proactively.

Eric

 

Because tissue stress can produce testable hypotheses. I predict that people with a medially deviated STJ axis will be more likely to get posterior tibial dysfunction because there will be a higher moment from ground reaction force. And I predict that lowering the pronation moment from ground reaction force will improve posterior tibial dysfunction.

Dennis, why do you think any foot type is more likely to predict any particular pathology? Why would you change the way an orthotic is designed for one particular foot type versus another? If you can't answer the question what have your lab technicians been doing differently when they see cast with one foot type as opposed to another, then the system is not testable by others. That is why I deem your system less valuable.

Eric

 

So do I as the flexible rearfoot types as I;m sure you have read as you have vetted my science with a fine tooth comb, have some level of medial deviation of their STJ axes.

For the same reasons as you.

Otherwise my system would of little value and upgrade to biomechanics.

My point is Eric as you have so well finally admitted, when referencing Tissue Stress:

"we have been calling our approach many things. Mainly, I have been using the term theory because it has not been fully proven. However, I beleive that it can be proven. I believe that we can predict which anatomical structures will be injured with some measurements. That we can predict which treatments will reduce stress on structures, that the stress will in fact be reduced and that symptoms will resolve when they are reduced. Maybe not for all diagnoses. The research has yet to be done".

As an innovator, expert and practitioner, whose work is based on beliefs and predicitions without evidence. your opinion has little weight above mine and I take it as constructive and relatively of little import as I would assume others that sit on our level away from your warm market would as well.

I think your work focuses too strongly on the rearfoot and that you intimate to students and the rest of the world that your work is evidence based when by your own admission It IS NOT.
I think you avoid realizing that it is the forefoot where most of the tissue stress is generated in our feet as a whole and not the rearfoot making the STJ Axis focus often pointless
I think you are in a bubble, claiming to be open and well versed in many other theories (Dr's Glaser, Dananberg and Shavelson as examples) when you are examining them mostly to reveal their potential faults and failings.
By doing that and applying a different set of rules to TS, you are missing out on the useful side of our biomechanical input and blind to your own shortcomings.
IMHO You are isolationist and a negative in the grand sense of biomechanics and you may be one of the root causes of confusion to those who are weak biomechanically but would love to practice it in America.

My one and only question that I feel you must answer to defend your positions, IMHO, is this:

As you and the other tissue stressers who share your unproven axioms (one recently stated that your science should be called self evident!.......in order to provide a smoke screen for your lack of evidence) like Payne, Spooner, Kirby, Isaacs et al and so many others performing and supporting research for so many years like Menz, Scherer, Ritchie, Nigg and PFOLA et al, why doesn't the evidence for Tissue Stress, the theory they seem to favor, exist?

Please opine on that in your next posting.

Dennis

 

Dennis, Rigid foot types can also have medially deviated STJ axes. So, Foot types are not as predictive as STJ axis position.

Actually, Dennis I think your foot classification system doesn't give any logical reasons to predict pathology. Do you agree with me? If not, why not?

Dennis, your reply makes no sense. Could you answer the question?

Actually, tissue stress is not fully proven. Some areas are. For example, there are studies that show that medial knee compartment arthritis is associated with ground reaction force creating an adduction moment on the tibia and that symptoms reduce when that moment is reduced. There is evidence that plantar flexion moments at the MPJ increase medial deviation of the first metatarsal. There is evidence that the windlass mechanism causes a plantar flexion moment at the MPJ. There is research that shows that lat wedging reduces tension in the windlass. Unfortunately, at this point in time, I am not aware of research that show that reduction in tension in the windlass reduces1st MPJ symptoms. That research has not been done yet. There is a logical progression.

Dennis, there is no logical reason, that I am aware of, that functional foot typing would be predictive of any pathology. There is also no explanation of why one foot type should get a different orthotic than another foot type. Dennis, you haven't even told us what your lab has been doing differently when someone sends in a cast and says it is one foot type as opposed to another foot type. Do they do anything different for different foot types? If yes, what?

This is why tissue stress is better than functional foot typing. In tissue stress you can explain why we do what we do. You can't even explain what you do, let alone why.

Dennis, In my paper on center of pressure and its theoretical connection to foot pathology, I described how center of pressure effects the whole foot. Saying that tissue stress just focuses on the rearfoot and avoids the forefoot is just wrong.

Where have I ever overstated the evidence for tissue stress? I haven't been attacking functional foot typing for lack of evidence (even though there is none), but I have been attacking it for a lack of logic. Where is the plausible explanation for treatment with foot typing?

Dennis, why shouldn't people point out flaws in arguments when they see them? That is the nature of academic debate. Here on the arena ideas compete.

What different set of rules?

Dennis, stop saying that American podiatrists are stupid.

As I explained above there is some evidence. The rest of the research has not been done yet. That is why it is not there, yet.

Dennis, really, you are criticizing tissue stress for lack of evidence, when functional foot typing can't even get evidence, because there is no hypothesis to test.

Eric

 

Eric has usual you have succintly expressed what many of us are thinking. I never got to the question asking phase with Dennis after he sent me his DVD's. It made no sense to me then and it makes even less sense now given the other methods available and there are more questions than answers as to why?

Dennis it is high time to admit that your patented system as it exists today is not original, biologically plausible, is not widely supported by your peers and even less supported by those of greater biomechanical knowledge. Interrupting numerous threads by introducing FFT also does not gain support for it; in fact it serves the opposite purpose.

 

I agree that rigid foot types can have medially deviated STJ Axes and that is very important Eric.

A medially deviated STJ Axis in the presence of a Rigid rearfoot is indicative of a large amount of forefoot pathology in the form of a flexible forefoot FFT.

You would never find a medially deviated STJ Axis in the rigid - rigid FFT.

Understanding the FFT's points you in the direction of where your treatment should be focused. The flexible RF needs antipronatory RF Care, the rigid rearfoot does not.

Remember when taking a FFT, you need both a rearfoot and forefoot exam and it is presented in a Rear/fore FFT that gives clinical information (no rearfoot focus here).

The fact that when one discussing the rearfoot and both the flexible rearfoot and the rigid rearfoot types may both have a medially deviated STJ Axis explains why I don't feel the STJ Axis to be of great import.

IMHO, it is SALRE or TS that fails here and not Foot Centering or FFTing.

Treating a medially deviated STJ Axis with the same anti-pronatory RF skive when it can present in both a flexible and rigid RF Type says to me that you are treating one or both of them inadequately.

No.
Asked and answered (apparently not to your satisfaction I'm sorry to suggest.

 

I agree that rigid foot types can have medially deviated STJ Axes and that is very important Eric.

A medially deviated STJ Axis in the presence of a Rigid rearfoot is indicative of a large amount of forefoot pathology in the form of a flexible forefoot FFT.

You would never find a medially deviated STJ Axis in the rigid - rigid FFT.

Understanding the FFT's points you in the direction of where your treatment should be focused. The flexible RF needs antipronatory RF Care, the rigid rearfoot does not.

Remember when taking a FFT, you need both a rearfoot and forefoot exam and it is presented in a Rear/fore FFT that gives clinical information (no rearfoot focus here).

The fact that when one discussing the rearfoot and both the flexible rearfoot and the rigid rearfoot types may both have a medially deviated STJ Axis explains why I don't feel the STJ Axis to be of great import.

IMHO, it is SALRE or TS that fails here and not Foot Centering or FFTing.

Treating a medially deviated STJ Axis with the same anti-pronatory RF skive when it can present in both a flexible and rigid RF Type says to me that you are treating one or both of them inadequately.

No.
Asked and answered (apparently not to your satisfaction I'm sorry to suggest.