How to determine forefoot/rearfoot relationship?

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Hi i'm a podiatry student and am just wondering how or if i can determine a pt's forefoot to rearfoot relationship by pt in a suppine position and weight bearing position. (Every time i view the forefoot to rearfoot relationship with the pt in a prone position but with some of the elderly or overweight pt it's really difficult or impossible for them to lie on their stomach)

any suggestions would be appreciated, thanks

Mike

 

Technically, you can't. The very definition of forefoot varus and valgus involves the relationship between the plantar plane of the forefoot and the posterior bisection of the calcaneus. Unless you can get to that posterior bisection of the rearfoot, you can not really make a decision.

CP

 

Mr. Payne ,
say if you really can't make the pt to turn on their stomach, does that mean you won't be able to tell their forefoot/rearfoot relationship and therefore unable to make the orthotics for them?

thanks

 

You don't need to know the forefoot to rearfoot realtionship to make orthotics.

 

Cast the foot and take measurements off cast.

 

Simon Spooner,
Something we agree on!
Our last dialogue was a few years ago.............
Regards,
davidh

 

You could have the patient in standing with one knee on a chair and holding on to another chair for balance. You can then sit behind the patient and view the foot.

Ann, PT

 

David,

If we all thought the same and agreed on everything........ this and other forums wouldn't exist.

What I didn't say in my last post was, why do you want to measure it? And, what do you think it is that you are measuring?

Back to my disagreeable self?

 

Hi Simon,
I actually don't measure anything - not in degree increments anway.
That would clearly be a nonsense since the variables, once an orthotic is in the shoe, are legion. Those of us who've done some real science all know that.

What I do is cast in an approximation of neutral, then look at the forefoot to rearfoot relationship on the neg cast. Usually its fairly easy to see if the FF is inverted or everted in relation to the RF.
From there I specify heel vertical, and either a FF varus or FF valgus post, usually intrinsic, and usually no more than 2 degrees.

As I said above, the variables are legion. Uneven ground, different footwear, diurnal variation - really all I try to do is balance the foot in an approximation of STJ neutral.

Regards,
davidh

 

David,
I agree.

 

Hi David,
Does this mean that i don't need to get out my goniometer and draw lines on people's feet/legs (lower leg and calcaneal bisection line)? Beacause I'm reading some orthotic-making books and they all seemed to start with teaching you how to measure the angles and transferring them to posting.

and speaking of balancing a positive cast to STJ neutral, it seems to me that we are only posting the forefoot or the rearfoot but what about the tibial angle wouldn't it have an affect on the total rearfoot angle relative to the ground? therefore do we need to consider this when we are trying to balance the cast? (am i correct here? am still trying to grasp the idea of orthotic-making/biomechanics )

thanks

Mike

 

I haven't drawn a line and measured an angle on a patient for years (however, do it for research) and we don't get the students to do it either (except for an occasional tutorial).

Ask yourself:
1. How reliable are the measurements? (most are not)
2. Do they predict dynamic function? (most don't)
3. What is the alleged "normal" actually based on? (usually nothing)
4. What are you actually going to use the measurements for? (?)

There are some I do measure (...or more appropriatly "approximate") as they are really important for orthoses prescribing - esp lunge test on and off orthoses.

Look at it another way - what do the measurements really mean? ie they either have adequate range of motion at a joint (based on their structure, daily acivities etc) or they do not have adequate ROM - does it really matter what the value is? How will your treatment change knowing the value vs knowing the adequate/inadequate ROM?

A case could be made for students to do some measurements to get a better "feel" for the angles.

 

Where were you when I was a student? Good to see students being challenged with that kind of thinking.

 

Good to see some discussion on this important topic.

For all my patients that are getting custom foot orthoses I do the following measurements: draw calcaneal bisections, measure STJ range of motion, FF to RF relationship, first ray range of motion, hip range of motion, malleolar torsion, ankle joint dorsiflexion, 1st MPJ dorsiflexion, plantar fascial prominence, STJ axis spatial location (standing), RCSP, maximum pronation test and gait examination.

Even though the measurements don't tell me a whole lot most of the time, sometimes each of these measurements tell me something very important about the foot and lower extremity of the patient that I wouldn't have known otherwise unless I had measured it in the first place. Since all the above measurements (excluding the gait examination) take me only about 5 minutes to accomplish, then why wouldn't I want to have this information for the benefit of the patient?? Do good primary care physicians quit testing for function of the cranial nerves just because a patient doesn't have apparent cranial nerve dysfunction?

Just because a measurement (i.e. skeletal deformity) does not allow prediction of the kinematics of gait, it doesn't also mean that it doesn't affect the kinetics of gait.

Just because one examiner can't agree with another examiner on a measurement, doesn't mean that a well-trained examiner can't use measurements in their own practice as a guideline by which to determine the structural and functional characteristics of one person to another.

And finally, even though one single measurement parameter may not determine a single orthosis prescription parameter, a well-trained clinician that uses a combination of measurements, tests and a gait examination to determine the structural and functional makeup of a patient will likely be able to achieve much better therapeutic results with foot orthoses than the clinician that uses none of these examination skills to produce foot orthoses.

 

Again Kevin adding a bit of sense to a topic,

Think about the comments made here.

Why do you think that orthotics are not a commomly used conservative treatment option for lower extremity joint and soft tissue complaints?

How many of you receive patients after they have seen the doctor,osteopath,sports therapist,physio for a sore heel!

And why even though every one of us that prescribes orthotics knows that they are a great way and very effective way of limiting/resolving patients symptoms we only see a tiny fraction of the people we should?

Do you think statements like "why bother taking any measurements" will help our cause? I dont!

If a G.P logged into this forum, what do you think his perception would be about the accuracy of foot orthotics? May he then question why patients are charged up to £500 for two bits of plastic that were made from guess work!

Can we afford to have such an attitude if we want to be taken seriously?

Scott

 

Is not taking measurements that lack reliability, lack validity, do not predict anything and knowing them does not actually change the treatment more likely to harm our cause?

There are mesaurements that are reliable, do have validity, do predict injury and knowing them do change the treatment, but how many people actually know what they are and are actually using them?

Trying to be pseudo-scientific is what will harm our cause and too much of that has already done so.

 

Craig, Kevin, Simon et al - I am with you. But you must remember that you have been involved in the revolution from the centre of it - so to speak. The rest of the practising community is feeling the centrifugal force as we seem to spin out of control (OK, we were never actual 'in control', but we felt we were!). For many years we were able to rest comfortably on the 'science' of STJ neutral based biomechanics.

It seemed to make sense (especially if you didn't test it);

it was a 'clean' theory that lent itself to practice - no messy physics, just some simply calming arithmetic;

you could explain to patients what was 'wrong' with them and how you could 'correct' them (black and white - cause and effect, lovely)

and blow me down, it seemed to work.

For those who were inculcated at Uni, and then went on to find that patients derived some benefit from the practice of this outdated theory - it is a hard road to the new understanding. I have been trying very hard to understand the newer paradigms, and I have to say they are not as neat and easy to digest (the articles on midtarsal axes alone stimulate in me an overwhelming urge for a Bex, a cuppa tea and a good lie down). These new theories are tricky, and they seem to have holes in them - which, of course, makes sense in a real world, and further proves that infallability of the STJ theory demonstrates that it was a false prophet (so to speak).

Be gentle with us. Yes, we should not be justifying our practice with 'pseudoscience'; we do have to emerge into the real science, and accept that there is a long way to go. But for the clinician at the coalface, and the insecure and ignorant young student looking for a handle on the whole thing; it really isn't easy. I am neither young, ignorant or even coalfaced -and I'm struggling.

It was a fundamentalist approach that led us a long way down the wrong path, let's not let our fervour trick us into that mistake again.

Whew! off my soapbox now.

cheers,

Felicity

 

Where's the biomechanics

In the absence of an accurate biomechanical exam, which must include the bisection of the calcaneus while the patient is laying in a prone position, whatever device you place down under the foot is at most, only an accommodative device. Without a cast taken in STJ neutral, with the bisection transferring to the cast, the labs has to guess at the degrees of possible forefoot varus and valgus as determine by comparing the forefoot to an absent vertical bisection of the calcaneus. Of course, if you don’t know how to take an accurate STJ plaster cast, none of this matters anyway.

It is demeaning to our profession to brush off the need for accurate biomechanical control by saying that after the orthotic is placed in a shoe, the shoe negatively affects the attempt at correction. Are you saying that you do not recommend specific shoe models? I have very little resistance from my patients when I tell them they will have to bring in the type shoes I recommended before I will dispense their prescription devices. How hard would it be for you to go to a sporting goods store, or specialty running store and identify stability and motion control walking and running shoes? And while you are at it, why not browse department store shoe departments for dressier shoes that are stiffer in the midfoot? When I recommend specific shoes, my patients are very impressed that I took the time to do the research, and it underscores my contention that it does matter. The shoe is the foundation and the prescription functional orthotic is the corrective interface.

What I know is that identifying the exact forefoot component is an absolute requirement for the manufacture of a functional custom molded prescription (Corrective) orthotic. And to accurately correct forefoot varus and valgus, the lab needs to be able to identify STJ neutral. You might be able to get away with approximations on your less active patients, but those patients who regularly exercise, whether walking, jogging, running, or cycling, need fully corrected devices. Less then that and you are cheating them, falling to correct alignment of the forefoot to rear foot, thus failing to relieve torque stress at the ankle, knee and hip.

In the past week, Dr. Kevin Kirby (California) was complaining of the sad start of biomechanical knowledge and practice in the USA, but from what I just read, it seems to be worse down under.

Robert Scott Steinberg, DPM, DACCPPS (BP)
Hoffman Estates, Illinois USA
doc@footsportsdoc.com

 

Those Holes

Dear Dr. Prentice,

Whew ! You do seemed trans -fixed on the holes you perceive in the biomechanical theory of the function of the forefoot, midfoot, and rearfoot, as it relates to us covering the ground. And if this hasn't humbled you enough, you should listen to a lecture by the most respected Dr. Kevin Kirby, who will definitely prove just how deep the subject is. (Said with the greatest respect for Dr. Kirby, BTW !)

But a lack of understanding should not be dismissed by defining it - in your words - as holes the theory. This is difficult stuff, and I have been at it for, OMG, nearly 30 years !

Sincerely, (Really)
Robert Scott Steinberg, DPM, DACCPPS (BP)
Hoffman Estates, IL
doc@footsportsdoc.com

 

Travel is the greatest barrier against prejudice. People need to visit with each other at various labs and share.

I measure things like KK does because when I, or my lab partners are tring to make sense and use of my assessments at a later time they (I) have very specific points of reference from which decisions of orthotics prescriptions can be made. It is also helpful if insurance companies request assessments....not that they have a great grasp on what we do all the time.

Sincrely
Freeman

 

I'm with you, Scott. Regardless of what the scientific studies currently say about podiatric measurements, I personally think they help me get my patients better, otherwise I wouldn't be doing them. I have been teaching podiatrists, podiatry students and podiatry residents now for over 20 years. There is no wonder that the studies all show the examiners have difficuly agreeing on measurements, since the examiners all use differences in the technique to arrive at the same measurements. I see this very clearly in the hundreds of students, residents and doctors I have trained.

However, since I am the one performing the measurements, and not someone else, it only matters to me, and to my patient, whether my measurements have significant meaning to properly diagnose and treat my patient. I really hate to see that podiatry students are not being taught to at least how to estimate the range of motion of the STJ, FF to RF relationship, hip range of motion, malleolar torsion, ankle joint dorsiflexion, first ray stiffness/ROM, and STJ axis spatial location and record this on a chart so that they can reference it for their orthosis prescription, since I know it helps me in my practice where I have made over 10,000 pairs of orthoses over the past 20+ years.

Like I said, I think that as we become more sophisticated and research evidence continues to accumulate, we will find that even though the kinematics of gait may not be significantly affected by structural deformities, we will find that the kinetics of gait will change depending on structural "defomities" within the foot and lower extremity. And how do we determine these "deformities"??.....we need to measure them!!

The main question for any teacher of podiatric biomechanics is whether they should teach basic examination techniques to their students that allows them to properly examine the foot and lower extremity and start to develop a feel for the mechanical parameters of the foot and lower extremity that may or may not have an effect on foot and lower extremity function? Or should they take the "scientific approach" of totally abandon teaching the taking of biomechanical measurements since the currently available research studies don't show that the biomechanical measurements taken do directly affect the motions of skin markers during gait in a relatively small number of subjects? I think it is more prudent to take the former approach where we train our students how to properly perform the basic measurement techniques and properly record them which will allow these students to know how to diagnose the multitude of mechanical pathologies that can occur in the human foot and lower extremity. This needs to be done in the hopes that these future podiatrists will be able to use some form of these measurement techniques when they have their own practices so that they can better diagnose and treat the mechanically-based pathologies of their patients.

 

Good to see you joining in on the discussion, Robert.

I just wanted to let you know that I have had the great opportunity to lecture in many countries including Australia, New Zealand, England, Spain, and Canada that has afforded me the opportunity to make the acquaintance with many fine podiatrists who have a deep knowledge and respect for biomechanics. Without a doubt, the podiatrists that I have met in Australia have as good an understanding of foot and lower extremity biomechanics as any group of podiatrists in the world.

Some of the most important fundamental research in foot biomechanics in the world over the past few years has come from an Australian podiatrist, Craig Payne, and his coworkers. I just lectured a few months ago at a seminar in Melbourne which was the best sports medicine seminar I have ever attended. In addition, there are many Australian podiatrists who are currently making very important contributions to the world literature on podiatric topics.

I have great respect for my Australian podiatric colleagues and just wanted you to know that, in my opinion, their knowledge in podiatric biomechanics is not any less than the knowledge in podiatric biomechanics exhibited by their American counterparts. In fact, in the lectures I have given there, their level of knowledge and especially their interest in biomechanics is, in many instances, greater than their American colleagues. I think you will find as you continue to visit this forum that there is a great level of knowledge in biomechanics in the podiatrists and other health professionals in countries other than the US and that we can all learn very much from each other.

 

Lets take some example measurements and look at it in detail -

Neutral calcaneal stance position:
There are so many studies on its reliability now and not one of them has shown it to be reliable. Kevin has commented several times on how different very experienced instructors at CCPM varied by 5 degrees in just the placement of the bisection. Not only is the measurement unreliable, two studies have also shown the poor repeatability in placing a foot in subtalar joint neutral (that NSCP is measured in) - not one study has shown it to be reliable.

Our own study brought home to me the problem. An assumption with biological measurements is that the more people that measure it and the more times it is measured, you get a bell shaped distribution clustered about a true mean. In our study we did not even get a bell shaped distribution - we got a rectangular shape to the "curve" - this means that any value under the curve was equally likely to be the true value (whereas in a bell shaped distribution, the value that the "bell" clusters about is more likely to be the true value). Statisticians call the bell shaped curve a normal distribution and the rectangular curve a random distribution --- in our study, just picking a random value was as accurate as measuring it.

So that’s it reliability and repeatability, what about validity? STJ neutral has never been validated; we now know the foot does not function about it; we know now that foot orthoses outcomes are not dependant on getting a foot to its STJ neutral position etc etc.

I agree that this "measurement" does have some value as you do need to tell the lab something when you fill out the prescription form for what angle you want the rearfoot post to be at - we are just so over using NCSP solely for this - I now tell the lab a value based on a whole lot of things, not just an unreliable and invalid measure. We have moved on from this...

First MPJ ROM
We have always assumed that 65 degrees is what is needed for normal activity - but that value is based on no data and appears to be have been picked by someone as a good figure and everyone has quoted everyone else until it has become another one of the podiatric folklores --- one study in JBJS did suggest that 45 degrees (I think) may be the normal for in-shoe ROM. Another study (sorry, it will take me too long to find all the references) showed that there was no correlation between the static non-weightbearing ROM and what was used dynamically. So we do not even know what a normal value is!!

There has been nothing really published on its reliability, but even if it can be measured reliably what do you do with that value? How does your treatment change knowing the value? If we accept that 65 degrees is the "normal" ROM - who cares if it 75 or 95 degrees or if its 22.5 degree or 38 degrees? - what is important is that they either have adequate or inadequate range of motion - what value do you add by actually measuring it? Even inadequate vs adequate is somewhat bogus because we do not know the normal range and that is likely to be different for each individual and for different activities (eg sedentary lifestyle vs being a sprinter) - so I know make a qualitative judgment of adequate vs inadequate rather than try to do a pseudo-scientific measurement.

Ankle Joint ROM
Same as for first MPJ...the value of 10 degrees was considered a good idea and has been quoted ad nauseum, it has entered podiatric folklore. We have no idea what the normal range is - we do know now that it is very specific to each individual (we just not clear yet on how to determine the specificity); that it varies with velocity of walking (some need more when walking faster and some actually need less - they just lift the heel off the ground sooner, regardless if they have a large range or not); that what is used dynamically has no relationship to what is measured statically in a non-weightbearing situation. So what is the point of measuring it?

Some argue that to measure it, you can monitor an exercise program --- but the measurement is so unreliable (documented in several studies), that on a subsequent visit you could measure an increase or decrease in ROM just based on the randomness of measurement error. Some argue that if its less than 10 degrees, they need to add heel lifts to the orthotic or cast slightly pronated --- I agree, you do need to do these things when ankle ROM is restricted, but why 10 degrees? (see above).

However, all is not lost and a lot of work is going on in this area -- we now know that ankle joint stiffness is more important than ankle joint ROM; the weightbearing lunge test for ankle ROM is showing huge promise in reliability; predicting dynamic function and adjusting orthoses prescribing based on it - we just need some more work on it to fully understand it. Hopefully soon we will know more about the subject specificness of ankle joint ROM.


As Kevin mentioned, these are exciting times for us as we are rapidly learning more about predictors of outcomes with foot orthoses, then going back to the clinical tests to see what has to be changed to improve these outcomes (much of that has been discussed here in other threads). We just need to give up on the gospels and folklores and the belief that measurement makes something scientific.

 

Who is the pseudo-scientist?

Dear Dr. Payne,

In a word, Really? When you say people , do you mean podiatists, or do you mean all those pseudo foot practioners ? I don't know what it is like to practice in Austraila, but in the USA, there are so many allied professional trying to be foot doctors , and failing miserably. Some of the worst are pedorthists, followed by PTs, chiropractors, and shoe store sale people. These must be the people you are refering to as practicing pseudo-science , not your colleagues, right?

Robert Scott Steinberg, DPM, DACCPPS (BP)
Hoffman Estates, IL USA
doc@footsportsdoc.com

 

Yes, I mean podiatrists everywhere. Even this study included two USA Podiatrist's (KK & DP) who could be considered experts in measurements:

and they achieved only moderate reliaility.

In Australia, we got over this a long time ago.

 

Kevin may remember a Weed Seminar a while back (maybe New Orleans or San Diego) when one of the participants (maybe Chris Smith) got a whole lot of participants to measure his STJ neutral. Where else in the world would you get a greater gathering of podiatric biomechanical minds than at a Weed Seminar? .... the results were appallingly embarrasing.

 

Craig:

In our discussion regarding measurements, I believe that much of this perceived difference in opinion between the two of us is because of the large difference between the clinical world versus the research world. What I would measure clinically to make a good pair of orthoses for a patient or try to better diagnose the mechanical etiology behind their pathology, may be different from how I would approach whether these measurements accurately reflect parameters that may be predictive of gait function. Nearly all clinical examination techniques, especially measurements, will have inter-examiner differences. However, the clinician must be able to take multiple observations to better understand the specific mechanical characteristics of the foot and lower extremity, and I don't know any better way than with the measurements I currently use.

Now, I know that a difference of between 60 and 80 degrees of 1st MPJ dorsiflexion is not significant, but the difference between 15 and 35 degrees of 1st MPJ dorsiflexion certainly, in my clinical experience, makes a huge difference for many individuals for causing gait pathology.

Ankle joint dorsiflexion measurement is probably not as a good a predictor of gait function as we had thought in the past due to the problem that it is not a good measure of ankle joint dorsiflexion stiffness. But certainly there must be some significance to the measurement since when I see a runner that has less than 10 degree of ankle joint dorsiflexion with the knee flexed, 90% of the time they will be a midfoot or forefoot striker in running.

By the way, I don't measure NCSP since I think it is a useless measurement. However, I do measure RCSP and use the maximal pronation test since I think these two tests, combined together, are very effective at giving me an idea how to properly order orthoses for the patient.

And as far as the involvement of Daryl Phillips and I in the paper by Bart Van Gheluwe, these measurements were not performed by Daryl or I, but the study was conducted in Belgium. Bart asked Daryl and I to help edit the paper to improve it for the podiatric audience it was designed to be written for.

Eric Fuller (and not Chris Smith) is the one that had people all bisect the calcaneus at a Weed Seminar, I believe. I think he found the heel bisections to be +/- 5 degrees between the 15 or so podiatrists (all experts) that made the measurements on a single individual. However, the exact details of this unpublished informal study are a little fuzzy in my mind.

The bottom line I would probably use almost none of these measurements I make on my patients when I perform a biomechanical examination if I were to design a scientific study, since I would want much more accuracy and reliability. However, when I have 20 minutes to evaluate and cast a patient for foot orthoses, these measurements certainly give me something objective to form the basis of my orthosis prescription so that I can feel that I have made a good foot orthosis for them to cure their foot and/or lower extremity complaints. As long as the clinician realizes their scientific limitations, I believe the measurements are very useful tools to inform the clinician of the basic mechanical makeup of our patients.

 

Dr Steinberg,
you wrote:
"but in the USA, there are so many allied professional trying to be foot doctors , and failing miserably. Some of the worst are pedorthists, followed by PTs, chiropractors, and shoe store sale people. These must be the people you are refering to as practicing pseudo-science , not your colleagues, right?"

Can't comment on that, but here in the UK we have something like 90% or a little over, of prescribed devices (thats by pods and others) which are not casted - i.e. pre-forms (information source - Algeo's). Then there's the system which allows the patient to stand on a mat at one end, and spits out a pair of orthoses at the other. (We have a few of those over here too).
What this strongly suggests to me is that most Pods in the UK don't understand biomechanics, and perhaps they don't want the responsibility of fitting an expensive pair of devices they have no confidence in. Certainly as a patient I would far prefer a decent pair of devices which are going to last (I wear orth myself which have lasted 28 years so far, and work perfectly) to devices which have to be replaced every few months.

I think the reason for the low custom orthoses prescribing rate is this:
That Pod Biomech has gradually evolved into a pseudoscience.
Its not just the footwear (which, of course, we can control) which throws up variables which can affect degree-based incremental measurements.
How about the supporting surface? Absolutely not even, (unless in a Shopping Mall), and then there's duirnal variation. Are you aware that in a relatively recent study a bunch of French Anaesthesiologists found a maximum difference in duration of epidurally-administered anaesthetic of 28% which they put down solely due to diurnal variation? (1)
Or how about the Japanese Orthodontic study which showed that tooth movement and changes in peridontal tissue in response to orthodontic force in rats vary depending on the time of day the force is applied? (2) I could also quote a study which look at the variation over a 24-hour period in ROM in finger joints - the variation, which was significant, was not linear.
The variables which can and do affect your degree-based increment orthoses posting are there for anyone to see.

Do I cast and prescribe orthoses? Certainly!
But I always post minimally (around 2 degrees) and usually FF-only. The goal is to give the lower limb a gentle helping hand, not scientifically "correct" it. My results are generally good. I'm not saying my methods are better than anyone else's. but I agree with Craig that the pseudoscience has done our profession harm. And guess what? Strip away the pseuodoscience, and the orthoses still get results.
Regards,
davidh

Refs:
(1) Debon R, Chassard D, Duflo F, Boselli E, Bryssine B, Allaouchiche B. Chronobiology of Epidural Ropivacaine: Variations in the Duration of Action Related to the Hour of Administration.. Anaesthesiology: Volume 96(3) March 2002 pp 542-545.

(2) Kotaro Miyoshi, Kaoru Igarashi, Shuichi Saeki, Hisashi Shinoda, Hideo Mitani. Tooth movement and changes in response to orthodontic force in rats vary depending on the time of day the force is applied.
The European Journal of Orthodontics. 2001 23(4): 329-338.

 

Hmmmm....this has evolved into a rather unusual discussion. While I believe that any atempt to find a biomechancial TOE (that's Theory of Everything, not the digit itself) is doomed to failure, I encourage all and any investigations that lead to greater understanding. My point (in a message posted only yesterday, but many messages back on this thread), was that we do need to move away from the fundamentalist approach of Root et al to embrace the more recent paradigms (Sagittal Plane, Tissue Stress, Supination Resistance, etc). The difficulty in any paradigm shift is gently urging the population to move with the revolution.

Dear Dr Steinberg, thanks for your thoughts and comments. Couple of points - thank you for the compliment but I'm not referred to by the honorific "Dr Prentice", this is a title adopted in Australia only by those who have gone to the greater glory of the PhD. (The rest of us are quite content to let our skills be our plumage). And, as Craig and Kevin note, it may be a bit pre-emptive to generalise about the state of knowledge of an entire nation on such a small quantity of data. I invite you to follow this forum, and hopefully one day even visit this sunburnt land, and I believe you may be pleasantly surprised at Podiatry "down under" (haven't heard that term in years).

cheers,

Felicity

 

Not a Pseudo-Science

Gee Dave,

So, biomechanics is a pseudo-science because:
1) It is hard to learn
2) It is even harder to apply
3) Your lab might not be able to follow your Rx
4) You might not know how to take a STJ neutral plaster cast
5) You might be dependinjg on too many devices made from a direct scan of a biomechanically unstable foot.

Lets forget about the foot for a minute and concentrate on the knee. Do you ever get that smart runner who feels his knee pain is due to a possible foot problem? Is a 2 degree forefoot post enough when 4 degress would being the knee into perfect alignment, thus reducing torque, misalignment and malo-tracking of the patella? Or are you using the fact that are also other variables like uneven surfaces to say, it's not really worth your time to figure all of this out?

A static biomechanical exam has to be looked at in the context of how the patient uses his foot. Some are "light" on there feet, others are not. Some people have a nautral "spring" in their step, others have feet that hit the ground with a "thud".

A biomechanical exam that finds the elusive neutral position of the STJ is not pseudo-science just because you want exact numbers for something that is as much an art as it is a science. Oh, isn't that just like that pseudo-science they refer to as medicine?

Robert

 

Dr Steinberg,
the sun don't shine much where you are from at the moment does it? I mean it must be cold and nasty, enough to make you really upset. But i will give you this, you got me into the discussion. So here goes.
Man i am all for pushing your case but how many times do authors have to show there is no reliability for you to listen. There's a start.

First off you can not accurately differentiate 2 from 4 degrees repeatably. So this makes your entire argument invalid. Second, there is no such thing as a smart runner. Just joking. My track career is proof of this!
Obviously there is evidence to suggest orthoses can aid reduction in knee torque and may be beneficial in aiding alignment and reduction of patella based symptoms. So since we are getting down to semantics here. Could you describe for me how you know the knee is functioning in perfect alignment? I mean if the correct orthotic can iad the knee an incorrect orthotic can be detrimental to the knee.
Now in a clinical situation with your smart runner, how would you know you have your orthotic working correctly to maintain their knee in perfect alignment?
That is if it worth your time to figure out.
Have a nice day,
DaFlip

 

Absolute Truth

 

Lets try and refocus this discussion in a different direction (and don't forget for 20 yrs of my professional life I drew lines on feet, thought I was reliable and practicing a science and worshipped the STJ neutral position --- and my patients got better).

At the end of the day what do we want? .... we want the patient to get better
How do we do that? ... various modalities (interventions) are used and advice is given

One of those interventions is foot orthoses.
What do we want those foot orthoses to do? ... alter the foot in some way, so that the symptoms are reduced
What alterations need to be done to the foot to achieve this reduction in symptoms? ...we don't really know !! - we must be doing it right as our patients get better and the RCT's and outcome studies show a whole range of types of foot orthoses fix people. What we do know that altering the pattern of rearfoot motion (ie getting foot to STJ neutral) is NOT predictive of outcomes.

If changing the pattern of rearfoot motion is not predictive of outcomes, what is?...we don't know yet, but it clearly related to altering forces and we are rapidly learning more in that with a number of studies underway

If it is the alteration of forces then how do we make foot orthoses to achieve that? .... don't know yet, but they will not be very different to what we currently do, but our predictive tools of what exactly to do will be better

If that is the desired outcome, then what clinical tests do we use? ...the tests that lead to a change in the orthotic prescription variable that is associated with better outcomes - we are getting a better understanding of what we do.

Should we use clinical test that do not predict dynamic function, do not alter our treatment and do not affect outcomes? --- is that not bad clinical practice?

...that is what science is about. Being able to measure something, does not make it scientific (that is the mistake the profession made when Mert Root gave us what he did).

Two clichés I use with students when teaching biomechanics are:
1. I used to know what I was doing
2. Half of what I am teaching you this semester is wrong ---- the problem is I do not know what half it is

 

Craig has raised some great points and i hope some of those who have been posting here on these topics take the time to read them, and then comprehend what is written. It is very frustrating when what you think you know may not be correct!
I understand i am a little on the slow side comparative to some of my more esteemed colleagues such as Dr Steinberg but could someone define pseudoscience since he keeps stating measurements such as frefoot/rearfoot are not pseudoscience?

Now if we are going to refocus this topic, Craig could you outline for us what tests you would use clinically to predict dynamic function. Can you seperate them into two groups.
1. Valid.
2. Questionable validity but useful assessment tools for aiding 1.
Regards
Michael Flip
'Pseudo-person' Podiatrist