Podiatry Arena members do not see these ads

Dear All

I am concerened about the future of podiatric biomechanics.
For quite a few years I have been reading Jiscmail Podiatry and Podiatry Areana and in all that time Kevin Kirby et al have proposed seeking and achieving the goal of a firm scientific structure and basis to the principles of clinical biomechanics. At first this seemed very academic to me as the techniques used to treat patients seemed to work very well and the theory seemed sound enough. With further education and reading the discussions on the topic I can now see the importance of establishing sound scientific theories to underpin the use of orthoses for the treatment of biomechanical dysfunction or trauma.
What made me sit up and think about this today was an advert for Podiatech, orthotic in clinic thermo moulding system, with the slogan "The angle of the dangle days are over". Obviously some seriously doubt the validity of the Root STJ neutral theory and meauring foot angles and positions as has been highlighted by recent discussions. Is the tide of opinion turning and and are we being too slow to evolve for the future. If too many learned and well known podiatrists and establishments insist on sticking with the Dogma of Root is the only model Kevin Kirby, Craig Payne, DanenBurgh, Eric Fuller et al will be figthing a difficult battle. Am I being to dramatic? I think not.

I feel that if we should work to quickly establish a new model which unifies and strengthens the seperate models of rotational equilibrium, tissue stress saggital plane progression and root. Otherwise we may end up going the same way as Phrenologists.

For Phrenology read podiatric biomechanics

REf; http://pages.britishlibrary.net/phrenology/ridicule.htm


Ridiculing Phrenology: "this persecuted science"

"Fool and Phrenologist are terms nearly synonymous" Blackwood's Edinburgh Magazine, 1823.
"The science has met with words enough to have overthrown the argumentative powers of any Irish barrister." 'Cranioscopophilus' in The Lancet, 1827.
Phrenology: "The science of picking the pocket through the scalp. It consists in locating and exploiting the organ that one is a dupe with." Ambrose Bierce

An author in 1838 summed up the feelings of many critics: "Phrenology is a mass of untruth! its physics are false and presumptuous, its metaphysics nonsensical, its ethics a gross ideotic blunder! And yet this system has numerous admirers, and its lecturers often appear in public, exhibiting the ignorance and audacity of the charlatan, in every sentence they utter, and they are generally surrounded by a gaping multitude, of bump-feeling people, eager to gain knowledge of the so-called "science.""
Many anti-phrenologists poked fun at the notion that the brain could be comprised of many organs. Since it was believed by most non-phrenologists that the brain was just as single an organ as the liver or heart, some lampooned the science of phrenology by proposing the study of other organs that might really be many rather than one as had been thought before. One of these humorous suggestions was for a science of "CORDIOLOGY"- so that the heart might also be made of many organs. Even more amusing was Punch's "Stomachology"- a new science which claimed that the stomach was not just a single organ as previously thought!
The much maligned phrenologists themselves, tenaciously insisted that phrenology was "the most important scientific discovery ever made". But none of them could doubt it was a "persecuted science". Analogies with Galileo's persecution by the Inquisition abounded as phrenologists took consolation in their belief that all great new sciences were first scorned and condemned by religious bigots and sceptical critics. Employing this story helped the phrenologists to feel they were members of an elite brotherhood (they were mostly men) of seekers after natural truths- abused by the ignorant and arrogant. Thus phrenologists, by putting a favourable spin on the "tide of ridicule and the abuse against them [which flowed] in an unabated stream" turned their exclusion into a virtue and the science continued through the 1830s and 1840s safely sheltered from serious questions and criticisms which might otherwise have tempered their extreme claims.


Cheers Dave Smith

Tweet

Share

David,

I see what you are saying but surely if we use our knowledge of anatomy to identify structures that are symptomatic and combine this with basic physics to identify the abnormal forces that are likely to be causing the stress etc on the symtomatic structure we are then able to design a treatment programme to reduce/eliminate the forces that are problematic (by whatever means seems appropriate). We do not then need a theorum (STJ neutral, sagittal plane etc) as established principles (physics, mechanics, anatomy) would be at the core of what we are doing. I agree that we need a sound research base but I don't know that a new paradigm is helpful.

Maybe I am thinking too simply?!

Louise

I propose that this new paradigm be called "physics"

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Dave

I couldn't agree more. One development of the Rothbart debates was the acknowledgement that clinical outcomes are essentially similar whatever devices are used. The RCT Craig referred to looked at orthotic intervention in plantar fasciitis, so I guess the clinical range of conditions was limited, but over the years I've noted that expensive custom devices perform much about the same as the most basic of shoe inserts in a variety of conditions. Why is this so? Does it reflect on the variances within the competencies of the prescriber or in the manufacturing process? Or is there another mechanism going on that we haven't yet accounted for?

I do believe the current approach to lower limb biomechanics is sound and has validity, but I also think that it's rather two-dimensional. I once had a patient with recurring plantar fasciitis who, after a number of failed devices, used to resort to her tried and tested method of sellotaping a small sharp stone underneath the 1st MTP Joint and wearing it for two or three weeks. Clearly this did nothing to correct the underlying problem which was a mobile foot complicated with obesity, but it did change her gait sufficiently to enable relief from the acute symptoms.

Kevin wrote in the other thread and I'm sure that's applicable for some patients, but obviously not all. I'm not all that comfortable with terms such as "changing the timing of the gait cycle" for example, but there may be other mechanisms that have not been considered - aside from the external factors like shoe design and activities.

If the stone in the shoe altered the patient's gait sufficiently to improve her underlying symptoms does it not follow that any shoe insert might have a positive effect (as well as a possible negative one) on foot conditions?

Regards (but with a huge groan that another thread like this has started )

Mark Russell

__________________
www.mark-russell.net

"citing an indisposition due to special circumstances"

My location

Louise


I agree that if there was enough RCT's with large enough numbers to show whether or not bespoke orthoses work better than an arch supports then this may be enough to convince doubters that the technique is valid (if it was). But who has the time and money to do such research. Only large companies and they would want returns on the investment so mass produced OTC orthoses would be their market. Drugs companies do not do expensive research and trials of commonly available products unless they could patent the product to make profitable financial returns. Cannabis for instance was recently turned down by the US FDA for licencing as an analgesic because there had not been sufficient research and trials to show it was effective and safe. But no drugs company would do that research if the drug was openly available to the public without patent because there is no profit there.
So its a catch 22 situation.

Simon

I don't know if that was an ironic or literal reply.
My point is that a large company, Sidas Podiatech, who employ orthopaedic surgeons, biomechanists, engineers, physiotherapists at professorship level, are prepared to produce an advert which plainly says Root model is outdated and invalid and ridicules the concept of measuring angles. The biomechanics side of podiatry was brought up on Root. The model had strong support which kept the paradigm concept strong. But now there is great debate and argument amongst the differing factions within podiatry (Kevin Kirby looks to the future with his equilibrium model, Jeff Root (understandably) is the defender of the faith, Danenburgh flys the flag for his saggital plane progression theory, and Eric supports tissue stress and strain reduction,and so, I believe there is much confusion amongst the general populace of practicing podiatrist.
Phil Wells talks of deconstructing his beliefs about the reasoning behind orthotic prescription and manufacture so that he can rebuild them into a strong and reasonable model which he can use to validate his designs. This need to reorganise may reflect his lack of belief in any one system (is that correct phil?).
This dis-harmony gives our detractors great opportunity to pour scourn and ridicule the 'science' of podiatric biomechanics. In the absence of reliable research and RCT's, which are unlikely to be forth coming in the near future,
I feel that the podiatry profession should produce a model/ paradigm which is underpinned by sound science of engineering physics and can be accepted by all (or at least a large majority) just like root was. They already exist in a fragmented way but to be able to defend this branch of our proffesion we should present a united front where we can all agree on basic principles of biomechanics.
I don't know this for sure but it seems to me that as a profession physiotherapists are strongly united with their treatment paradigms. I doubt that very many of those have been subject to rigorous research and trials yet not many seem to question their effectivness. Is this is because they all beleive as a whole in the techniques they use.

Cheers Dave

Dear All,
This is a debate that will continue to run and run, in regard to being able to apply a cohesive biomechanical paradigm to large numbers of individuals with predictable outcomes.
In regard to this, I have to agree with Simon that at this time, the nearest we can come to this is the application of physics, as Newtonian laws provide predictable outcomes.
However, in this scenario we treat the foot / body as a passive structure that reacts purely in regard to the forces applied to it.
As we all know this is not the case and we still struggle to determine the outcomes when applied to a dynamic responsive physiological system.
As much as I can see the limitations of the current podiatric paradigms, the application of physical principles lends us credibility and hopefully keep us away from the fate of the phrenologists.
Just a thought!!

Tony

Dave
It is not as much as a lack of belief in any one system, more the lack of understanding by practitioners that physics underpins everything we are trying to do. (It is very hard to advise people on orthotic prescribing when I (we) speak a different language to them) All paradigms use physical terminolgy but the majority of practitioners I speak to have not been exposed to Newtons Laws in relation to foot function. If they could understand simple terminology - force etc - then I beleive we could move forward.
I definatley agree with your initial statement about needing to agree on new goals. This would then underpin biomechanical treatment at all levels, from chiropody to diabetic footcare.
Maybe it is time for a qualatative research study using interview techniques based on the discussions in the Podiatry arena. I have been told by social science friends that this is valid and may define a framework/book for others to begin there understanding of physics.

Phil

Bio-netizens

Phil wrote
>It is not as much as a lack of belief in any one system, more the lack of understanding by practitioners that physics underpins everything we are trying to do.

I think that is the kernal of the argument.

Anecdotal evidence supports the continued use of posted shells whereas there is no scientific proof they work. Fait un complé

There are without doubt gifted clinicians capable of tweeking to perfection with merciful relief of patient symptoms, but they are the exception. To mere mortals (like what I am) there is no sense in podiatric biomechanical theory and hence no predicable outcome. That does not mean I would not use the "arch support*", I do usually as a placebo. Amazing how this often coincides with a change in symptom patterns :) However I still cannot explain it.

* arch support in reference to sagittal plane analysis of the foot function.

As I have said before PBm is a cool way to describe three dimensional movement in the foot but is not referenced or determined by universal laws. Which is I think what Phil has said.

Cameron
Hey. what do I know?

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Colleagues:

David is right on the money in his analysis of the situation currently within podiatry. Unless podiatry starts to take biomechanics more seriously, not only in your own countries, but in the States where I practice, we will soon find that another profession has taken more interest and have developed better skills in the subject than we have. When that occurs, podiatrists will no longer be considered the medical experts in foot and lower extremity biomechanics. Podiatry would only have itself to blame if this occurs.

The comment was made "We do not then need a theorum (STJ neutral, sagittal plane etc) as established principles (physics, mechanics, anatomy) would be at the core of what we are doing." Yes, however, for over 30 years, podiatrists believed that the STJ neutral theory was consistent with known physics, mechanics and anatomy teachings. I have been fighting, along with others such as Dr. Eric Fuller, against the disciples of STJ neutral theory for our whole practice careers and we still continue to fight to this day. Eric and I went through quite a bit of frustration while at CCPM trying to start getting these ideas taught in the late 1980s since Root biomechanics was still king at CCPM, "the home of podiatric biomechanics". Now, in year 2006, talking about medial and lateral STJ axis deviation, medial heel skives, and pronation moments, to many of you, is "old hat". But soon after the year of 1985, when I started teaching these subjects at CCPM, I was given a T-shirt that read "Beam Me Up Scotty" by one of the Biomechanics Fellows that pretty much summed up my reputation within the CCPM Biomechanics Department. In other words, my propensity for using "complex" words such as "STJ axis location", "medial and lateral STJ deviation", "moment arms", "moments" and "GRF vectors" definitely made me seem on the fringe within the department, at the time.

Now, for it to be suggested that all we have to do now is to rely on physics, mechanics, and anatomy is not only an incredibly simplistic analysis but also, I believe, is basically an insult to those of us who have worked very, very hard for over half their lives in trying to produce workable alternative theories of foot function for podiatrists to replace the STJ neutral theory that all of us accepted as fact 20 years ago. I think that we deserve a little more credit than that.

And finally, as far as I'm concerned, anyone that does not think that there is a considerable therapeutic difference between over-the-counter and prescription foot orthoses should not be making prescription foot orthoses in the first place. For the past 21 years of busy podiatric medical practice I have changed the lives of patients who have tried over-the-counter foot orthoses with little to no relief only to have their pain cured and the normalcy to their lives returned by the wonderful benefit of correctly prescribed custom foot orthoses. All the research in the world is not going to convince me or my patients that over-the-counter inserts work as well as "expensive custom devices" for them and their lives.

By the way, those of you who can only see prescription foot orthoses as "expensive custom devices", I think need a little lesson in the value of medical treatments. In other words, prescription foot orthoses may seem expensive to those on the outside who don't have chronic foot pain and haven't been treating patients for two decades effectively with foot orthoses. However, to those of us that have considerable clinical experience in prescribing orthoses effectively to relieve their patient's pain, they will also know that many of their patients wouldn't let us buy back their prescription foot orthoses (and have their foot pain return) for many times the monetary amount that they paid for them originally. That, now, is a much more realistic measure of the true value of prescription foot orthoses to a patient and not just the amount charged to the patient for the service.

When a podiatrist says that over-the-counter orthoses are just as good as prescription foot orthoses it just tells me one simple fact: these podiatrists were never trained properly in the many facets of orthosis prescription that I was trained in and that I have trained thousands of podiatrists around the world in over the past 20 years. If we continue to design foot orthosis research so that the expected outcome of the research project is to show that there is no difference between over-the-counter foot orthoses and custom foot orthoses, then we have not done a service to our many current and future patients that may need a custom foot orthoses to relieve their symptoms the most effectively. If we continue to take little interest in foot orthoses because it is "too hard" or "too complicated", then another more interested medical professional will take our place to become the expert in biomechanics of the foot and lower extremity. Are we ever going to learn as a profession?...only time will tell.

David, I congratulate you on your ability to see the forest, in spite of all the trees that were in your way. Let's hope that podiatry, as a whole, also takes this seriously soon and starts producing new leaders in foot and lower extremity biomechanics within our profession since the current generation of leaders will not be around forever. Hopefully, some of you reading this short message will take me seriously enough to realize the importance of what I am talking about so that podiatrists can continue to be recognized as the leading medical professionals in foot and lower extremity mechanical injuries for many generations to come. That would allow me to be extremely satisfied with the direction and wisdom of podiatric medicine as a whole when I retire from the profession in the coming years.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin

I understand your concerns but would charge you in the most pleasant way to consider the rationale for some of your statements. Scientists do not set out to prove anything. Viewing these intellectual works in anything other than a genuine intellectual enquiry would be quite inappropriate no matter how we may find the conclusions disagreeable. OTC devices are no better or worse than bespoke orthoses in their therapeutic effect which is supported by hard evidence.

>Now, for it to be suggested that all we have to do now is to rely on physics, mechanics, and anatomy...

I am certainly not suggesting anything simple about the bioengineering systems whatsoever. As a scientist I believe in determinism and the physical world follows universal rules and am more sceptical of phenomenolgy.

>I have changed the lives of patients who have tried over-the-counter foot orthoses with little to no relief only to have their pain cured and the normalcy to their lives returned by the wonderful benefit of correctly prescribed custom foot orthoses.

So you have evidence and matybe now would be a great time to publish this collective works in an independent refereed journal. It would make most interesting reading.

I am certainly intrigued at your desciption of outcome and would respectfully ask how can foot orthoses "cure pain" ? Foot orthoses are inert so clearly there is no pharmaceutical benefit or pharmo-chemical neurological influence and the only action they exert would be physical (dermined by universal laws). You qualified success of prescribed bespoke orthoses in terms of returning normalcy to peoples lives. How would this happen unless there was a psychological dimension.

It may be (I do not know) but part of the success of foot care is the influence of the carer combined with the motivation of the client who values professional interest, genuine counselling and physicians focused on their predicaments.

What say yopu?

Cameron

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Kevin,

I was not meaning to be disrespectful to yourself or others who have worked hard to challange the STJ neutral theory and who have opened the eyes of many Podiatrists (including myself) in the last 30 years. My point was that a new theorum runs the risk of becoming 'prescriptive', telling us all to do 'x' when we see 'y' (in the way I was taught STJ neutral theory in the 90's) rather than using our skills and knowledge (of anatomy, physics etc) to evaluate each case individually, proving that we are offering something infinately better than issuing an OTC orthotic.

Apologies,

Louise

Colleagues,

Yesterday at a Biomech Workshop I and others witnessed a remarkable change in both posture annd gait in one attendee. More, her face changed (smiley) postural pain went away, and her voice changed in both resonance and pitch.

What were the miracle devices which produced these almost magical instant alterations?
Rothbarts Proprioceptive Insoles?
Masei Barefoot Technology Shoes?
Expensive custom, casted orthoses (with whatever the latest "innovative" addition is - your choice)?

No - simple cork heel-lifts and someone else's borrowed orthoses.
A one off you may think.
Again, no. Each delegate (7 in all) showed much improved gait/posture - either with simple heel-lifts alone, or with borrowed orthoses.
Lucky?
Perhaps - except that this was a repeat of the Workshop we ran 2 weeks ago. We did much the same thing with the 11 delegates there.

Actually what was interesting was that we were able to demonstrably improve the gait and posture of each delegate......

Anyone care to have a stab at the (very) common denominator present in each case ?
Clue - it wasn't a podiatric biomech "condition".

Regards,
davidh

David (Smith),

In my opinion, this thread is completely missing the point as to what Podiatech are trying to say!

I have had the Podiatech rep around with his 'machine', which involves standing on vacuum formers (sand bags) and then the air is sucked-out of the vacuum-formers whilst you are held in 1st mtpjt dorsiflexion. The orthoses are then heat-moulded to this shape.

I tried them in my shoes and guess what they did........................................?

Less than b***er all!

The product they are marketing is aimed at people who are not Podiatrists, but want to be able to provide orthoses (custom-made), without learning anything / referring to a Podiatrist. So what they are in fact saying is:'The age of the Podiatrist is over'. This is a similar concept to Gaitscan sytems etc.

Unfortunately, the product is doo-doo and the results likewise.

However, Podiatech do another 'machine' that they market to the Podologists in France which is massive and has the vacuum formers, but also grinders and all the other stuff you would expect to see in a lab (except, I might add CAD-CAM design and Laser scanning which most labs offer now).

Therefore, I think it's best not to be too concerned!

However, linking in to the debate about 'expensive' bespoke functional foot orthoses, Podiatech retailers in some areas (shoe shops/ski hire etc) will sell their products for up to £200. I still believe bespoke is best and most durable and I've yet to have a bad outcome on that basis.

Perhaps a better reflection would be how many of us as clinicians are wearing bespoke, casted orthoses and how many custom-made/chairside? I wore chairside for 5 years, but now I have bespoke, I can't believe why I bothered as bespoke are far superior and can attain pain-free status far more easily.

As a profession, the best step forward we can make in Musculoskeletal Podiatry is:

a) Raise profile nationally
b) Get recognition by more medical insurance companies (pitiful at present, despite our conference being sponsered by BUPA, who don't even let patients see us without a Consultant referral).
c) Stop thinking that orthoses will help everything and work more collaboratively (get to know what muscles make up the core)
d) Begin to relaise that we ARE the lead clinicians in gait pathologies and market ourselves as such!

Sorry, too much artificial colouring again at lunch - rant over!

__________________
nicpod1

I have so many responses to make to this topic, I do not know where to start (and have less time due to a recent upheaval ), so will just initially respond with this:

Will there ever be the "one" theory of foot function? ... put simply the answer is NO....(Message to students: Sorry, but you need to know them all)

I think I have been probably teaching and thinking about all the different theories longer than almost anyone else has ...

The students even get a lecture on the theory of theories as part of the biomechanics course. To distill this lecture down, consider this analogy:

In politics there are two basic approaches - the left/liberal and the right/conservative sides (with different shades of both). Whichever camp you are in, you view the world differently; you have a different perspective of what goes on; your 'world view' is different; you view the world through a different tinted lense; etc. This two basic sides have some underlying principles that define them -- there is and never can be evidence that one is right and one is wrong, as they are nothing more than theoretical frameworks to make sense of the world around us. They are used to interpret things differently. For eg consider a fact of a 3.2% unemployment rate. .... that is a fact no matter which political side you are on .... but the right/conservative intrepretation of that fact is very different to the left/liberal interpretation of that fact. For some individuals the right/conservatice perspective helps them understand the world better and for others the left/liberal perspective helps them more. Neither perspective or framework or theory is better than the other, but the right/conservative think they are correct in their interpretation and they think the left is wrong (and vice versa) --- sit back and watch an episode of Hannity & Colmes on Fox to see fantastic examples of this in action.

Similarly, in sociology (in which I have a BA), consider the facts about the role of women in the workforce. A Marxist would interpret those facts very differently to a Feminist. Marxism and feminism are nothing more than theoretical frameworks in which to view the world (and sociology has many different theoretical frameworks and shades of those). Neither theory will ever be proved right or wrong. However, Marxists think feminists are wrong (and vice versa) because they are using their own theoretical framework (ie Marxism) to interpret another (eg Feminism).

So it is also with how we view, what I prefer to call, clinical biomechanics. We have our theoretical frameworks through which we view the world (or in this case the foot). Each of the theoretical frameworks have some basic principles (like the right/left political dichotomy) that underpin them. Generally, these underlying principles will never be proved right or wrong, as they are the basic tenets of the "lens" in which the world (or foot) is viewed (ie the 'paradigm'). (HINT TO STUDENTS: make sure you can identify and learn what the underlying principles of each approach is).

The challenge then becomes one of being explicit about the framework that you are using to evaluate an approach. Each approcah needs to be evaluated on it own terms within its own framework rather than use the lens of another (eg a Marxist can never adequately evaluate a feminist perspective). Evaulating a concept wearing a "lens" leads to all the issues we have seen in a couple of recent threads, especially around the "blind faith" and the tactics used in debating (you see exactly the same thing being done in politics and sociology).

Theoretical frameworks that get established with the principles that can never generally be proved right or wrong can come and go as being fashionable and get more or less numbers of people supporting it (eg Marxism is not exactly currently in 'fashion'). How much support it gets depends on how well it explains the world around us (or the foot) for each indivudal person.

We each use theoretical frameworks to interpret the world around us (whether you admit it or not) and we each use theoretical frameworks to interpret the clinical biomechanics of foot (whether you admit it or not).

What has this got to do with patient care and making better orthotics? Many have "faulty" perspectives in which the underlying principles are proved wrong (ie they persist due to the "blind faith") (BTW - the underlying principles of "Root" theory have not been proved wrong). This affects peoples ability to learn and incoporate new information into their clinical practice. We should be more explicit to ourselves about the framework or theory underpinning your own world view of the foot when reading different (maybe new) information.

Can you see why there will NEVER be a unifying theory?

Don't ya just love this stuff?

__________________
Craig Payne
__________________________________________________ ___________________________________
Follow me on Twitter | Run Junkie | Latest Blog Post: Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

Here is the beginning of something I have written that will be appearing elsewhere, but its appropriate to post it here for now:

__________________
Craig Payne
__________________________________________________ ___________________________________
Follow me on Twitter | Run Junkie | Latest Blog Post: Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

Nicpod1,
I wear custom orthoses - the same pair for 28 years. Great value and they do the job. I also prescribe custom orthoses, but hardly ever pre-fabs.
My reasoning being if I believe the pt could be helped by orthoses, which they may need to wear long-term, why mess around with pre-fabs?

Agree with everything else, apart from - why on Earth did your professional body allow BUPA to sponsor the Conference?

Regards,
davidh

There are some "commercial issues" here so I will enter it as somebody who supposedly knows a bit about Business Marketing Strategy and a bit about the Podiatry Market.

I sell 50 Preform Insole types and 1000s of Materials and products for Custom Manufacture so the either/or question does not bother me but my input on that may not be relevant to this thread.

In answer to David's original post about an advert. My company spends £20K+ a year advertising in UK Podiatry "journals" alone, but my marketing manager has to justify the spend in return of investment (ROI) under a number of criteria. Every company that advertises a product is trying to sell something for profit, myself included, or why bother!

A Podiatrist makes an informed clinical decision based on their Training and Experience. This means that a Podiatrist should be able to look at an advert (or mailshot, web page etc) and disseminate the information given and see if it has value to his/her clinical practice, a considered choice is then made to the benefits or lack of them of the Unique Selling Point, Validation of Concept, Price v Value, etc etc.

Does this rational internal questioning happen? - Replies on a postcard please!!!! Is my £20K+ well spent???

If any company wants to sell a weight-bearing moulding system allegedly against the accepted (another debate) principles of modern Podiatry Biomechanics they are perfectly entitled to do so and allowed to by the Editorial Board of the Journal (another debate). It is the choice of the educated Podiatrist if they find it a useful tool to use in their clinical practice.

Any company who pays to advertise will only continue to do so if there is a response to that advert and there is a ROI. If you look at the "Foot Pain Insert - miraculously cured" adverts in the Sunday Newspaper colour supplements they would not be running for so long if they did not pay for themselves (£10K to £30K a pop) an insole costing £2.50 is sold to the unsuspecting public for £19.99 plus £5 p&p. Does it work or have a Podiatric use? a picture of a nice friendly looking Schiropodist wearing a white coat says it does, so it must be good. Don't get me started on the quackery seen at the Ideal Home show!!!!!

As far as Podiatry is concerned Podiatrists and Biomech Specialists especially, have to make informed choices to give value of care to their patients. There is a lack of Patient knowledge about Biomechanics and unfortunately also a lack of informed decision making by many Podiatrists. As a Marketeer and Business Strategist I would love to see an informed Public and a well educated Profession. A Commercial company can sell anything to anybody. A healthy profession, content in its own value to its patients, should be able to make those informed choices and not be pushed into wrong choices by sales people or a glossy advert.

Cheers

Jamie

Great thread!
This comment from Jamie, in the context of what Craig had to say, jumped out at me. Craig wrote: I don't think as a student I really appreciated at the time what my teachers were really tring to do. I applaud Craig's efforts, especially his comments I read somewhere here about using Podiatry Arena to supplement the classroom teaching. Where was it when I was a student?

Davinci - I am still tryig to work out who you are ..... anyway, thanks. I just responded to a student here:
http://www.podiatry-arena.com/podiat...ead.php?t=2085
with a list of threads she should be reading...

__________________
Craig Payne
__________________________________________________ ___________________________________
Follow me on Twitter | Run Junkie | Latest Blog Post: Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

Louise,

No need to apologize since I thought your comments were actually stimulating and made me think about some aspects of our profession that I haven't recently visited. However, a few things you said in your original posting needs to be expanded on so you can see how they could be misinterpreted by someone like me who has been teaching podiatric biomechanics for over 22 years.

Your original posting included the following statement "We do not then need a theorum (STJ neutral, sagittal plane etc) as established principles (physics, mechanics, anatomy) would be at the core of what we are doing." Here I disagree. What we do as podiatrists is much too specific and detailed to simply say we should be using physics, mechanics and anatomy to know how to best treat patients.

When a student or podiatrist asks me, "Dr. Kirby, when you treat posterior tibial dysfunction, how do you design your orthosis differently compared to other patients?", how should I reply. Should I say, "Just use your knowledge of physics, mechanics and anatomy, since this should underpin everything you do for this condition, and the patient will get better"?? Or should I give a more detailed and very specific mechanical analysis of how, in the human foot, individuals that develop posterior tibial dysfunction always have a medially deviated STJ axis that causes increased magnitudes of STJ pronation moment from GRF that then requires specific orthosis measures to increase STJ supination moment, such as the medial heel skive, to make the individual's symptoms improve??

The former reply teaches the student little, assumes that they actually have a good working knowledge of physics, mechanics and anatomy, they they know how a specific mechanical pathology is caused, assumes that they have enough clinical experience treating these problems to know what works best in different situations and assumes they have the technical skills with orthoses to accomplish the goal of getting the patient better. The latter reply, where I use the STJ axis location/rotational equilibrium theory as a framework to help them better understand the mechanics and treatment of the pathology, can at least can get into some very specific reasons of why the injury occurs in some individuals, how it affects STJ moments, and how to design the orthosis/shoe/therapy program with these pathological forces in mind to specifically treat this painful and disabling condition.

While I have been lecturing year after year after year on the importance of podiatrists needing to learn physics and mechanics in order to better understand how we may mechanically treat many conditions of the foot and lower extremity, and I have seen some progress in the podiatry schools in this regard, the truth is that if I were to ask 100 podiatrists how a rotational force (i.e. moment) is determined (i.e. force x moment arm), probably only 20 of these podiatrists would be able to answer my question correctly. So, as far as I'm concerned, if a podiatrist doesn't understand what a moment is, they can't possibly undersand the concept of rotational equilibrium, can't understand the basic function of the foot and lower extremity, can't understand the details of how many injuries are produced, can't understand how STJ axis location affects the internal forces within the structural components of the foot, and can't understand the mechanics of the midtarsal joint and metatarsophalangeal joints.

Unless we can assume that all podiatrists do have this basic physics and mechanics knowledge, which I can tell you with great certainty that they don't, then we must be continually striving to produce better theory so that podiatrists will have a better framework by which to make clinical decisions when treating their patients with mechanical problems of the foot and lower extremity.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Cameron:

Just last week I used a 22 mm long, 3.0 mm diameter, titanium-allow cannulated screw to surgically fixate a modified-Reverdin osteotomy for correction of a hallux abducto valgus and bunion deformity. The patient did not need to ingest the screw for her to receive therapeutic benefit from the specific mechanical construction, material, and geometry of this surgical fixation device. These surgical implants are specifically made to be inert so that they can be retained within the body for a patient's lifetime to avoid host implant rejection. Would you also ask the same questions for this surgically implanted screw used for bone fixation to the surgeon that effectively uses this mechanical device just as you have asked the question regarding another mechanically-based medical therapeutic device, prescription foot orthoses?? Does the titanium-allow screw need to have a psycological dimension to be effective? I think not.

Since I don't have the time now to explain how foot orthoses work at relieving pain in patients, I will list the papers, book chapters, and two books I have authored and coauthored on how foot orthoses may exert their mechanical effects on patients with mechanically induced foot and lower extremity pain. These are listed below for your reading pleasure:

Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989.

Johnson ER, Kirby KA, Lieberman JS: Lateral plantar nerve entrapment: Foot pain in a power lifter. Am Journal of Sports Medicine, 20 (5):619-620, 1992.

Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992.

Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992.

Kirby KA.: Podiatric biomechanics: An integral part of evaluating and treating the athlete. Med. Exerc.Nutr. Health, 2(4):196-202, 1993.

Kirby KA: "Troubleshooting Functional Foot Orthoses", pp. 327-348, in Valmassy, R.L.(editor), Clinical Biomechanics of the Lower Extremities, Mosby-Year Book, St. Louis, 1996.

Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997.

Kirby KA.: Biomechanics and the treatment of flexible flatfoot deformity in children. PBG Focus, J. Podiatric Biomechanics Group, 7:10-11, 1999.

Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000.

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001.

Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

To throw some fuel on the fire --- we got some new data we just about to submit for publication that shows that Formthotics (prefab) got rid of “shin pain” in 1.5 weeks and custom made in 4.17 weeks!!

HOWEVER, interpet with caution as the data was retrospective; did not use a validated outcome measure; and no severity measures were used to compare groups at baseline.

However, there is a big difference between 1.5 and 4.17 weeks

__________________
Craig Payne
__________________________________________________ ___________________________________
Follow me on Twitter | Run Junkie | Latest Blog Post: Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

Kevin

My questions were rhetorical of course. I know how much you have written, believe it or not, I have read quite a bit of it. However as a fellow educator my comments would relate to the focus of the works you cite which concentrate upon technique and supposition. All are based on the assumption that foot orthoses (which is a closed surgery technique) translate to reduction of symptoms. Absence of qualitative analysis and reliance only upon subjective reports however would make these narratives open to intense scientific questioning.

It is very important and highly valued in a profession bereft of a written culture to document pragmatism but at the same time necessary to not exclude impiricism. Simply put clinical experts and clinical scientists may have different perspectives which frequently result in them agreeing. That is perfectly understandable. So I guess we just need to amicably disagree.

Finally the actions of external bodies who control access to the health dollar currently prefer evidence based practice based on independent inquiry and not pragmatism. Frustrating as this may be as an autonimous clinical expert that is the global trend.

So this may be a very good time to rethink

As always, yours in good faith
Cameron

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

The very fact with have these differing biomechanical models is what makes us the best at what we do. It guarantees a strong future for the profession. I, like the rest of you no doubt, can't stand the thought of these computer systems/scanner etc replacing our role in biomechanics (And the system working).


BTW Craig, were the formthotics straight out of the pack, with no adjustments?

Congratulations on the upheaval, Craig. :)

I do agree that there will likely never be a long-lasting unifying theory since we will always be adding bits and pieces to even the best theory as new knowledge is generated by research. However, just because we may never have a long-lasting unifying theory in foot and lower extremity biomechanics does not mean that we should not strive toward achieving that goal. Just like the theoretical physicists are continually striving toward the goal of developing a unifying theory of physics, I think that podiatry needs to also continually strive toward the goal of developing a unifying theory of foot and lower extremity biomechanics. In other words, I feel it is defeatist to take the attitude that "there will never be a unifying theory". Theory is much too important for the foot and lower extremity biomechanics clinician to give up on improving it or even striving to unify it. The more all-inclusive the theory is, the more useful it is for the clinician since it helps to not only explain more phenomena, but also helps to allow more effective treatment of mechanically-based pathologies of the foot and lower extremity in the clinician's patients.

On a final note, the idea of unification of theories that Dave suggested has been something that has been on my mind for many years. Eric Fuller and I talked about this same idea 5 years ago while lecturing together in the UK. Because of our common interest in wanting to combine our ideas into a more unified approach to mechanical foot therapy, we collaborated to write a chapter in a book that we finished over a year ago using his ideas of tissue stress combined with my ideas of subtalar joint axis location and rotational equilibrium.

Neither Eric or I consider our theories competing theories. Instead, we consider them to be complementary theories. Eric and I have now blended our two complementary theories into a more complete theory of mechanically-based foot therapy called "Subtalar Joint Equilibrium and Tissue Stress Approach to Biomechanical Therapy of the Foot and Lower Extremity". Our chapter should be published before the end of this year in the book titled "Lower Extremity Biomechanics: Theory and Practice", edited by Stephen Albert, DPM. I am hoping that for those of you who are interested in seeing podiatry strive toward the goal of developing a more unified approach to foot function and mechanical therapy, this chapter will be viewed as bringing us a step closer toward achieving that goal.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I was really interested in the responses to your post. I was just going to say that you are looking through the lens of the tissue stress paradigm. You have the tissue stress paradigm as your "new" theorum, so you therefore do not need another theorum. I did appreciate Kevin's distinction on the differnece in saying that posterior tibial dysfunction is the result of physics from saying that posterior tibial dysfunction is the result of a high pronation moment from the ground. I agree with Kevin's point that you should not get lazy in your thought processes no matter what paradigm you use.

One of the problems that I felt occured with the use of STJ neutral theory was simplification (lazy thought) of the theory in some practioners minds. I recently talked with a student and asked how he thought orthoses work. "The orthotic holds the foot in...." There was a comment that no one has disproved the STJ neutral theory. You can certainly blow some holes in the logic of the theory if you are willing to think through all the points of the theory. If you look deep enough you can find the many inconsistancies and leaps in logic that exist. So just because you stand on an orthotic casted in neutral position, you should stand in neutral position??? I don't think that

I agree that it always has to come back to physics and anatomy. If a joint starts moving a moment was applied. If a joint doens't move and there is a obvious moment that would trying to make it move, then there must be some other moment that brings the net moment to zero. Newton's laws are pretty well established. So, if your pardigm talks about preventing motion, then you are intelectually lazy if you do not think apply Newton's laws to your paradigm. If an orthotic is supposed to hold the foot in a certain position then you have to identify the sources of moments that are preventing motion. If you believe that sagittal plane blockade causes arch collapse then you need to look for the moments that cause the collapse. (A delay in calcaneal unweighting is the exact opposite of what should happen if a functional hallux limitus is supposed make the foot a longer lever which then cuases arch collapse. ?long gear push off is a good thing? More inconsistancy.) You could say that I am asking everyone else to look throught the lens of the tissue stress paradigm. However, if you don't examine forces and moments, within your paradigm, you are essentially questioning the validity of (or choosing to ingnore) Newton's laws. They should not be ingored.

I agree with Kevin that our writings/ideas are not mutually exclusive. In fact I veiw them as the same line of thinking. Kevin's paper on rotational equilbrium paper, where he talks of interoseus compression force, is talking about tissue stress. His writings on PT dysfunction are a discussion of tissue stress. I believe it was Kevin who pointed out to me that McPoil may have been the first to use the term tissue stress. What I really appreciate about Kevin and our way of viewing the foot is that we have independently arrived at the same conclusion in a couple of cases. I remember reading his medial heel skive paper and then thinking, "why not a lateral heel skive for over supinators?" Sure enough, he writes about the lateral heel skive soon after. I also remember being told by other members of the CCPM biomechanics department that this moment stuff is too complicated and confusing. It is actually quite simple as long as you have not had another paradigm already installed in your head. Craig Payne's students think they are unlucky in having to learn multiple paradigms. You would be much worse off being taught the wrong paradigm. When I was in school I often heard, "I got good grades in biomechanics, but I sure don't understand it." There is something wrong with that picture. I blame the paradigm for being confusing and not the students for not understanding the material. On the other hand what could be simpler than, "when you push upward medial to the STJ axis the STJ supinates and when you push lateral to the STJ axis the STJ pronates."

Cheers,

Eric Fuller

Hi Eric,
You said (much cut):
""The orthotic holds the foot in...." There was a comment that no one has disproved the STJ neutral theory. You can certainly blow some holes in the logic of the theory if you are willing to think through all the points of the theory. If you look deep enough you can find the many inconsistancies and leaps in logic that exist. "

I believe that the STJ neutal theory holds true, but with some important caveats.
1. Our lower limbs have not adapted for a hard and flat surface, and mostly when I place feet in STJ neutral (an approximation of) I see inverted feet.
2. Most of the biomechanical conditions or anomilies (forefoot varus/supinatus, equinus, plantarflexed 1st rays) - are simply variations of normal, which depend upon a hard flat surface/GRF for them to either cause symptomology or distort the foot, usually by causing a flattened MLA or an everted calcaneus.
3. We cannot, no matter how much we want to, without using invasive techniques produce either meaningful measurements of ROM of the foot/lower limb, nor produce an accurate (in degree increments) orthosis which will retain its accuracy once in the shoe and being worn.

Given these caveats do you believe that you can still "find many inconsistencies and leaps in logic"?

BTW, I don't have a problem with Newtonian physics - I just think the whole biomech scene (certainly in the UK, where very few podiatrists I come across even understand simple basic biomech, never mind lever arm moments ) can and should be boiled down to a few simple tenets which make sense, and can produce (within reason) predictable beneficial results for our patients.



Respectfully,
Davidh

Kevin,

Thanks again for your comments. I am not in education so my perspective is different and I agree that mechanics and anatomy alone have no context. My reason for the inital posting is brought up in your reply and the one from Eric. Many Podiatrists have no knowledge of Newtons law, moments etc and more worryingly see no reason to!! They have been taught (as I was) that 'biomechanics' was a set of instructions to be learnt and followed, the physics we were taught was done in complete isolation and no context ever given. I did not understand why we were learning it as it was not put together. The students who did well in biomechanics exams were those with good memories!! This is something that needs to be adressed.

I have been worrying recently about the lack of clinical diagnoses and clear mechanical reasoning in the assessments of my team. I see too many assessments made up of random observations about RF this and FF that and yet it is not clear form the record what is actually hurting! I then see a prescription without any reference to what it is trying to achieve. To try to address this myself and a colleague covered some basic physics and used your thought experiments which were set as tasks to be completed. With a lot of inital resistance it seems to have been a positive exercise. I hope that as a team we are thinking more about what we are doing and are able to explain this to other colleagues and to patients. I am not trying to tell my colleagues that any paradigm is wrong but rather to make them think about what they are doing and to use anatomy and physics as the basis for their thinking.

Sorry to waffle!

Louise

As devils advocate, doesn't the example of explaining Tib Post Dysfunction to a student show very classically using theories as "lenses" or "models to aid understanding". To say to the student "use your knowledge of physics and anatomy" or explain "STJ axis location, axis deviation and equilibrium" are both correct.

The "theory" gives the 1st statement a "context", perhaps?

The next pt who comes in could have "low back pain". They might demonstrate all of Howards observations in their gait. You might explain this as being due to functional hallux limitus and that in itself secondary to the function of their medial column and their STJ. Again the "theory" giving a context to the application of Newtons Laws of Mechanics.

If you have a sound underpinning of mechanics and tissue stress, surely all "models" or "theories" are not necessarily competing or opposing or in need of unification. They simply offer a means of simplyfying the mechanical situation to one that is easier to visualise and not need any complicated computation. Moreover all the models have certain specific pt presentations wherein they are particularly useful and dare I say it... describe the same phenomenon from an alternative perspective.....

I think at its core where the STJ neutral theory (we really should all STOP calling it "Root" theory) goes most awry was not explaining how pt's actually hurt. Kevins and Erics observation or mindset shift that it is the structure providing the opposing moment that hurts is a subtle but very significant stepping stone to understanding (or it was for me!). Beyond that its a case of figuring out the why and then how does one change the situation for the better. If you use a model for this or not is really up to the individual, perhaps to not use one would represent a very high level of understanding to which we (read me) aspire.

All of course assuming that what we do makes the pt better not our pleasant relaxing surgeries and charming bedside manner. ;-))

Louise:

What you are experiencing with your team of podiatrists is a very common occurence. Most podiatrists do not know how to organize their thoughts well in regard to musculoskeletal injury, I think, because they were either taught poor concepts by their professors or never learned the good concepts their professors tried to teach them.

What you have described with your team coming up with the rearfoot deformity and forefoot deformity without a firm diagnosis when they examined a patient was something I saw every day while I was teaching 3rd and 4th year podiatry students during my Biomechanics Fellowship at CCPM in 1984-1985. This type of "improper diagnostic emphasis" is caused directly by podiatric biomechanics professors strictly adhering to only teaching Root et al's STJ neutral theory where the determination of structural "deformities" are emphasized far above the importance of the anatomical location of injury and the type of tissue stress that is causing the injury to occur. This dogmatic teaching of STJ neutral theory as the only truth of podiatric biomechanics is something I have been fighting for over twenty years. I realized, early on in my Fellowship, that many of these measurements that I had been taught to take on every patient actually correlated very poorly to the pathologies I was seeing in my patients at the time.

In late 1984, during my Fellowship, I first started discovering the correlation of STJ axis spatial location to mechanical pathology in my patient's feet, and started realizing its mechanical significance in regard to the many clinical phenomena that could not otherwise be explained. I still remember where I was, driving home on the freeway from my clinic at Kaiser Vallejo toward my home in San Francisco, when I realized the powerful significance of this way of thinking about how the foot works. I can best describe this epiphany as opening a door into a brightly lit room where I could see everything quite clearly after, what seemed like ages, I had been walking aimlessly in the fog created by my confusion and frustration with STJ neutral theory. I thought that you, and possibly others, might enjoy this story since it describes an important instance within my development of STJ axis location theory.

Now, on to training your team properly..... here is a great little clinical demonstration/brain teaser for them. Get two books, each the same thickness (about 2-3 cm), and lay them on the ground so that a person can step on one book with their left foot and on the other book with their right foot, in relaxed bipedal stance. First, position one of your team member's right foot on the book so that only their 5th metatarsal distal shaft is hanging off the book, and have them take note if their foot feels more pronated or supinated at the STJ (the rest of the team should also observe the foot during this experiment). Second, position their right foot so that now their 4th and 5th metatarsals are off the book, and have them take note if their foot feels more pronated or supinated at the STJ. Third, position their right foot so that now their 3rd, 4th and 5th metatarsals are all positioned off the book, and have them take note if their foot feels more pronated or supinated at the STJ. Next, repeat the same with the 1st, 2nd and 3rd metatarsals hanging off the book with the lateral forefoot only being supported by the book.

Now, after you all make your observations, see if they can explain the observations using STJ neutral theory or using sagittal plane facilitation theory. They won't be able to because these theories do not offer an explanation for this experiment. If they understand STJ axis location/rotational equilibrium (SALRE) theory, then they will be able to easily explain the results of the experiment.

This little experiment, which can easily be performed on patients, students or podiatric colleagues, is another application of SALRE theory that I have never written about but I have lectured on many times over the past decade to the podiatric surgical residents that I train on how partial forefoot amputations will affect STJ moments. I use this demonstration to clinically demonstrate to the surgical residents how having this knowledge regarding the removal of GRF plantar to selected metatarsals by partial forefoot amputation will affect STJ moments and can be used to predict the new STJ rotational position that will be assumed by a patient's foot after the surgery is performed.

I just thought that this little experiment may stimulate more interest with your team in the practical application of Newtonian mechanics (using the idea of STJ moments and rotational equilibrium) so that they can better understand and appreciate the biomechanics of the foot and lower extremity.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************