Originally Posted by drsha

{Admin note: This article has been copied from the thread on measuring lld)

The Inclined Posture, The Neoteric Biomechanical Key to Diagnosing Frontal Plane Lower Extremity Imbalance

Dennis Shavelson, D.P.M.

Abstract

One of the tenets of Neoteric Biomechanics is that the two limbs need to be balanced to each other. The Inclined Posture is a new and fresh paradigm for diagnosing and treating frontal plane imbalances of the lower extremity commonly that have been called “Limb Length Discrepancy until now.

The paradigm may be new and fresh but is the concept? Is new and fresh supposed to be a metaphor for modified and improved? How does TIP differ from LLD?

Deviations in Lower Extremity symmetry on the frontal plane are common, and require compensation by the body to function efficiently. With time, repetitive compensations for asymmetry are pathologic and produce predictable signs and symptoms. When differences in the length, strength and/or structure of a person’s limbs lead to pathologic compensation, the clinical entity is defined as The Inclined PostureTM. A subject has The Inclined Posture until proven otherwise when the clinical signs and symptoms are apparent.

This paper presents a simple test for diagnosing The Inclined PostureTM (TIP) as well as additional tests and signs that confirm the diagnosis. Treatment options for TIP at the foot/shoe interface are presented, which reduce the need for internal compensation. By controlling TIP we can decompensate its pathological compensations and prevent it from impacting performance and quality of life as we age.

How do you define simple?
When it comes to evaluating hip and lower limb posture and gait compensation Dr Stanley Beekman is my personal guru. I think after many many years of education, research and clinical work in this area he may not agree that this is a simple subject.
Dennis - How have you made this simple and effective?

Introduction

Neoteric Biomechanics is a new and fresh paradigm for practicing Functional Lower Extremity Biomechanics 1. The tenets of Neoteric Biomechanics include the need to balance one lower extremity to the other when weightbearing. Until now, no organized or efficient manner in which to diagnose and treat what is currently called Limb Length Discrepancy (LLD) has surfaced.

Is this true? or is it that you have just invented a convenient new paradigm defined by conventions that are not valid in the current model of postural assessment. Therefore of course they cannot describe TIP as defined by your new paradigm.


The Inclined Posture does not involve itself in the debate over structural vs. functional origin.

1) Refer to my last question

2) So by your own admission you totally ignoring current wisdom and research. You can therefore circumvent any critisism of your new TIP paradigm.
This, as I have mentioned before in correspondence to other posts by you Dennis, is a trick, a tautological argument that is only valid within it's own system of definitions.

Is this good science?

It simply determines if a subject has made pathological compensations due to the influence of a short leg in closed chain and presents a quick method of compensating imbalance by the use of lifts and platforms at the shoe/foot interphase. It does not prevent skilled practitioners from balancing for TIP internally by lengthening the bones or stretching tight ligaments, capsules and musculotendonous units over time to cure TIP internally

So are you saying this is a system for the educationally challenged or the downright lazy then? And would you say therefore that it is secondary and inferior to a more conventional and in depth assessment and intervention program?

The Definition and Relevance of TIP

Human function requires shifts in the center of gravity from one side of the body to the other. Thus, a symmetrical body has the most efficient gait2. Deviations on all three body planes are compensated internally by the body in order to remain centered and balanced3. These compensations tax the system progressively, reduce performance and efficiency and eventually causing degenerative signs and symptoms. Deviations on the frontal plane compensate by making predictable compensatory adjustments in the posture as the body leans to one side. The resultant clinical entity with its signs and symptoms is defined as The Inclined PostureTM or TIP for short.

The literature points to the fact that humans are not symmetrical3,4. When measured, a person’s two feet are not the same length and width and the muscle mass of almost any region on the left side, is different than that of the right. This paper focuses on the fact that the majority of our population exhibits some amount of variation when it comes to the lengths of our limbs, while functioning and The Inclined Posture deserves early recognition and treatment due to the fact that our population is living longer lives and extending its quality of life.

Noah was 600 years old when the floods came Genesis 7:6

The Leaning Tower of Pisa has no internal compensatory mechanism and so its structure has continued to lean more and more over the centuries. Biomechanically, the human race has built in mechanisms such as the ability to shift the spine and hips, tilt the pelvic and shoulder girdles and pronate or supinate the feet in order to maintain our center of balance and erect posture in reaction to postural deviation on the frontal plane (figure 1) 5. Unfortunately, since our ability to compensate internally is limited, leaning forces that make us lopsided often become excessive and if left untreated, symptomatic. This leads to pathology in predictable locations within the postural chain6.

Clinically, unless the difference in limbs is greater than 1.5 centimeters (the true definition of a limb length discrepancy or LLD), it is difficult to determine its origin and impossible to accurately measure its existence. This means that The Inclined PostureTM is a clinical entity diagnosed by confirming the existence of specific compensatory signs and symptoms that develop in affected subjects as they try to maintain center of gravity and balanced posture over a lifetime.

The Inclined PostureTM compensates at specific locations of the postural chain when performing specific activities. For example, when standing still, the pelvis tilts downward to the short side and when walking, the short side supinates at the subtalar joint as the long side pronates2.

While I think this can be true with some subjects in others, many others, it does not. I think you'll find there is lots of research in opposition to your statement above but as your argument disallows the validity of evidence outside your paradigm it cannot impact upon your conclusions.

Do you see a pattern here Dr Sha?

It is important to note that if closed chain asymmetry is present in subjects without taxing the posture, the signs and symptoms of TIP do not develop and by definition The Inclined Posture does not exist.

So, if I understand you correctly, you are saying that TIP only exists if there are signs and symptoms of it.

Sign - what the clinician experiences or notices about the patient
Symptom - What the patient experiences or notices of themselves.

What else is there?

So if closed chain symmetry is present and noticed by the clinician is this not a sign?

Is this a philosophical proposition? like if a tree falls in a wood and there is nobody there to hear it does it make a noise.

or perhaps more like the schrodingers cat proposition

http://www.maths.lse.ac.uk/Personal/...York/lect5.pdf

1Introducing the measurement problem — Schr¨odinger’s cat
We introduce the measurement problem by considering ‘Schr¨odinger’s cat’. In this thought experiment,a live cat is put in a box with a radioactive source that has a 50-50 chance of emitting a radioactive particle. If it does emit such a particle, then a phial of poison is broken and the catperishes. If it doesn’t, the cat lives. The situation is set up so that we cannot observe the state of the cat — i.e. whether it is alive or dead — unless we open the box. Thus, we don’t know whether the cat is alive or dead until the box is opened.
If this situation is thought of in a classical manner, we want to say that, at all times, the cat is
either dead or alive depending on whether the radioactive source emitted a particle or not. In this case, we open the box merely so that we can come to know what has passed since the box was closed — i.e. the probabilities are epistemic. Further, if we observe that the cat is dead, it has been dead since the time when the poison was released.
However, Schr¨odinger was concerned with what would happen if we treated this situation in a quantum manner. Prior to the opening of the box, the cat is supposedly in a superposition of states. One state corresponds to the cat being alive and the other to the cat being dead. Since the probability of the radioactive source emitting a particle is 50-50, the probability of finding the cat alive or dead on opening the box is 50-50.1 Now, prior to opening the box and hence making the observation, since the cat is in a superposition of the alive or dead states, we can’t really say what the state of the cat is. That is, since it is in a superposition of the alive and dead states, it is neither alive nor dead and it can’t be both alive and dead (since that would be contradictory). Also, it is certainly not ‘half dead’ nor ‘half alive’ — whatever we are to take these terms to mean. However, on opening the box— i.e. on making an observation — the superposition supposedly collapses onto one of the two states
it contains. That is, it collapses into the alive state and we find a cat that is alive or it collapses into the dead state and we find a cat which is dead. Indeed, by a similar argument, we can’t say that the radioactive source emitted a particle, or that it didn’t, until we open the box. That is, prior to the box being opened, the source is also in a superposition of states, namely the states where it has and hasn’t emitted a particle.
Now, the measurement problem runs as follows: Nothing appears to happen until we open the box. That is, prior to opening the box, the source has neither emitted a particle nor has it notemitted a particle, and consequently, the cat is neither dead nor alive. But, on opening the box, the superposition of these states collapses and either the source has not emitted a particle and the cat is
alive or the source has emitted a particle and the cat is dead. Thus, according to this everything must happen instantaneously at the moment of observation even though the source had a 50-50 chance of emitting a particle and killing the cat at any time during the cat’s captivity in the box. Isn’t this absurd?

Yes! isn't it Dennis?

2On the other hand, when the signs and symptoms of the inclined posture are present in subjects they reflect the existence of pathology in the postural chain and therefore, by definition, TIP exists. The effects of The Inclined Posture are progressive and degenerative and since it affects a majority of people, TIP plays an important role as a component of many overuse syndromes, postural degenerations, deformities, and performance issues.

When it comes to limb length, the literature continues to debate two issues; how to measure limb length accurately and what amount of asymmetry needs diagnosis and treatment5,7,8. These questions remain unanswered. We believe this debate diverts us from appreciating the clinical impact when one limb is functioning longer than its mate, even if the difference is seemingly immeasurable. Simply put, if there is asymmetry in a pair of limbs is creating pedal and postural sequelae, it deserves diagnosis and treatment.

Again you choose to disregard any evidential contrary positions and continue to use your system of belief and passion in its stead. I.E. We believe and so it is! I believe therefore I am.
Incredible really don't you think Dennis, almost God like?.

Until now, The Inclined Posture has not been considered as an entity even though there has been active debate about the importance of diagnosing and treating limb asymmetry4,5,7,8. Studies have shown that limb length discrepancies of less than 25 mm are not observed during routine musculoskeletal examinations5. Discrepancies of this level go unnoticed by the patient as well5. Since almost everyone has TIP and less than 4% of the population has a diagnosed Leg length Discrepancy (LLD) actively being treated9, the importance of the inclined posture and its need to be treated is being underestimated.

In principle I agree with this statement Dennis, except for your belief that where you imagine an entity it therefore exists. Do you recognise a certain amount of narcissism in your reasoning?

In an evolutionary sense, ambulating on uneven surfaces and performing tasks that require uneven function (i.e. going up a flight of stairs) has forced the human posture to adapt to unequal stresses. This adaptation comes in the form of biomechanical and muscular compensation.

Are mountains, Valleys, planes and meadows all smooth and even?
Haven't all land animals developed the ability to negotiate rough terrain. Surely the environment developed by humans is far more symmetrical than nature. Have you walked around a shopping mall or a super market recently?

This appears to be another Shavelsonism - I imagine so it is. Dennis, Do you consider this as a reasonable way to construct a new and fresh system of biomechanics?

When standing still, a person with The Inclined Posture (TIP) leans towards the short side on the frontal plane in order to maintain an erect posture.

What do you mean - "leans toward the short side"? Surely, as a generalisation, the torso tends lean to the long side, however this is not always so and some lean to the short side. What if the compensations, that you describe as supination and pronation of the STJ's, occur and result in no visible leaning at all.

B Dennis you said

So what if in this case compensation result in no visible assymetry and no pathology has yet developed?

When active (i.e. walking or running), this same person functions more long sided, developing a “super” side. An example of this type of biomechanical compensation is the “super” arm, shoulder, and torso that a tennis player develops on the functionally dominant racket side.

So are you saying these people by definition won't develop a super side?


Surely a tennis player develops a super arm because he uses it to play tennis or is this encompassed in the TIP paradigm as an assymetrical compensation?

Is this contrary to Wolf and Davis?

Wolff's law is a theory developed by the German Anatomist/Surgeon Julius Wolff (1836-1902) in the 19th century that states that bone in a healthy person or animal will adapt to the loads it is placed under. If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading.The external cortical portion of the bone becomes thicker as a result. The converse is true as well: if the loading on a bone decreases, the bone will become weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for continued remodeling that is required to maintain bone mass.[1]

Associated laws

In relation to soft tissue, Davis's Law explains how soft tissue remolds itself according to imposed demands.
[edit]Examples

Tennis players often use one arm more than the other
The racquet-holding arm bones of tennis players become much stronger than those of the other arm. Their bodies have strengthened the bones in their racquet-holding arm since it is routinely placed under higher than normal stresses.

Surfers who knee-paddle frequently will develop bone bumps, aka exostoses, on the tibial eminence and the dorsal part of the navicular tarsal bone from the pressure of the surfboard's surface. These are often called "surf knots."

Astronauts who spend a long time in space will often return to Earth with weaker bones, since gravity hasn't been exerting a load on their bones. Their bodies have reabsorbed much of the mineral that was previously in their bones.

Weightlifters often display increases in bone density in response to their training.

Martial artists who punch or kick objects with increasing intensity (or of increasing hardness) to develop striking power to damage opponents, often display increases in bone density in the striking area.

BTW Dennis, have you noticed if your right wrist bigger than your left or are you left handed.

To make things even more complicated,

Is this going to get complicated because I thought the principle tenet of TIP was simplicity?

there are concomitant factors that influence how much TIP affects subjects. This means that The Inclined Posture alone does not determine the amount of biomechanical compensation needed or the amount of compensatory pathology that is produced. Some of the concomitants affecting The Inclined Posture are excess weight, underlying biomechanical pathology, activity level, compensatory equipment (i.e. shoes, orthotics), reduced health state, and environmental factors such as inclines in the road. Concomitant influence must be considered because the need for treating TIP increases as the number and magnitude of these factors increases.

How does one modify the TIP intervention to cater for all these constantly variable variations?


Daily activities, such as washing dishes, waiting on line, or walking about will have a cumulative adverse effect upon the posture when performed lopsided. Add to this the negative effects that a lifetime of play, sport and exercise have when performed lopsided, and you can begin to sense the value of diagnosing and treating TIP.

I agree that it is important to diagnose and treat pathological asymmetry but I'm still not sure what TIP is exactly. Please could you be more specific in your definition of TIP?

Perhaps the concomitant factor influence upon TIP can be better understood if we examine an example. When we talk about TIP being impacted by activity level, we know that when a person walks, maximum heel strike is one times the body weight

Wrong!! As a standard reference the force at heel stike or initial stance is 120% bodyweight. This is certainly not true of pathological gait which can vary enormously from this reference point.


but when running, heel strike is three times the body weight. This means that functionally, a 5mm TIP difference in our limbs in stance converts to a 15mm TIP when running.

Dennis, I must warn you that your poetic licence was once owned by Spike Milligan and it has not been renewed since 1983. Please note that although new licences may be issued they will not have as much leeway as post millennium documents due to the lack of humour experienced with the present Neo biomechnical situation

At this point I feel it is only fair, right and proper to insert a WTF in response to the last paragraph above of Dennis's paper

This means that additional treatment may be necessary at specific times of exertion. In our example, a small amount of additional heel lift on the short side when the subject is running eliminates the need for internal compensation.

Dennis you are surpassing yourself now. Are you trying to say that a person who requires a 5mm heel lift while walking then requires a 15mm heel lift when running? Are you also saying whatevere the aetiology stick a huge heel lift in a runners shoe and they will get better (without any internal compensation What does that mean???)



Look Simon and Robert I'm sorry, But I was trying to be nice with him and make rational comments without insults but this rubbish is just to insulting to any self respecting clinician of any discipline, so if you've still got that peeler and salt-----.


Until now, practitioners have focused on the chief complaints that result from a posture influenced by The Inclined Posture and treat the unilateral bunion, the long sided knee arthritis, the low back pain and sciatica, as well as the generalized postural aches and fatigue without diagnosing and treating the root problem. Treatment protocols for the inclined posture will prevent many predictable neurological, orthopedic and postural problems from appearing and will assist in the treatment of those that exist.

I like many many other always look for the root problem where possible. We don't do your simple technique of sticking a heel lift in whatever. This is the summation of the TIP system is it? If it leans over prop it up! if it's any more than that Dennis please I am keen to find out but currently I am cutting my tongue out with a rusty and MRSA infected hook scalpel just to relieve the frustration.

Diagnosing TIP: The FEJA Test

G.R.O.A.N.!! Not another acronym

The author has developed an accurate, reproducible test for the diagnosis of TIP called the Functional Equinovarus of the Joints of the Ankle or FEJA Test.

The test is based upon the fact that functionally, if TIP exists,

Quite IF TIP EXISTS!!

the long side is compensating to shorten and the short side is compensating to lengthen. Eventually there are soft tissue and adaptive osseous changes, in specific locations, that can be used diagnostically.

G.R.O.A.N!!

In the functional lower extremity biomechanics (FLEB) literature, Mann and Inman call the ankle joint and the subtalar joint “the joints of the ankle” and located them as the primary compensators of the lower extremities10. These two joints, as a unit, become the first line of compensation and the first areas where fixed changes occur in reaction to the inclined posture. When comparing a pair of limbs, The Inclined Posture exists if there is a relative Equinus deformity between Ankle Joints and a relative Varus deformity between Subtalar Joints, until proven otherwise.

Proof! Proof! Why bother with such niceties at this late stage Dennis we are in a metaphysical wonderland now where ahything Deniss imagines is truth absolute.


This diagnostic test for The Inclined Posture is called The Functional Equinovarus of the Joints of the Ankle or FEJA Test for short.

But not for long let hope

The Inclined PostureTM compensates in the sagital plane of the long side ankle joint by dorsiflexing in order to shorten its limb. On the other hand, the short side ankle joint compensates by plantarflexing in order to lengthen its limb. This balances the incline on the sagital plane seen in TIP. In time, soft tissue contractures create a relative difference in dorsi/plantar flexion of both ankles with the short side being plantarflexed (in relative equinus). The Functional Equinus portion of The FEJA Test is performed by forcibly dorsiflexing the ankle joint of both limbs and noting any difference when measured (Figure 2). If the inclined posture and its concomitant factors are enough to cause internal compensation, the side with a relative plantarflexion (equinus) in relation to its mate is the short side until proven otherwise.

The Inclined Posture compensates in the frontal plane of the long side subtalar joint by pronating (inverting) in order to shorten its limb. On the other hand, the short side subtalar joint compensates by supinating (everting) in order to lengthen its limb. In time, soft tissue contractures create a relative difference in inversion/eversion of both subtalar joints with the short side being inverted (in relative varus). The Functional Varus portion of The FEJA Test is performed by forcibly inverting the subtalar joint of both feet and noting any difference when measured (Figure 3). If the inclined posture and its concomitant factors are enough to cause internal compensation, the side with a relative varus position in relation to its mate is the short side until proven otherwise.

Dennis some of these test sound very familiar but you have yet to define exactly what TIP is and what Inclined posture is and what leaning means relative to the body posture. What happens when the long leg has the equinus ankle? or is this another Shavelsonism ie the equinus side is always the short side?? ?

In summary, a positive FEJA test exists when one limb (the short side until proven otherwise) has both a relative plantarflexion (reduced dorsiflexion) when comparing the ankle joints and a relative varus (increased inversion) when comparing the subtalar joints.
The REJA test would be reported as a positive test for the short side of The Inclined Posture (i.e. FEJA +, Left). Since the amount of Equinus and Varus are relative, exact measurements are not necessary for a positive FEJA Test.

And what happens when the patient has an equinus ankle that results in a TIP with a positive FEJA but because you leave mobilisations to more skilled practitioners you stick a heel lift in that side??
If you do not measure how do you recognise improvement on revision and how can you be sure that you visual analysis is reasonably accurate in terms of comparison?

The Confirmatory Signs and Tests for TIP

1. Weighing Scales
Observe the patient marching in angle and base of gait for 10 seconds and then ask the patient to freeze. The separation of the feet and the angle which they sit determine the angle and base of gait. Trace the patient’s footprints, and in those footprints, put two weigh scales. Then ask the patient to step on the scales. Since TIP causes a person to shift weight to the short side in stance, if the scales do not read the same, the greater of the two readings will be on the short side.

I would say this is fairly true as a generalisation if they do not stand with the heel of the short or equinus side raised.

1. Gait Pattern Confirmatories

TIP shows predictable changes in gait that reflect the asymmetry in the feet and posture. There is a longer stride length on the long side with a longer foot plant. There is a relative external rotation of the hip and limb on the short side with a greater arm swing when comparing the short side to the long side. There is a relative flatter arch (pronation) when comparing the long side to the short (or a relative higher arcj on the short side (supination).


2. A Unilateral Postural Complaint, or a bilateral complaint that develops from a one sided complaint. i.e. unilateral Bunion, heel spur, plantar fascitis, ankle, knee and hip arthritis and pain syndromes. Unilateral nerve problems such as sciatica

The increased work accepted by the longer side with every active step and movement, in subjects with TIP, places greater stress upon the joints, muscles, tendons, and ligaments of the long side. Overuse syndromes and progressive degenerative syndromes attack overstressed locations in the posture with the most force and early. This results in additional compensation in these locations in the posture with early pathology and symptoms.

For example, when examining the feet of subjects with TIP, the long sided foot performs more work than the short sided foot in supporting and moving the posture. This increased demand exposes any biomechanical weaknesses to overuse and degeneration. Since the long side foot is pronated, more force is applied to that medial column. If other deforming forces such as a hypermobile first ray have predisposed this subject to develop bilateral bunions, a more pronounced Bunion (hallux abducto valgus) deformity develops on the long side. Similarly, the increased pronatory forces of the long side cause additional collapse of the medial arch and compensatory pull of the plantar fascia on the long side. Thus, plantar fasciitis and heel spur syndrome develop on the long side first.

3. Unequal Shoe Wear Pattern
With the increased inversion noted at the subtalar joint of the short side, bony adaptation in addition to contactures of the associated musculature, capsular, tendon and ligament soft tissue structures fix the subtalar joint in more varus than its mate. During the heel contact phase of the gait cycle the short sided heel is contacting the ground more supinated and this leads to additional lateral wear of the shoe.
The additional weight and time that the long side spends in active function in subjects with TIP leads to increased total shoe wear on the long side.

4. Excess Lateral Column Callus on the short side
The increased weight on the lateral column as a result of the varus loading on the short sided heel, in gait, results in the existence of a unilateral or a more extensive 5th metatarsal callus on the short side. In Flexible FootTypes, this can also lead to increased callus under the 2nd metatarsal.

5. Low Back Pain or one side dominated sciatica, A Pelvic Tilt in angle and base of gait, to the short side and/ or A Shoulder Girdle Tilt in angle and base of gait, to the long side
In TIP, at the level of the pelvis, one limb is functionally (or structurally) longer than its mate. This fact causes a downward tilt in the pelvic girdle from the vertical lopsided towards the short side (figure 1.) This can be measured or “eyeballed” by placing markers on both anterior superior iliac spines (ASIS’s) and noting the presence of the incline (i.e. The Leaning Tower of Pisa). This incline of the pelvic girdle with the short side lower causes L-5/S-1 and L-4/L-5 degeneration and low back pain and radiculopathy. In order to maintain the center of gravity and erect posture, the lumbar vertebrae shift towards the long side and form a concavity. This compresses the lumbar nerves on the long side and leads to compression and eventual sciatica on the long side. The curvature in the spine tapers and becomes less exaggerated as it extends all the way to the shoulder girdle. At the shoulder girdle, the compensatory need to keep the center of gravity causes a tilt with the long side lower.

6. The Long Sided Foot is Larger, longer and/or wider and reveals an Increase in Pronation when compared to the short side in angle and base of gait.
The long sided foot accepts a dominant role in stance and in function and performs more work than its mate. Over a lifetime, this is reflected with greater muscle mass, bone density, supportive tissue as well as a widening of the longer foot. This translates into the fact that the long sided foot, in TIP, is larger than its mate both in length and girth.

As stated previously, the long sided subtalar joint compensates by pronation in order to functionally shorten the limb. This additional pronation places more of the limbs weight on the medial column and drives additional stress into the midtarsal joint. In patients with a flexible forefoot, this force will unlock the midtarsal joint and create a hypermobility in the forefoot that will cause it to stretch and spread. Over time the long sided foot will become larger and wider.

7. Larger Mass on the Long Sided Limb (i.e. calf, thigh)
Since, functionally, the long side dominants in subjects with TIP, the compensatory increase in muscle mass, bone density and connective tissue strength leads to the long sided limb developing larger than its mate.

Measure the diameter of both calves 5 cms below the tibial tubercle to record calf girth. Measure the diameter of both thighs 5 cms above the proximal patella to record thigh girth. The side with the higher measurements is the long side until proven otherwise.

8. Walking Down Stairs
Observe the subject walking down a flight of stairs. Due to the compensatory abduction of the short sided hip, the angle of gait will appear windswept to the short side if TIP is present. If it is no t present the angle of gait will appear relatively straight.

The Diagnosis of The Inclined Posture

The Inclined Posture exists in a subject when there is a positive fEJA Test and the existence of two or more of the confirmatory tests and signs, until proven otherwise.

TABLE 1 See Table 1 In Appendix

Concomitant Factors affecting TIP Syndrome
1. Excess Weight
A subject’s weight determines how heavy a body the posture must support and carry. The amount of compensation necessary for a body to overcome biomechanical pathology, including TIP, increases proportionally to its weight. Therefore the more overweight a subject is, the more exaggerated the signs and symptoms of TIP will be.

2. Environmental Factors
Uneven terrain causes the need for more compensatory reaction in order to maintain the center of gravity and balance. Increased incline and tilt in surfaces, the hardness of the surface, and even the friction coefficient of the surface play a part in determining how much compensatory energy is needed in order to function on that terrain. Compare the effort needed to run the same distance on a flat straight surface in hot weather to running that same distance up a hill, tilted to the left, in cold weather, when the ground is hard. This comparison can show you the impact of the environment on function and on The Inclined Posture.

3. Equipment Factors
Scientists, designers and manufacturers have developed equipment that can compensate for biomechanical pathology, including TIP. These products reduce the impact of TIP by absorbing shock or controlling motion. Running Shoes, foot orthotics and therapeutic socks are just some of the products available.

Both the quality of the products and the level of wear must be considered as well as the specificity of matching the compensatory need with a products ability to decompensate specific problems.

Dennis much of your diagnoses come from the assumption that the long side compensates by pronation and the short by supination. This has been shown by research not to be so, or is it that in your paradigm pronation and supination defines the diagnosis of short and long and so indicates TIP. i.e. another tautological argument.
Have you not considered that other factors will influence the relative weight bearing foot posture I.E. STJ axial position, foot placement angle, knee angulation, muscle tone, neuropathy etc. etc.


4. Functional Foot Type Classification and Treatment

The feet of every human being can be placed into one of ten groups

Ten Groups? is it Ten, twelve or sixteen groups in the FFT. Some places you say 10 others 12 and yet others 16 which is it. In your table in one of you earlier posts you showed a 4x4 matrix with 16 foot types??


known as The Functional Foot Types (FFT) 11. FFT classification is based upon the open chain and closed chain positions of the joints in the rearfoot and forefoot of the foot when divided in two by the talocalcaneal and calcaneocuboid joints (the midtarsal joint). Rearfoot position is determined by noting the position of the subtalar joint at its end range of motion in open and closed chain. Fore foot position is determined by noting the end range of motion of the medial column of the foot with the rearfoot neutral and the lateral column at its end range of motion in both open and closed chain. In this manner, the rearfoot and forefoot can be classified as rigid, stable, flat or flexible. Each of the nine Functional FootTypes has its own predictable signs, symptoms, compensations, pathology and treatment. Once classified, every patient can have their foot type decompensated with FFT specific plaster casting techniques and a prescription that is incorporated into a foot orthotic.


5. Activity Level

The impact of TIP and its need for treatment increases in direct proportion to the activity level of the subject. The time of performance, the frequency of performance and the intensity of each activity must all be considered. The object of treatment is to maintain or increase activity level while reducing the impact of TIP.

How is this increased treatment achieved? what is increased treatment????

6. Reduced Health State and/or Fitness Level

When dealing with quality of life issues there are two distinct factors that determine ones ability to be active. They are health and fitness. It is just as possible to be fit and in poor health as it is to be healthy and unfit. The health state of a subject can deteriorate to the point that it will have a negative impact on compensatory reserves

What are compensatory reserves? does a person with less compensatory reserves and by your definition in poor health, compensate less than a fit person.

So does an unhealthy person with a short leg and TIP pronate less in the long leg than the healthy person? Wouldn't this mean that if you want to avoid all those complications of pronation, as a compensation for a long leg, that you describe earlier, then smoke a hundred fags a day until you get really unfit and unhealthy and by definition the amount of long leg pronation compensation will reduce and your foot will get much better??

and so if a subject has a poor health state it must be treated simultaneously and the treatment plan for the inclined posture must take health state into account. Simultaneously, fitness level must be determined and if weak it must be treated simultaneously and the treatment plan for the inclined posture must take functional condition into account.

What is a treatment plan for TIP? How does it change with regard to state of health?
Is it within the scope of practice of a DPM to advise on fitness and prescribe routines to improve it?
Can a DPM assess fitness levels of a client? in what terms are you defining health and fitness levels

Treatment for The Inclined Posture

1. TIP Paddings
Initially, The Inclined Posture can be compensated by placing a heel pad of one eighth to one quarter of an inch thick in the heel of the shoe on the side showing a positive FEJA Test. Materials can vary but adhesive felt is a readily available option. There should be an immediate improvement of most of the signs of TIP


There may be an immediate improvement in appearance but does this correlate with a reduction in pathology and will it always result in doing no additional harm?
Why is there a fixed prescription of 1/4 inch thickness does'nt it depend on the individual TIP presentation.

and the pad can be adhered to the shoe or moved from shoe to shoe daily.
Simultaneously, rearfoot, medial arch and forefoot pads can be adhered to a shoe to decompensate the subjects Functional FootType, if pathologic.

2. Custom Foot Orthotics
Custom Foot Orthotics used to treat The Inclined Posture are fabricated in pairs and have three basic components, a semi rigid thermoplastic shell created from an non weightbearing neutral or cast corrected plaster cast for each foot, asymmetric rearfoot posting and/or a heel lift on the limb having the positive FEJA test.
The semi rigid thermoplastic shell should be fabricated from an non weightbearing neutral or cast corrected plaster cast in order to capture the Functional Foot TypeTM of the subject and the anatomical differences in the two feet.
The assymetric rearfoot posts should be fabricated in shock absorbing crepe or a similar material and should reflect the neutral position of the subtalar joint of each foot since the short side (+FEJA) will have a neutral position that measures greater in varus than the long side. The thicker rearfoot posting on the short side will add lift to the short side as it compensates for the additional varus deformity on the frontal plane.
A heel lift fabricated in shock absorbing crepe or a similar material can be added to the rearfoot of the short side (+ FEJA) if the amount of TIP deformity needing compensation is greater than the asymmetric rearfoot posts can accomplish.
3. Sole Heel Lifts or a Sole Platform Raising The Short Side Shoe
If The Inclined Posture is excessive (i.e. A Limb Length Discrepancy) and cannot be compensated in the inside of a shoe than a heel lift tapered to the heads of the metatarsals or a platform lift of appropriate thickness can be added to the Outer Sole of the shoe on the short side.

Some of this is quite correct for some patients but as a treatment protocol for all postural asymmetry it sucks. Of course as a treatment for TIP it is excellent because that's how the tautology of your system works. Seriously Dennis can't you see the flaws and extreme limtations of this system. You have taken your own un-validated non researched beliefs and built a system around them that allow no validation by any other system that is reasoned and researched. Its rediculous, take a step back and re evaluate for your own sake.

Discussion

10,000 years ago, man became civilized and created paved roads, cities, shoes and playing fields to satisfy a desire to expand life and add to its quality. At the same time the medical and physical sciences committed to extend the human lifespan and make it more productive and comfortable.

The civilized forces of unyielding ground surfaces and hard shoe boxes, when added to the pull of gravity, create an unyielding negative force that challenges our bony and soft tissue structures with every step we take during our entire lives. Genetics and compensatory mechanisms that exist in all of us work to prevent these forces from reducing our performance and quality of life. To these, we have added external equipment to compensate negative forces before they impact our bodies and postures.

We ask you to imagine “The Inclined Road”. Imagine the cumulative negative forces that would occur in one lifetime, as we took millions of steps, if all of our roads were paved with even the slightest amount of incline to one side. Pelvic tilt, low back pain and scoliosis would develop. Compensatory heel, ankle, knee and hip asymmetry and degeneration as well as muscular and soft tissue compensations would reduce our performance and quality of life. We would be functioning on a lopsided surface. “The Inclined Road” doesn’t exist because as much as possible, our hard, unyielding roads and floors are level.

and yet earlier in the same paper you said
Anyway, regarding your postulation on walking along an inclined road, would it cause pathology? How do you know this (ah! That old stump of evidence again, which as we know you choose to diregard) As an example what about the Nepalese people who live most of their lives in mountainous terrain. Do you imagine that they have one short leg and only walk one way around a mountain. Like those famous cows of Fujiyama. Or do they all suffer similar pathology? does this pathology improve as their health deteriorates and their compensatory reserves reduce and they compensate less for the inclined surface they walk on??

Now we ask you to imagine “The Inclined Posture”. Imagine the cumulative negative forces that would occur in a lifetime, as we took millions of steps, if functionally, our limbs had even the slightest difference in length and were inclined to one side. Pelvic tilt, low back pain, scoliosis would develop. Compensatory heel, ankle, knee and hip asymmetry and degeneration as well as muscular and soft tissue compensations would reduce our performance and quality of life. We would be lopsided people. In reality, The Inclined Posture exists in a majority of the human race. Until now, there has not been any focus or energy placed in the direction of diagnosis and treatmentfor The Inclined Posture in order to make people level and remove this never ending deforming force from impacting our performance and quality of life.

Dennis we have imagined the asymmetrical posture and gait and we have been addressing it for many years quite successfully in many cases. Why do you insist that you are the only person ever to notice these things and have the " energy and focus " to deal with them properly. Do you not recognise this as extreme arrogance, face up to it man and loose you delusions of grandeur and self importance before it destroys you.

Stimulated by personal experience, the senior author has been studying and teaching about “The Inclined Posture” for more than two decades. This paper is meant to alert the medical and scientific communities of the importance of TIP and its diagnosis and treatment, as we expand our lifetimes and upgrade our quality of life.

Dennis I don't know what you've been reading or what planet you have been teaching on but hopefully no humans have been harmed by your lunatic aspirations.

Since examination, diagnosis and treatment for The Inclined Posture is easily accomplished without invasion or discomfort to the patient, we strongly advise that practitioners dealing with the posture as well as the orthopedic, podiatric and biomechanical arts and sciences, become familiar with and take the time to diagnose and treat The Inclined Posture.

Conclusion

This paper discusses leg length asymmetry, no matter how small and calls the compensatory result The Inclined PostureTM (TIP). Limb length discrepancies less than 25 mm are rarely discussed in the literature yet they are almost universal in functional subjects5.

Investigators should perform the FEJA test for TIP whenever performing a biomechanical evaluation but especially where deformity, degeneration and symptoms are unilateral or assymetrical.

TIP exists if there is a positive FEJA test accompanied by two positive confirmatory tests or signs. All cases of TIP deserve treatment. It is our opinion that semi rigid custom foot orthotics with asymmetric extrinsic rearfoot posting and heel lift modifications are the gold standard for treating TIP.

Dennis I often do this as I'm sure that many other podiatrists do, however your reasoning for doing this is less than optimal and in my opinion may even be injurious to many patients.

As our population ages, quality of life issues deserve more and more attention. If you had a table with one leg just a little short of its mates, you could let the table wobble and tilt as you ate on it or you could put a small amount of material under the short leg and eat your dinner in comfort. The diagnosis and treatment of TIP will extend us a more injury free, better performing improved quality of life with less postural breakdown over our lifetimes.

Originally Posted by drsha

Simon States:
You can sell bull**** to some of the people, some of the time; but you can't sell it here today.

Dennis States:
Perhaps you could do a double blind preliminary study utilizing two subjects that would determine the weight of anything Ph.D. that you say.
Dennis

Originally Posted by drsha

Dr. Smith:

Please send me one of your foam boxes so that you can make me a custom orthotic as promised on your website homepage.

dennis shavelson dpm
200 east 72nd street
NYC NY 10021

Originally Posted by Simon Spooner

I suspect you'll need to follow the instructions on Dave's website for this. Why do you think posting this here is the right approach? Simple question that requires simple answer, but you'll be incapable of answering this Dennis because... Anyway, I'd like you to make a pair of orthoses for me Dennis, so I can tell you how **** they are, because I'm completely unbiased.

Originally Posted by drsha

Dr. Smith:

Please send me one of your foam boxes so that you can make me a custom orthotic as promised on your website homepage.

dennis shavelson dpm
200 east 72nd street
NYC NY 10021

How dare you critique me as an authority of weight!!

Lots of email success and profits.
Dennis

Originally Posted by drsha

Simon quoting an article on foot typing that uses two types, pronated feet and normal feet (30 and 5 respectively) that claims that others are at least publishing is so unfair in that The Arena trusts him to suggest valid articles but he is charged with bias.

Originally Posted by drsha

I was just being forced by your rage and arrogance to put my shoe onto your foot for a moment.

Originally Posted by drsha

Simon:
If I published an article and stated one of my foot types as NORMAL
you would have DESTROYED IT!
C.mon
Fight fair.

My point is that the fact that you are getting a list from google and not previewing them shouldn't add power to your arguments.
and I bet your Arena followers think you know them inside and believe in their evidence or you wouldn't suggest them in the first place when that is not the fact.
Dennis

Originally Posted by Robertisaacs

To be entirely fair, we would have torn it to bits!

I think the difference here is that Simon is not claiming to have discovered the next x men style jump in the evolution of biomechanical theory. Dennis is. Claims like he has made, including that other peoples insoles cannot hold a candle to his, require that the supporting evidence be bloody amazing!

If anyone cares to cast their eyes back over the Arenas more... lively threads they will notice a common thread within these threads (what a veritable tapestry).

Those who make small claims and support them are admired. Those who make large claims and support them are greatly admired. Those who ask large questions (including about their own work) and approach the discussion with an open mind are applauded (because a good answer is only one post but a good QUESTION stimulates many good answers.).

Those who are toasted are those who approach with the view that they know best and then act as if everyone else should accept it.


To be honest, I find all of the ideas which wander in here, like baby rabbits hopping curiously into a foxes den, rather interesting. MASS, Proprioceptive insoles and FFT alike are all fascinating ideas which I'd love to examine. Its just so bloody hard to explore them or take them seriously when they are wrapped in so many layers of exaggerated claims and hyper-defensiveness.

Its a little like the frustration I feel regarding acupuncture. Enough around it that I find the idea interesting but so obviously not the panacea it is claimed to be. The fluff and fuzz which obscures such things make it hard to find what could be a precious nugget of truth within.

Perhaps a pearl of biomechanical wisdom is simply a small piece of crap which sneaks into an oyster (the arena) is coated in precious gleaming knowledge as the arena reacts to the irritant and strives to render it tolerable, and finally emerges as something beautiful and wonderful. To much crap, however, and the oyster simply spits the whole lot out.

Gosh I'm feeling whimsical this evening. Damn, I've spilt allegory all down me now!

Regards
Robert