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Which begs the question: if we sell a patient a custom foot orthosis when the clinical evidence suggests that equally efficacious outcomes could be obtained using a much cheaper prefabricated device, are we not guilty of obtaing money by deception, unless the patient is given a fully informed choice?

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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."

Would this still work in open chain i.e., in the absence of GRF? Or would the orthosis just rotate with the foot without GRf beneath it?

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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."

I think it depends on the patient education and experience, too. Probably, for the first time, it will be preferred the practitioner who use a pressure map instead of goniometer or a foot scanner instead of plaster...
I believe that a possible answer is : "the one who can solve my problems " !

Daniel

What an interesting discussion.

I answered yes prior to reading as I interpreted the "orthopaedic" question a tad differently.

I don't bisect the calc as I know my reliability is shocking and I'm not sure what use it is though I was taught it long ago.

I take measures of things that I am trying to change to that I know whether I have or not. Primarily the 2 I do the most are the lunge test and popliteal angle, I use a digital inclinometer for both and I know my reliability is good. The other thing I put numbers on is manual muscle testing, while I know my personal reliability is good, the next person that grades strength will probably grade differently so if I was in a setting where it mattered a great deal I would use a dynamometer. There is something very cool about seeing a change in range or strength after a stretching/strengthening program. I do also if needed do the hip range.

As for the others, as I primarily work with children I predominantly use prefab's so measurement for prescription is something I don't have to think about a lot.

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Cheers,
Cylie.... in a permanent state of confusion

Hi just came across this thread

Eric you wrote
Now that's a good idea that I don't use at present, cheers for that.

As far as measuring goes, I like to measure and record those measurements for future reference. For example I might see several people for assessment but I don't write their prescription straight away, often I like to review data, (perhaps 2D video and pressure mat plus clinical notes and biometrics) and ponder the biomechanical variations and decide on the prescription I will make.

If measured biometrics have a wide variation in repeatability and reliability then I would suspect that some visual estimate of the same parameter would have a much greater variation. If you say that you use other measures other than direct measurement, like palpation of supination resistance, well I can do that too but how variable is the estimation intra clinician from patient to patient and day to day. These things will be extremely variable but they have not been researched and written about formally yet as some biometrics have.

I like and agree with Lawrence Bevans point about visual estimations of biomechanical / biometric variations and I like and agree with Kevin's reasons for taking measurements too.

Ian I can respect your methods and entirely believe that you get good results but I like the more formal method that to my mind has providence and provenance built in.

This is good for inter professional communication and these are things that customers will pay for, can respect and accept as proof of professionalism and I think as others have said, they are more willing to be compliant and see the value of the whole treatment plan.

Cheers Dave

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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.

Dave

Just a quick amendment to measuring the heel pad width. Its useful to do but measuring the heel width of the shoe the devices are going into ensures orthoses fitiing 1st time.
This method has reduced the amount of orthoses being returned for adjustment due to not fitting the shoe down to virtually zero.

Cheers

Phil

Simon:

Using measurements of an individual's joint range of motion and structural variability should not be considered to "deceiving the patient/insurance company" if the podiatrist is truly using that information to learn more about that patient's structure and function. In addition, whether we like it or not, "the psychology of the clinical encounter" is highly important when we all are treating patients and I would expect that every successful clinician knows how to relate to people so that they feel comfortable with them as physicians. This is not a matter of trying to deceive patients but rather a matter of trying to give patients more confidence in your treatment so that better therapeutic outcomes are more likely to occur. As I said earlier, we aren't treating machines, we are treating humans.

In addition, I wouldn't be so confident that taking measurements is never going to produce an association with gait kinematics and gait kinetics and that taking orthopedic measurements is useless or even "deceiving". About six months ago, I was a reader on a Master's thesis from the Biomechanics Lab at UC Davis which showed that there were quite a few biomechanical measurements that significantly correlated to biomechanical function. Maybe the right studies correlating structure to function just haven't been done yet.....I honestly think that this is the more close to the truth.

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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
**************************************************

Hi Dave,

I suppose when it comes down to it whatever we do the main thing is that we get results and outcomes that are favourable. I said from the start 'each to their own'

I too often like to ponder over data and consider things for longer sometimes so will end up writing a prescription days or even weeks following an assessment. I suppose what I have been doing is attaching detailed written descriptions to my patients records rather than numbers; so that when I read my notes back I can immediately visualise the foot based on how I have described it, the same as I guess you visualising a foot based on numerical measurements.

Since this discussion started I have taken a look at the way I practice and realised that despite not owning a tractograph, not drawing on patients, and not assigning numerical values to measurements that I technically still 'measure' things (thanks for opening my eyes Lawrence)

Ian

Good point. Often all it takes is increasing the angle on the bevel. I just haven't gone to the hardware store and remembered to by the other kind of calipers.

Cheers,
Eric

When a STJ pronates and the forefoot abducts on the rearfoot, and the talus becomes promenent medially, the medial to lateral distance of the foot will increase weight bearing and non weight bearing. If an orthosis has a medial and lateral clip that is less than the maximum medial to lateral distance then it is possible for the orthotic to resist "pronation" with transverse plane forces. The problem is that you would have to attach the device to foot and practically it will fall off unless it is attached to an AFO or something.

Practically, it is very difficult to apply significant forces in the transverse plane becuase the location at which the forces are applied usually become uncomfortable. It might take a few tries to find the optimal stiffness of orthotic material and casting position.

Regards,

Eric Fuller

This thread has become a fascinating discussion. I do "Root measurements" on my patients that are getting custom foot orthoses even though I know they may not always give me much valuable information which may change my orthosis prescription. However, I have never believed that these measurements that I perform and record in the patient's chart is just about making better orthoses for my patients.

I have always felt that my job as a foot doctor and biomechanics specialist was to be able to tell the patient as much as possible about their foot and lower extremity structure, mechanics and function, when compared to normal, so that they could feel as if their money and time was being spent very well in seeing me. In other words, my goal has been over the past 24 years of practice, to provide my patients with more information regarding the structure and function of their foot and lower extremity than they have received from any other health professional. I feel that the measurements that I do are simply a part of what allows me to provide this service for my patients.

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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
**************************************************

This is great Eric, thanks. Thats why you are where you are and I am where I am. Your discussion on the peroneal contracture is probably what was up with my patient and you have discussed this before - stupid me for forgetting. This is a good example of how trying to use but a handful of tests to pigeon hole patients ultimately leads to missing things.

In your example of large FF valgus and large RF varus I reckon you can get that info from the Root style examination but your way is more pragmatic.

L

Shhhhh Simon the patients and insurance companies will hear you!!
I think it is possible for an individual to train so that their own measurements are reasonably repeatable so it's not that reprehensible!

Also mental medicine is all part of the game, dog. You feelin me? Kevs being thorough and gaining the patients confidence, filling an appointment with waffle to bill more is different.


L

Lawrence,

But if the measurments are still a waiste of time, as we all know they are, because they do not predict dynamic function, you are selling the proverbial snake oil!

regards

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Graham:

Since the F-scan, or any in-shoe pressure analysis system for that matter, does not tell you anything about either joint kinematics or joint kinetics of the foot or lower extremity, as we all know, you are then selling the proverbial snake oil by performing such an exam on your patients!

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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
**************************************************

So. To recap.

Those who "take measurements" are selling snake oil cos they're not predictive of dynamic function.

Those who use F scan are selling snake oil because its not predictive of joint kinematics and kinetics.

Those who do neither must by inference be selling snake oil because if we assume the above two have no useful data from their measurements they have exactly the same level of useful data (ie none).

But I bet all three methods can produce useful orthotics based on the paradigm of your choice. I'd further bet that if Kevin, Ian, Graham, Lawrence and me all saw the same patient we'd come up with similar end products and get the patient better.

I would venture to suggest that what defines snake oil is not how a prescription is arrived at, rather the claims made of the product to treat the condition.

Its a big accusation to level at someone and should not be done so lightly IMO.

Regards
Robert

Sorry for my stupid question but simply, I don't understand ! Why do you perform "Root measurements" if sometimes, these don't help you with the prescription ? It is not enough only to tell to the patient about these measurements ? Generally speaking, how much time it takes to perform all necessary measurements ?
Thank you !
Daniel

Robert:

You are right.....I was just giving Graham some of his own snake oil medicine so he could see how it tasted.

Unless someone has much more knowledge about foot biomechanics or the available foot biomechanics research than I do and can prove me wrong, it seems very clear to me that there are currently many ways to properly evaluate the foot and lower extremity, both structurally and functionally, both with and without making measurements, to make proper foot orthoses for our patients. Until someone can show me that by my performing my measurements somehow prevents me from making therapeutic foot orthoses for my patients, then I will continue doing my measurements. Since I am regularly drawing patients from a 100 mile radius here in a densely populated area of northern California, and making 80 - 100 pairs of custom foot orthoses a month in my practice, then I probably am doing something right.

Once the research has been done that conclusively demonstrates that a single well-trained practitioner doing biomechanical measurements on a number of individuals can not ascertain certain structural characteristics of an individual's foot and lower extremity by performing these measurements, then I will start to pay attention to those who say that measurements are of no value or are "snake oil". However, contrary to the popular belief of many here on Podiatry Arena, that research has not been done yet.

Have a nice weekend....even you too, Graham.

__________________
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
**************************************************

Daniel:

Does every clinical test that your family physician does to test the proper function of your cranial nerves or your peripheral reflexes, or does every routine lab test that he does always test out positive for abnormality? When you answer that question, I will answer your first question.

As far as time required, about 10 minutes is required to perform a full biomechanical examination, including gait examination.

__________________
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,

Apples and Oranges.

F-SCAN assissts in identifying what you are doing with an orthoses when looking at the force/time parameters. It is not used as the only tool in the prescription of the orthoses. Physical assessment of health, ROMs, assymetries and gait are also required

Structural Measurments, which have been shown to be both relatvely inaccurate and a poor predictor of dymanic function have no place in a profeesional examination. Especially when you know they are not useful.

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Graham:

So glad to have your valued opinion on this matter about what I should and should not be doing for my patients. Instead of telling me and other podiatrists how we should practice, why don't you, more than once in your life, try publishing some of the valuable information that you think you possess about how you think all podiatrists should practice biomechanics since you seem to be quite judgemental about what we all do in our clinical practices? I won't hold my breath.

It is always amazing to me how those who live in glass houses are so fond of throwing stones.....

__________________
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,

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I'm not telling anyone what they should or should not be doing for their patients. However, there is ample research evidence on the lack or reproduceability of measurements between practitioners and beween our selves on diferent days.

Also evidence that indictes that certain structural measurments, that we thought were a predictor of dynamic function, and therefore influenced our prescriptions, are not and will not tell you with any confidence what an orthotic will achieve based on those measurments.

As a Podiatrist who I respect I am surprised you advocating the use of these measurments clinically when you have moved so far ahead theoretically.

And Kevin. We all are doing something right and have patients that travel long distances to see us. We all make foot orthoses Etc Etc Etc. This doesn't add much to the discussion!

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

What I really need is a job where someone pays you to sit and think.

There are many ways to gain information about the foot. When I had access to an EMED force platform there were times when I took the patient to the gait lab and had them walk over it. There was a time when I had the FScan and had a patient with a partial foot amputation that kept ulcerating. With the FSCAN printout I was able to modify the device so that ulceration healed. I did it faster with the FSCAN than I could have done it with patient coming back every week to see if it healed. So, there are times when its use is indicated.

I also do some of the tractograph measures but don't write them down. When I see an ankle joint that can dorsiflex to perpedicular I will add a heel lift. When I see a plantar flexed first metatarsal I will add a reverse morton's extension. If there is also a long 2nd metatarsal, and callus sub 2nd met I will change that reverse Morton's extension to a forefoot valgus wedge.

When you look at, and hold and manipulate the foot you are getting information about that foot. The hard part is putting what you see into a protocol that someone else could follow. Or even a protocol that you could repeat with the next patient or the same patient at a later time. If you are going to be scientific about it, you should be able to say when I see "A" I will do "B" It is much better to have your decision making process out in the open than to have it in your subconscious. That is you may have subconsciously learned that a particlular orthotic variable may work better when you see a plantarflexed first ray or a laterallized center of pressure path. The protocol needs to be written down so that variations in the protocol can be tested. Saying it's too complicated is no excuse.
Regards,
Eric

Seeing as it was brought up I thought I'd throw this is in.

As the owner of an F-SCAN it can be useful but its probably one of the least reliable, least repeatable things I can do with a patient. COM-nalysis software is in particular "interesting" but often absolutely all over the place. If anything is a piece of patient assessment "theatre" IMHO F-SCAN is it.

A lot of the time I find it far more reliable and valid to decide visually if a patient has a plantarflexed 1st ray or a forefoot valgus and prescribe a valgus wedge, standing eversion height permitting (Eric ). Took me £KK to learn that
IMHO if anyone was thinking of putting the in-shoe presure at the heart of a consensus on foot orthotic precsribing protocol e.g.COP progression, then I would hold it in doubt.

Is my failure down to old theory:new lenses dyspraxia? No doubt.

The only measurements I take are those measurements in which I actually do something meaningful with the number.... ie not very often.

__________________
Craig Payne
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Follow me on Twitter | Run Junkie
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

I wonder what many of us would think of a neurologist who did a electromyogram/nerve conduction study (EMG/NCS), but only tested the nerve that he thought were involved in causing the patient's symptoms, but wouldn't test the other nerves that are normally tested in a EMG/NCS since he thought it would be "wasted information" or didn't want to test the other nerves since he was worried that another neurologist would say he/she was doing "snake oil" since doing those tests could possibly be within normal limits or may have nothing to do with them getting better.

I also wonder what many of us would think of a rheumatologist whose standard of practice was to do a full panel of blood and serological studies to try and diagnose a patient's joint pain. What if, in this physician's attempt to be thorough and trying to rule out problems that could be causing the joint pain, all of these expensive tests came back as being "within normal limits". Would we say that he/she was doing "snake oil" even though each and every one of these many expensive tests may be normal and we thought that he/she "couldn't do anything useful with the number".

I pride myself in being something more than just an "orthotic technician" for my patients when they present with unknown causes of mechanically-related foot and lower extremity pathologies. My goal is not just to be a technician that will do the absolute minimum amount of tests or measurements that will produce a workable orthosis for the patient.

I pride myself in being a podiatric physician. I choose to do all these tests and measurements not just so that I can possibly use or not use the information, as I see fit, to make the patient more therapeutic orthoses, but also to rule out restrictions in subtalar joint range of motion (e.g. asymmetrical tarsal coalition), rule out torsional abnormalities (e.g. internal hip or malleolar position), rule out ankle joint dorsiflexion restriction (e.g. equinus deformity/ankle joint dorsiflexion stiffness), determine first ray position (e.g. metatarsus primus elevatus deformity), determine amount of hallux dorsiflexion with and without first metatarsal loading (e.g. functional hallux limitus), rule out abnormal frontal plane forefoot positions (e.g. excessive inverted or everted forefoot deformities), rule out abnormal STJ spatial location (e.g. medially deviated STJ axis), determine STJ rotational position while in RCSP (e.g. STJ maximally pronated or not), and rule out abnormal gait function.

In my quarter century of doing these measurements, I have never, even once, had a patient complain that I performed too thorough of an examination on them, or complained that I performed more measurements than than the other podiatrists they had seen for foot orthoses. Take note.....this is the case even though many of my measurements simply told me that their foot and lower extremities were "within normal limits".

If that means that I am practicing more like my medical colleagues, the neurologist and the rheumatologist, that routinely do tests and measurements that they know will probably be "within normal limits" in their desire to get to the bottom of their patient's diagnosis, then that doesn't bother me in the slightest. Also, if in doing all these measurements, even though many of them turn out to be normal and have absolutely no bearing on how I design foot orthoses for them, I am distancing myself from many of my podiatric colleagues, then I have absolutely no problem with that either. I'm not here to impress or be friends with anyone, I'm here to teach other podiatrists what I have learned from my professors and from my years of practice experience, and also to learn something in return. I will sleep very comfortably every night in doing the things I do for my patients, even though it may take a little extra time out of my day and it may not be the "popular" thing to do within the international podiatric biomechanics community.

__________________
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've been hidden under wraps by Uncle Sam for most of my professional life so Kev's post just seems common sense to me. But now that I have an additional clinic on the outside and am getting to know the medical community better, I'm finding many more Physicians and Therapists do not take measurements and rather rely on their visual memory and recall days later to write scripts or build devices. Outrageous! I can't believe the result of the poll so far. What are you referring to when you review your notes? Don't your patient's ask you HOW you derive at your conclusions? Aren't your notes audited? Don't insurance companies request your notes to justify rationales and conclusions?
Which would you trust more, your eyes or a goniometer? (or don't ya'll have one at your desk?) Which one do you think has greater intrarater reliability? Do you care?
Look, if you want to be the best, be able to prove it through documentation. Even if it's only for your own piece of mind. I charge a crap-load for my thorough evals and wild orthotics but you know what? My patients respect me because I show them everything and bring them along for the ride. Then on delivery day, they understand the science and fully believe in my product and direction. Compliance is high, success rate is high, and I just rebuilt my 3rd vintage Harley:Fingerwag:

(Admin: can we get a finger-wag emoticon pls?)

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Horsepower is how fast you hit the wall, Torque is how far you move it

Hi Lawrence

Mmm, I'm coming to a similar conclusion, since doing somewhat of a literature review recently. I have used it a little - just on family and friends at this stage.

I feel that COP is really of no use. There may be something useful in the force/time curves but its interesting that although these are mentioned often by Tekscan FScan proponents, they are not used at all in any research - there is not any quantitative information gained from them, even from instructions from Tekscan. And there is next to no helpful information about peak pressures and what they mean for biomechanical anomalies. Leg length inequality is often mentioned as being able to be diagnosed with FScan, but it doesn't give you definitive info on which leg is shorter (see Bruce Williams knee case study from Tekscan), just like you cat rely on which foot pronates / supinates more. The other biomechanical anomaly that is supposedly able to be diagnosed with in-shoe pressure analysis is functional hallux limitus - but you should see the list of findings that are meant to depict FnHL. The Tekscan case studies confuse more than inform.

From what I have read about CoM, it is a measure of overall gait efficiency that doesn't have the inaccuracies that CO2 output and pulse rate have. I think this must be a great measure but pelvic, hip and knee function figure heavily in this measure, not just foot function.

So although on the face of it FScan can give very useful information because we are measuring in a dynamic situation and in the shoe, Inshoe pressure parameters have not been proven to be reliable or valid either. As only vertical pressures are measured, using FScan to evaluate orthosis successs is a bit dubious. This would be less of an issue just in the shoe (no device). But I'm yet to decide if or how to use FScan in-shoe in my practice.

Rebecca

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Do your patients ask you? More pertinently, how do the measurements you take dictate your prescription?

On occassion. But rationales/conclusions can be justified without quantitative measurements in my opinion.

Well done on all your success. I'd be interested to know some of the 'science' that your patients understand. As it was my belief the whole point of discussions like this one, (and also one of my favourite ever threads on the arena: see here) is that most of us don't entirely understand the science. When you measure a RCSP of 6 degrees everted in standing are you telling them a rearfoot varus post of 6 degrees will return them to 'normal'???

Ian