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This thread has been rattling around in my hindbrain for a while. Two things have pulled the trigger to make it solid.
One was that I have the misfortune to be reviewing a paper recently published by our own dear Brian Rothbart. The usual dangerous mix of what looks like science but is actually a thinly veiled infomercial, and before and after pictures. It includes the claim that if the forefoot is not plantargrade in neutral static stance, this must be due to talar torsion and as such requires treatment.
Garbalosa, from memory, found an average forefoot inversion angle of 8 degrees. So that would be everyone then.
Foot typing systems often raise this question as well. One does not generally see a "healthy" foot type in the selection. It is presumed that an insole is required and the question is only, which type.
Finally, we have the good old "overpronation" correction. Often based on nothing more sophisticated than a static RSCP. I'm indebted to Simon for posting this study
Which shows a Mean RSCP of 7 degrees everted in a healthy population. So thats insoles for everyone there then.
So here is the question. Are such models as suggest that everyone / most people require orthoses for "correction" (as opposed to pathology) anything more than cynical attempts to cash in on people's credulity to make a few quid? Or are they actually based in anything approximating to science.
I note in passing that the three models I described are highly diverse and unified only in that they teach that pretty much everyone needs insoles.
Be careful of your interpretation of the statistics, Robert. Just because the population mean is above a clinical threshold, it does not infer that everyone within the population is above that threshold. Understand?
Be careful of your interpretation of the statistics, Robert. Just because the population mean is above a clinical threshold, it does not infer that everyone within the population is above that threshold. Understand?
Crystal.
I'll have to dig it out but from memory the number was 81% had FFvarus of 5 degrees or more. So not all. But most. My bad.
This thread has been rattling around in my hindbrain for a while. Two things have pulled the trigger to make it solid.
One was that I have the misfortune to be reviewing a paper recently published by our own dear Brian Rothbart. The usual dangerous mix of what looks like science but is actually a thinly veiled infomercial, and before and after pictures. It includes the claim that if the forefoot is not plantargrade in neutral static stance, this must be due to talar torsion and as such requires treatment.
Garbalosa, from memory, found an average forefoot inversion angle of 8 degrees. So that would be everyone then.
Foot typing systems often raise this question as well. One does not generally see a "healthy" foot type in the selection. It is presumed that an insole is required and the question is only, which type.
Finally, we have the good old "overpronation" correction. Often based on nothing more sophisticated than a static RSCP. I'm indebted to Simon for posting this study
Which shows a Mean RSCP of 7 degrees everted in a healthy population. So thats insoles for everyone there then.
So here is the question. Are such models as suggest that everyone / most people require orthoses for "correction" (as opposed to pathology) anything more than cynical attempts to cash in on people's credulity to make a few quid? Or are they actually based in anything approximating to science.
I note in passing that the three models I described are highly diverse and unified only in that they teach that pretty much everyone needs insoles.
The concept of everyone needing insoles (ie mechanical interference) is not biologically plausible; it would have done the whole Root model a load of good to go back to proper biology (and please do not forget, medicine is simply a branch of applied biology) before it produced some of its more ludicrous suggestions. I remember reading, but now forget where, that all of us needed orthotics.... Evidence first please, gentle persons. Rob
__________________
I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps
Raises interesting questions though. I work (largely) on the basis of symptomatology. So an individual with a RCSP of 7 degrees inverted is symptomatic. All other things being equal, should an individual with no symptoms who displays the same presentation not be treated on the basis that it is demonstrable that they might display the symptoms as time goes on?
Raises interesting questions though. I work (largely) on the basis of symptomatology. So an individual with a RCSP of 7 degrees inverted is symptomatic. All other things being equal, should an individual with no symptoms who displays the same presentation not be treated on the basis that it is demonstrable that they might display the symptoms as time goes on?
All the best
Bill
P = G + E + (G x E)
P= phenotype (or pathology in this example)
G= genotype
E= environment
Raises interesting questions though. I work (largely) on the basis of symptomatology. So an individual with a RCSP of 7 degrees inverted is symptomatic. All other things being equal, should an individual with no symptoms who displays the same presentation not be treated on the basis that it is demonstrable that they might display the symptoms as time goes on?
Only if the rscp is the only element in the equation. And all other things will never be equal. Even if every other biometric element is the same, the environment will not be. The person with the symptoms could have picked up an injury entirely independently of the biometric presentation. Through trauma by example. In which case the fact that they have an RSCP of 7 degrees inverted or everted might be no more relevant than their hair colour.
To boil the question down, we are talking about 80% or so of the population, by inference of data contained in a few studies, having the rearfoot (RF) or forefoot (FF) inverted relative to the supporting surface. The magnitude of inversion is probably important, the actual quantification (is it 7 degrees or 8 degrees) less so, because diurnal variation means that joint movement, which affects compensatory changes which may or may not be responsible for producing symptoms, will be different depending on the time of day.
The supporting surface is the key. When it is hard and flat, as it is for most of us for most of the time in the West, the inversion (and corresponding compensation) becomes obvious. When the ground is undulating and soft in places the inversion and compensatory changes become less obvious.
We were never designed to stand or ambulate on hard, flat surfaces, and it is nonsense to suggest or even suppose that we have evolved for doing so. Therefore the proposition that we all have RF or FF inverted relative to a hard flat surface would seem to me to be perfectly reasonable. Indeed a foot which is slightly inverted is in an ideal position to come up onto the forefoot for rapid propulsion as and when needed - think being in the wild either chasing or being chased.
I offer this question for interest and as something to consider. Please note that I'm not suggesting it as proof of anything.
Has anyone on the forum ever seen Roots criteria of normalcy anywhere but in an anatomical model of the foot?
Do we all need orthotics? No.
However, most of us will find some kind of support (usually a shoe with a small heel suffices) more comfortable than bare feet when standing or walking on hard flat surfaces for any length of time.
As ageing, overuse (and sport), and/or degenerative disease cut in and produce symptomology of one sort or another some of us may find orthoses helpful.
__________________
Old guys rule!
Last edited by davidh : 26th July 2011 at 01:48 AM.
Reason: clarification
P= phenotype (or pathology in this example)
G= genotype
E= environment
=No.
RI quote
Only if the rscp is the only element in the equation. And all other things will never be equal. Even if every other biometric element is the same, the environment will not be. The person with the symptoms could have picked up an injury entirely independently of the biometric presentation. Through trauma by example. In which case the fact that they have an RSCP of 7 degrees inverted or everted might be no more relevant than their hair colour.
Has anyone on the forum ever seen Roots criteria of normalcy anywhere but in an anatomical model of the foot?
DH quote
Do we all need orthotics? No.
However, most of us will find some kind of support (usually a shoe with a small heel suffices) more comfortable than bare feet when standing or walking on hard flat surfaces for any length of time.
As ageing, overuse (and sport), and/or degenerative disease cut in and produce symptomology of one sort or another some of us may find orthoses helpful.
Precisely - so treat according to presenting complaint (exceptions proving rules).
Raises interesting questions though. I work (largely) on the basis of symptomatology. So an individual with a RCSP of 7 degrees inverted is symptomatic. All other things being equal, should an individual with no symptoms who displays the same presentation not be treated on the basis that it is demonstrable that they might display the symptoms as time goes on?
All the best
Bill
If you could show that your measurement was reliable and if people with that measurement could be shown to be to be reasonably certain to develop a pathology prevented by orthotics and treatment with orthotics did not cause worse problems, then you could treat the mesurement. Think high blood pressure as a model. No symptoms, but predictive of pathology.
This doesn't get past the first "if" If you measurment to treat needs to be accurate within 2 degrees (heel is more than everted 5-7 degrees) and the measuremnt error is +/- 5 degrees then you can't accurately determine the rest of the conditions for treatment.
Now, if we could put a number to STJ axis deviation, we might be able to predict certain types of pathology.
I work in a Hospital where the majority of my patients do not pay for their treatment. I am also expected to provide the highest level of care and the material costs are really not an issue.
We also see quite a few athletes who do not have specific symptoms- ie I see them as part of an overall screening.
When I am considering foot orthoses for these individuals I of course look at a range of biomechanical factors... (although FF to RF relationship would not be one if it was a quick screening).
One thing which I think is important is a history. Often patients will have warning signs that they are at risk of an overuse injury- they may have had shin soreness in the past, or complain of low grade MLA pain when fatigued.
You also have to get an idea of loading levels and their aims. What may not be significant to a sedentary person can become very significant to an athlete. I have had athletes that have been running 120km a week, but get injured if they do more- a biomechanical intervention then allowed them to push to 160km a week.
So... if I see concerns in my assessment- medially deviated STJ axis, increased 1st MTPJ stiffness, end ROM pronated, increased supination resistance etc... and they have a history of problems which may be related... I would look at orthoses for them despite them being essentially asymptomatic.
Compliance is another matter.
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Eric makes a good point here. What are needed are predicitve models such that we can assign risk.
We developed A method of quantifying transverse plane stj axial position about a decade ago for an undergrad project.
Quote:
Originally Posted by efuller
If you could show that your measurement was reliable and if people with that measurement could be shown to be to be reasonably certain to develop a pathology prevented by orthotics and treatment with orthotics did not cause worse problems, then you could treat the mesurement. Think high blood pressure as a model. No symptoms, but predictive of pathology.
This doesn't get past the first "if" If you measurment to treat needs to be accurate within 2 degrees (heel is more than everted 5-7 degrees) and the measuremnt error is +/- 5 degrees then you can't accurately determine the rest of the conditions for treatment.
Now, if we could put a number to STJ axis deviation, we might be able to predict certain types of pathology.
We palpated the axis then used an instrument we built which was basically a sheet of clearPerspex folded at a right angle to form a heel seat. The main face under the plantar foot had a fine grid printed on it which enabled us to set up a x, y coordinate system. We recorded where the projection intersected the x and y axes and used trig to work out angular deviation. You could probable use a flat bed scanner and a basic piece of software to do it these days.
Yep. We did reliability trials intratester was fair ICC 0.78; inter poor ICC 0.66
What would be important is ranking of most medially deviated to least across testers. If that could be established as reliable then the absolute number would not be as important once and individual tester had established average values.
Actually, what I find quite interesting is that, despite being a foot typing system, it partially follows a tissue stress model in that a neutral foot is every bit as capable of being pathological and symptomatic than a "severe pes planovalgus" type. This is probably where the correlation ends, however.
__________________
I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps
Simon's simple but effective equation - P = G + E + (G x E) is really only a re-statement of Waddington's famous work from the 50's, in which he proposed an epigenetic landscape, essentially suggesting that we are a product of both our genetics and are environment. HOWEVER - he went further. More than implicit in his work is the principle of genetic assimilation - that is the crossing of Weisman's barrier and genetic assimilation. Put another way, diploid to haploid transition. If correct, and I undersstand that though a mechanism is not as yet forthcoming, it is accepted as a very basis of evoution, this has profound implications for pathology. Come back H P Du Gillet (sp?) and the atavistic theory of Hallus Valgus - all is forgiven!
I am astounded at the concept suggested that everybody needs orthotics when there are in fact very few if any conditions that have been scientifically proven to be cured by orthotics in well conducted prospective randomised controlled trials and definitely no evidence that orthotics will prevent any pathological states in a general population, especially an asymptomatic one. Arguments about sub talar angles, hind and mid foot supination/ pronation are ridiculous without massive population studies to determine normal values at all ages and in all races and sexes. We do not even have standardised terminology let alone standard measurement techniques. Are we comparing apples to pears ? We don't know whether these values change from day to day or with activity or age. In the real worls we must identify pathology and treat it, not devise so called treatment modalities for conditions that don't exist or are just part of the normal population variance.
We treat patients not goniometer measurements. To suggest that the vast majority of pathology is due to a particular biomechanical variant is naive and narrow minded. We must provide evidence from well conducted research to prove our teatments are both necessary and effective rather than suggesting our interventions are going to enhance an otherwise asymptomatic patient population.
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There has been a trend toward sarcasm on the arena of late, and you might look at the suggestions that everyone needs orthotics in that light.
Quote:
Originally Posted by docbourke
I am astounded at the concept suggested that everybody needs orthotics when there are in fact very few if any conditions that have been scientifically proven to be cured by orthotics in well conducted prospective randomised controlled trials and definitely no evidence that orthotics will prevent any pathological states in a general population, especially an asymptomatic one. Arguments about sub talar angles, hind and mid foot supination/ pronation are ridiculous without massive population studies to determine normal values at all ages and in all races and sexes.
I wouldn't call discussion of subtalar angles ridiculous. There is a quite plausible explanation of how variation of the projection of the STJ axis into the transverse plane may be relevant to the prediction of pathology. See my paper on Center of Pressure and its theoretical applications to the prediction of pathology.
Fuller, E.A. Center of pressure and its theoretical relationship to foot pathology.
J Am Podiatr Med Assoc. 1999 Jun;89(6):278-91.
There are studies that show that there is variation in the population and there would be no need to do further studies also including race and sex as this is a mechanical effect that would not be affected by those variables.
True, there are no published studies on reliability of the measurement, but this is an excellent area for further research.
Doc, how would you prefer to be addressed? Welcome to the arena.
True, there are no published studies on reliability of the measurement, but this is an excellent area for further research.
Doc, how would you prefer to be addressed? Welcome to the arena.
Eric
We should have got that study published- my bad. It was on the agenda and never got around to it. Don't even know where the student who carried it out is now. Kate Claydon- where art thou? Still have a copy of the dissertation.
We should have got that study published- my bad. It was on the agenda and never got around to it. Don't even know where the student who carried it out is now. Kate Claydon- where art thou? Still have a copy of the dissertation.
Yeah, Doc, what are you a Doc of?
from profile.
Quote:
Age:
45
Biography:
Orthopaedic Foot and Ankle Surgeon
Location:
Melbourne, Australia
Does Everyone need Insoles?
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