Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Glasses, Braces, orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Smilingtoes, Nov 26, 2012.

Tags:
  1. Smilingtoes

    Smilingtoes Active Member


    Members do not see these Ads. Sign Up.
    It was only ten years ago single segment biomechanical foot models overlooked necessary foot compensations as insignificant. Modern multi segment motion analysis has exposed the flaws of these past determinations with the plantarflexing power of the midfoot shown to be important during propulsion and repeatedly underestimated by as much as 53% (Bruening, Cooney et al. 2012) and ensemble averages of participant trials underestimating midfoot power by between 35% (Bruening, Cooney et al. 2012) and 39% (MacWilliams, Cowley et al. 2003).

    I am confounded by our professions lust for diminishing the value of prescription foot orthotic treatments in the literature. I understand the research is inconclusive and especially limited in the case of longitudinal studies. I am also aware many studies focusing on, prescription orthosis effect, test a single prescription on multiple participants (hardly custom treatment).

    If our children had trouble reading and we took them to an optometrist, how would we feel if we were advised to purchase the inexpensive glasses at the petrol station without out the option of prescription glasses or if we took our children to the dentist with concerns for their teeth development and told not to worry they’ll grow out of it and told expensive braces are unnecessary and simple heat moulded mouth guards (sold at the chemist) should resolve the symptoms of headaches from grinding teeth etc.

    I simply pose the question: do we know enough, not to offer prescriptive treatments’, for 33 joints, 28 bones, 16 muscles and over 100 ligaments; that we plan to stand on with limited rest for the rest of our lives?

    References
    Bruening, D. A., K. M. Cooney, et al. (2012). "Analysis of a kinetic multi-segment foot model part II: Kinetics and clinical implications." Gait and Posture 35(4): 535-540.
    MacWilliams, B. A., M. Cowley, et al. (2003). "Foot kinematics and kinetics during adolescent gait." Gait and Posture 17(3): 214-224.
     
  2. Lab Guy

    Lab Guy Well-Known Member

    [QUOTE
    I simply pose the question: do we know enough, not to offer prescriptive treatments’, for 33 joints, 28 bones, 16 muscles and over 100 ligaments; that we plan to stand on with limited rest for the rest of our lives?

    And how many in the profession know how to examine, cast and prescribe the proper Rx variables for their patients?

    Perhaps if the profession had the skill set and passion of the Podiatry Arena gurus, prescription orthotics would be well worth the extra charge as the short and long term results would be much improved.

    Steven
     
  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Smiling toes,

    I share your frustration.

    My neighbour is an optometrist. When I discuss the broad divisions that exist between academic and clinical podiatrists about the efficacy of prescription foot orthoses he finds it quite amusing. There is no such debate in the optometric profession.

    Down the road lives another acquaintance, an orthodontist. He is a registered 'specialist' dentist. All he does every day of the week is prescribe and fit braces for improving the functional and cosmetic appearance of teeth. My brief discussions with him reveal no hint of disquiet in the dental profession about his services and approach to care.

    At the hospital I visit, an orthotist runs the most extraordinarily busy clinic servicing the referrals from orthopaedic surgeons for custom foot orthoses and footwear modifications. He laughs at any mention of dispute over the relative merits of customised approaches to foot deformities and chronic pain conditions. When reconstructive surgery or amputation is the next option on this list, there is no debate over trying the most effective non-surgical approaches available.

    But these are just all anecdotes. They mean nothing in the purist world of EBM.

    In podiatry (?more so outside of the US), we are stuck in this muddle of studies being produced by a cohort of reserachers proving the value of prefabricated generic devices for 'heel pain' or whatever, and next to no investigations for the swathe of other conditions I see every day that require custom devices.

    How/why would I put a generic 'antipronation' device into the shoe of someone with Charcot-Marie-Tooth. How can I utilise a prefabricated device to manage someone with a transmetatarsal amputation and subsequent transfer lesion under a lesser MT head?

    Its one thing to fit a prefab for plantar fasciitis in a normal-ish foot. No argument from me. Its just the 20 other patients seen in the day with slightly more complicated problems where this approach falls over and the research is absent.

    The profession needs to offer grants to researchers to focus on these issues, and prioritise funding for the areas that support the activities of everyday practitioners - before the health funds withdraw due to their own assessment of the current literature.

    Rant over,

    LL
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    While not disagreeing with the above, you need to be careful with analogies in argument as they are false arguments. Here is an early draft of an essay I working on for another place:

    Argument by Analogy Fallacy
    It very common to find a lot of analogies used to support a particular approach or cause. Everyone is probably familiar with it. We come across them every day and we probably use them every day as reasoning by analogy is a common way to inform decision making and make sense of the world around us. Analogies are a very useful communications tool and very useful to illustrate concepts.

    An analogy uses the line of reasoning that two or more things may be similar in some respects and then concludes that they are probably also therefore going to be similar in some further respect. However, the use of analogy as an argument for support of something is a fallacy and fails. This approach can be very misleading and have an insidious power to make people believe things that in reality has no basis in fact. Arguments by analogy are widely shown to not be deductively valid.

    For example on the issue about if foot orthotics are long term or short term interventions, some use the analogy that they are like eyeglasses and correct a problem that is permanent, so like eyeglasses, foot orthoses are a permanent or long term interventions. Another, perhaps more outlandish example, is the analogy that animals do not need running shoes to run fast, therefore humans don’t either.

    Arguments by analogy like these examples are fallacies. As Skeptico notes:
    The flaw is simple: the analogy always breaks down somewhere. If the analogy breaks down, the conclusion the arguer is trying to draw from the analogy just doesn’t follow. That’s all there is to it. Argument by analogy is rarely as good as an argument by logic, evidence or facts. Clearly if the arguer had any logic, evidence or facts to support his case he would present them. That he resorts to argument by analogy shows his argument is probably devoid of logic, evidence or facts.
     
  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Very important point Craig, and I agree entirely.

    Unfortunately, most of us humble clinicians have little else to use to support our case but anecdote and analogy.

    The EBM juggernaut has relegated experience and opinion to the bowels of hell, and left coal face clinicians with little else to discuss, where evidence is inconclusive or absent.

    Round and round the merry-go-round...yawn.

    Better go and do my design work for my Stage 2 PTTD patient with severe medial STJ axis deviation from 15mins ago. I just cant understand why the physio's prefabs didnt help her chronic tenosynovitis...

    LL
     
  6. CraigT

    CraigT Well-Known Member

    Let me guess... and the pre-fabs gave them blisters?

    I think part of the problem we have is that it is very easy to get positive outcomes with just about any foot orthosis for a fair proportion of the people who walk in the door. The best outcome might be a whole lot more difficult... but this is also more difficult to quantify!

    I think it is important to move forward with research to try to put the pieces of the puzzle together- clinicians being involved with this is important as clinical experience can be a valuable contributor to the pool of knowledge
     
  7. drsha

    drsha Banned

    Steven:
    The arrogance and bias of your statement that self proclaimed and verified "Podiatry Arena gurus" have "skill sets" and "passion" that make your orthotics "well worth the extra charge" reflects the pathology that is accomplishing just the opposite.

    Calls for the research you cannot provide and another year (its almost December) with no new research of any clinical value to back up your skills and passion leave you limping IMHO. You are EBMers with no EBM, no more, no less, no better, just like me and other passionate biomechanical gurus.

    Worst is the time and energy you put into deriding free thought when it comes to biomechanics from passionate gurus and practitioners who do not appreciate or blindly follow your skill sets or passion.

    To me, subtalar joint axis biomechanics is weak and has poor clinical applicability in my clinical biomechanical scheme. it is a red herring clinically in many cases.


    When was the last time you actually measured a subtalar joint axis in practice or are you just guessing?
    When was the last time you admitted to yourself that the primary reason that many of your patients have a secondarily medially deviated subtalar joint axis is flexibile pathology that they inherited in the forefoot as you prescribe your medial skives and treat the frontal plane of the rearfoot as your first prescribing act?

    Dennis
     
  8. efuller

    efuller MVP

    Actually the difference between the part of tissues stress that is STJ Axis Location Rotational Equilibrium (SALRE) and functional foot typing is that there is a logical explanation of how SALRE works. (If there is high pronation moment from the ground and the injury that you see is theoretically related to high pronation moment then you reduce the pronation moment from the ground.) On the other hand there is no logical explanation why a classification system based on supination end of range of motion should be related to anything. So, Dennis you may be as passionate, but until you provide a plausible explanation of why SERM should be important for anything you will not be on equal footing with SALRE and tissue stress.


    Dennis, perhaps your feeling of poor clinical applicability comes from the fact that you erroneously think that SALRE is purely frontal plane and rearfoot based. SALRE is three dimensional and applies to the whole foot.


    Tissue stress looks at the foot as it is, not as how some theorist thinks it ought to be. Looking at whether the STJ axis is primarily or secondarily medially deviated is irrelevant. Yes, you may see someone with PTTD who has developed more forefoot abduction on the rearfoot which will make the STJ axis appear more medially deviated. An orthosis that increases supination moment from the ground will help this person regardless of whether the axis position us primary or secondary. Short of an arthroresis, surgical fusions, or an Evans calcaneal osteotomy, how are you going to treat the forefoot collapse (abduction) that you claim is the problem? An orthotic is not going to fix that forefoot abduction.

    Eric
     
Loading...

Share This Page