Abnormal Ontogenetic Development of the Calcaneus resulting in the PreClinical Clubfoot Deformity

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The PreClinical Clubfoot deformity (PCD) is a fairly common congenital foot structure society. Below is a brief abstract of a paper published in Podiatry Today on this foot structure.

Ontogenetic Development of the calcaneus resulting in the PreClinical Clubfoot Deformity

‘The calcaneus does not complete its normal ontogenetic (torsional) development. When this foot is placed in its anatomical neutral position, the bottom surfact of the calcaneus is inverted relative to the longitudinal bisection of the tibia.

When weight is applied to this foot, at heel contact gravity forces the PCD foot to twist (abnormally pronate) in order to bring the entire bottom surface of the heel bone down to the ground.’

The Primus Metatarsus Supinatus (Rothbarts) Foot and the PreClinical Clubfoot Deformity: A Brief Introduction

 

A more complete description of the PreClinical Clubfoot deformity and the Primus Metatarsus Supinatus foot (abnormal genetic foot types) can be found in the following papers:

Discussion (with embryonic photos) of the ontogenetic development of the PreClinical Clubfoot Deformity and the Primus Metatarsus Supinatus (aka Rothbarts Foot)

• Rothbart BA, 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal of Bodywork and Movement Therapies (6)1:37-46

Differential diagnosis - PMS vs PCCd

• Rothbart BA 2010. The Primus Metatarsus Supinatus (Rothbarts) Foot and the PreClinical Clubfoot Deformity.Podiatry Review, Vol. 67(1)

Pressure plate study of the PMS vs PCCd

• Rothbart BA 2004. Pressure Plate Analysis of the Medial Column Foot Insole. A Statistical Study. Online Journal of Sports Medicine (Italian), November Issue.

• Rothbart BA 2005. Tactile therapy shifts patients towards equilibrium. Biomechanics. Vol XII, No 10:61-68.

Hopefully this information will open up a discussion on these two foot types and their impact on the practice of Podiatric Medicine.

 

The PreClinical Clubfoot Deformity can cause skeletal deformation in the cranium. A radiographic investigation linked gravity drive pronation (resulting from the PreClinical Clubfoot Deformity) to frontal plane distortions in the cranial bones.

• Rothbart BA 2013. Prescriptive Insoles and Dental Orthotics Change the Frontal Plane Position of the Atlas (C1), Mastoid, Malar, Temporal and Sphenoid Bones: A Preliminary Study. Journal of Cranio Manidibular and Sleep Practice, Vol 31(4):300-308.

 

A preliminary study links Gravity Drive Pronation (resulting from the PreClinical Clubfoot Deformity) to an increase Beta Wave (CNS) Activity.

"Beta waves are high-frequency, low-amplitude brain waves that are commonly observed in an awaken state. They are involved in conscious thought and logical thinking, and tend to have a stimulating effect. Having the right amount of beta waves allows us to focus." (https://ScienceDirect.com/topics/Medicine-and-Dentistry/beta-wave)

In my practice I have seen some PreClinical Clubfoot patients fitted with proprioceptive insoles relating a decrease in disturbing, hyperactive thoughts. These anecdotal subjective reports could be explained and understood from the results of this preliminary study. Also, it dovetails with the 2013 investigation that links Gravity Drive Pronation to alterations in the frontal plane alignment in the cranial bones.

This preliminary study on changes in B-Wave activity is not definitive and needs to be repeated with a larger N study (currently in the works).

Alteration in Plantar Pressure Gradients (Foot Function) Linked to Alterations in Brain Wave Activity

• DOI:
• 10.13140/RG.2.2.26657.43364

 

Following is the summation of my published research on the PreClinical Clubfoot Deformity:

• The PreClinical Clubfoot Deformity results in torsional mechanics and skewed proprioceptive signals
• Torsional mechanics places the weight bearing joints under increased stress and increases the propensity to overuse injuries
• Skewed proprioceptive signals results in a skewed global postural alignment, foot to jaw
• Skewed proprioceptive signals change the vertical facial dimensions and alters the frontal plane alignment of the cranial bones.
• Skewed proprioceptive signals alters brain wave activity!

The impact the PreClinical Clubfoot Deformity has on the total health of the body (both mechanically and physiologically) is profound.
This is where I believe the future of Podiatry will be directed towards - stabilizing the body mechanically and physiologically.

 

In 2016 I published a paper that presented a differential intervention diagnosis - PreClinical Clubfoot Deformity vs Primus Metatarsus Supinatus (aka Rothbarts Foot) using Pressure Plate Analysis. Below is a reprint of the paper's abstract:

Standing barefooted, surface area (X) and media pressure (Y) readings were recorded on 11 PreClinical Clubfoot Patients and 6 Rothbarts Foot subjects using the Podolab 2000 pressure plate analysis system. A second set of surface area and media pressure readings were then recorded after each subject used their proprioceptive insoles for 60 seconds. The collected data was statistically analyzed using ‘Best Fit’ Hypothesis. The results of the ‘Best Fit’ Hypothesis suggest that prescriptive proprioceptive insoles shift postural tonicity patterns towards homeostasis. From a clinical point of view, pressure plate readings may prove useful in prognosticating the appropriateness of specific prescriptive proprioceptive insoles when treating either PreClinical Clubfoot Deformity or Rothbarts Foot patients.
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Rothbart BA 2016. Pressure Plate Analysis of the PreClinical Clubfoot and Primus Metatarsus Supinatus Foot Deformities

• April 2016

DOI:10.13140/RG.2.1.3627.4320

 

Do your insoles provide arch support ?

 

The etiology of Adolescent Scoliosis has long been a discussion in the orthopedic literature. In 2013 I published a preliminary study that linked scoliotic thoracic curves to gravity drive pronation (resulting from the PreClinical Clubfoot Deformity). Below is the abstract taken from my paper:

"Scoliosis in patients between 10 and 18 years of age is termed adolescent scoliosis. The most common type of scoliosis in this age group is one in which the cause is unknown, and still referred to as Adolescent Idiopthic Scoliosis. I have long suspected a link between abnormal foot motion (gravity drive pronation) and the development of abnormal curves in the spinal cord.

A study I published in 2006 (JAPMA) statistically linked the unleveling of the pelvis, which forms the base of the spine, to abnormal foot pronation. It is only logical to suspect that if the base of the spine is unlevelled, it could also unlevel the entire spine. This was my motivation that led to this study.

It is to be noted that this is a preliminary study and certainly needs to be repeated using a larger sample size. However, the outcome of this study does suggest that the development of scoliosis may indeed be linked to abnormal foot motion."​

• Rothbart BA 2013. Preliminary Study: Adolescent Idiopathic Scoliosis Linked to Abnormal Foot Pronation. Podiatry Review Vol 72, No 2:8-11.

 

Simple question , do your proprioceptive insoles include medial arch support ?

 

From all that I have written above, one can appreciate that one must be diligent in the use of any type of orthotic placed underneath the feet. Orthotic intervention is a two sword blade - the potential for good is equal to the potential for harm.

Orthotics (or proprioceptive insoles) can:

• Increase or decrease scoliotic (and kyphotic) curves
• Increase or decrease weight bearing joint pain (foot to jaw)
• Increase or decrease dental malalignments
• Improve or exacerbate visceral dysfunctions
• Impact mentation (increase or decrease beta wave activity)!

Just to name a few.

When I was trained (Root biomechanics), we used orthotics (basically arch supports with or without heel posting) whenever we diagnosed abnormal (?) pronation. That protocol is now, or should be, discarded.

Before initiating any type of orthotic (or proprioceptive) intervention, one should (must) determine the cause of that unwanted pronation. The cause of that disruptive pronation is what requires attention and will determine what type of orthotic is used (if any).

If you disagree, let's hear it.

 

Do your proprioceptive insoles include medial arch support ? " let's hear it. "

 

To expand on the link between abnormal foot function (e.g., gravity drive pronation) and malocclusions, in 2014 I published a paper in Cranio UK on this link.

Since then, other research teams have reported similar findings. The one I find most illuminating is the 2018 cross-sectional research study conducted by Marchena-Rodriquez et al, that linked foot posture (pronated feet) to dental malocclusions in children between the ages of 6 to 9.

Hopefully, a more global approach will be taken by our Podiatrists, realizing the entire body is interconnected. The orthotic you put underneath your patient's feet can impact their dental occlusion!

• Rothbart BA 2014. Malocclusion and Abnormal Foot Motion. Cranio UK (Journal of the British Society for the Study of Craniomandibular Disorders), Issue No. 1, pp 26-29.
• Marchena-Rodriquez A 2018. Relationship between foot posture and dental malocclusions in children aged 6 to 9 years. Medicine, Issue 19:97, May.

 

Differential Diagnosis - Knee Bend Test

Primus Metatarsus Supinatus foot structure

• Weight over the calcaneus (knees straight) - STJ in neutral position
• Weight over the forefoot (knees bent) - STJ in gravity drive pronation

PreClinical Clubfoot Deformity

• Weight over the calcaneus - STJ in gravity drive pronation
• Weight 0ver the forefoot - STJ in gravity drive pronation

 

Gait Analysis - PreClinical Clubfoot Deformity, Left Foot
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Using Proprioceptive Insoles vs Not Using Proprioceptive Insoles:

• Note the attenuation of Gravity Drive Pronation at heel contact and midstance
• Note the decrease in whipping of left foot during toe off

These frames were extrapolated from the gait analysis video specifically for left foot analysis​

 

The PreClinical Clubfoot Deformity functions around Gravity Drive Pronation during stance phase of gait which results in a series of postural chain distortions, foot to jaw (Rothbart 2004, 2006, 2008, 2013):

• Innominates rotate anteriorly
• Temporal bones rotate posteriorly
• Sphenoid Bone flexes

• Rothbart BA 2004. Postural Distortions. The foot connection. Online Journal of Orthodontics, May 10; 6(1): 1-8

• Rothbart BA 2006. Relationship of Functional Leg-Length Discrepancy to Abnormal Pronation. Journal American Podiatric Medical Association;96(6):499-507

• Rothbart BA 2008. Vertical Facial Dimensions Linked to Abnormal Foot Motion. Journal American Podiatric Medical Association, 98(3):01-08, May.

• Rothbart BA 2013. Prescriptive Insoles and Dental Orthotics Change the Frontal Plane Position of the Atlas (C1), Mastoid, Malar, Temporal and Sphenoid Bones: A Preliminary Study. Journal of Cranio Manidibular and Sleep Practice, Vol 31(4):300-308.

 

Gait Example: PreClinical Clubfoot Deformity (PCFD) with concurrent Sphenoid Extension (sPext)

Example of Descending Pathomechanics reaching the foot

PCFD = Foot Pathomechanics

• Pronates (Gravity Drive) both feet, heel contact to heel lift

sPext = Foot Pathomechanics (Always unilateral)

• Supinates right foot, heel contact to heel lift

Frame 1 (Foot Flat)

• Left foot - Pronated (result of PCFD)
• Right foot - Supinated (sPext rotates the foot out of gravity drive pronation and into supination)

Frame 2 (Late Mid Stance)

• Left foot - Pronated (result of PCFD)
• Right foot - Pronated (sPext reduces the apparent severity of pronation)

• 

 

The animation below delineates the chain of cranial events initiated by temporal rotations (Rothbart 2008). Specifically, in the ascending distortional patterns, we are dealing with the results of a posterior temporal rotation (e.g., cranial flexion). This temporal bone rotation is bilateral, the more posterior displaced temporal bone being ipsilateral to the more pronated foot:

Posterior temporal rotation (using simplistic terminology):

• Rotates the sphenoid forward
• Which rotates the malar backwards
• Frequently resulting in a Class II Malocclusion

Knighton rated this research as one of the strongest published research papers linking stomatognathic system to global musculoskeletal changes.

• Rothbart BA 2008. Vertical Facial Dimensions Linked to Abnormal Foot Motion. Journal American Podiatric Medical Association, 98(3):01-08, May.

• Knighton K (2010) as the strongest published research paper (between 2000 - 2008) linking stomatognathic system to global musculoskeletal changes

​

 

PreClinical Clubfoot Deformity

• At flatfoot, the right foot is hyperpronated (red arrow)
  • the right foot motion is being driven by gravity drive
• At Late Mid-Stance, the right foot is pronated (red arrow)
  • the right foot motion is being driven by gravity drive (Rothbart 1988)
  • If the right foot was being driven by hip drive, the clockwise transverse plane rotation of the pelvis would rotate the right foot into supination

• Rothbart BA, Esterbrook L, 1988. Excessive Pronation: A Major Biomechanical Determinant in the Development of Chondromalacia and Pelvic Lists. Journal Manipulative Physiologic Therapeutics 11(5): 373-379

• Rothbart BA 2010. The Primus Metatarsus Supinatus (Rothbarts) Foot and the PreClinical Clubfoot Deformity.Podiatry Review, Vol. 67(1):

 

PreClinical Clubfoot Deformity - supinatus remaining in the calcaneus and talus



Note how the torsion (remaining supinatus) in the neck and head of the talus locks the entire medial column of the foot in supinatus

 

Embryology - The Key to Understanding the Inherited
Foot Structures that Result in Chronic Muscle and Joint Pain

​

Published in the Podiatry Forum: Anatomical Origin of Forefoot Varus Malalignment - 23rd September, 2012

Below I have delineated several key axioms that are presented in almost every embryological textbook:

• Axiom 1: In the developing limb, all torsional changes occur sequentially, centrally to distally (proximally to distally in the lower limb)
• Axiom 2: Supinatus is the term used to describe the inverted structural twist of the part relative to the midline of the body (or part of the body, e.g., midline of the foot)

The following two axioms are eluded to only. I have developed these concepts more fully in my clinical research (Rothbart BA 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal Bodywork and Movement Therapies)

• Axiom 3: When the calcaneus (heel bone) goes through its' ontogenetic torsional development, it takes the lateral embryological column with it (the cuboid, the intermediate and lateral cuneiforms, the lateral growth center of the navicular and 4 lateral metatarsals and adjoining phalanges)
• Axiom 4: When the talus (bone sitting on top of the calcaneus) goes through its' ontogenetic torsional development, it takes the medial embryological column with it (medial growth center of the navicular, internal cuneiform, first metatarsal and adjoining phalanx and hallux)

KEY EVENTS in Late Embryogenesis (approximately Week 6 - Week 8 Post Ovulation) - which can result in inherited abnormal foot structure - summarized:

I. The Clubfoot Deformity

• Around Carnegie Stage 21 (CS21), the plantar surfaces of the right foot is facing the plantar surface o the left foot. That is, both feet (heel to toe) are in supinatus.
• If the ontogenetic torsional development of the foot stops prematurely at this stage of development, the child is born with a Clubfoot Deformity (Bohm M 1929. The embryologic origin of clubfoot. Journal Bone and Joint Surgery (AM), 11:229.)

II. The PreClinical Clubfoot Deformity

Around CS22, the heel bone has partially unwound (and with it, the lateral embryological column of the foot). If the ontogenetic torsional development of the foot stops at this stage, the heel bone would still retain a slight valgus torsion, but the entire embryological medial column of the foot would be in supinatus.

What would this foot look like?

I suggest that when the PreClinical Clubfoot is placed into its anatomical standing (obviously post gestation) neutral position (e.g., Subtalar Joint Congruity - not Roots 1/3 - 2/3rds definition)

• The heel bone would still be in slight supinatus (but less so as it was in CS21)
• But the talar bone would had just started its' OTD. That is, the talar bone (and medial column of the foot) would, more or less, still be in full supinatusLooking at this foot structure, you would see the structurally inverted position of the heel bone and the elevated first metatarsal and hallux (assuming the foot is in its' anatomical neutral position).

III. The Primus Metatarsus Supinatus Foot Structure (AKA Rothbarts Foot)

If the foot's ontogenetic torsional development stops prematurely in Late CS22/EarlyCS23, the calcaneus would have completed its' OTD. But the talus would still retain some of its supinatus (and with it the medial column of the foot).

What would this foot look like?

• The posterior bisection of the heel bone would be perpendicular to the the transverse plane of the body (e.g., and with it the lateral 4 metatarsals and adjoining phalanges)
• The talar bone (and medial column of the foot) would still be in supinatus (structurally elevated and inverted) Looking at this foot structure, you would see the entire plantar surface of the heel bone lying on the ground, but the first metatarsal and hallux would be structurally elevated and inverted.

Measuring Rothbarts Foot

In the mid 1990s, I approached Dr Cummings and Higbie at Georgia State University. I suggested a study to see if Rothbarts foot could be reliably measured clinically. The results of there study can be accessed in the following publication: Cummings GS, Higbie EJ 1997. A weight bearing method for determining forefoot posting for orthotic fabrication. Physiotherapy Research International, Vol 2(1):42-50. [This study was funded by a grant from the College o Health Sciences at Georgia State University]

Any one of these three foot structures will eventually result in chronic muscle and joint pain throughout the body.

LUFLER'S Study

Anatomical Origin of Forefoot Varus Malalignment
Rebecca S. Lufler, T. M. Hoagland, Jingbo Niu, and K. Douglas Gross
J Am Podiatr Med Assoc 2012;102 390-395

Background: Forefoot varus malalignment is clinically defined as a nonweightbearing inversion of the metatarsal heads relative to a vertical bisection of the calcaneus in subtalar joint neutral. Although often targeted for treatment with foot orthoses, the etiology of forefoot varus malalignment has been debated and may involve an unalterable bony torsion of the talus.

Methods: Forty-nine feet from 25 cadavers underwent bilateral measurement of forefoot alignment using adapted clinical methods, followed by dissection and measurement of bony talar torsion. The relationship between forefoot alignment and talar torsion was determined using the Pearson correlation coefficient.

Results: Mean ± SD forefoot alignment was −0.9° ± 9.8° (valgus) and bony talar torsion was 32.8° ± 5.3° valgus. There was no association between forefoot alignment and talar torsion (r = 0.18; 95% confidence interval, −0.11 to 0.44; P = .22).

Conclusions: These findings may have implications for the treatment of forefoot varus since they suggest that the source of forefoot varus malalignment may be found in an alterable soft-tissue deformity rather than in an unalterable bony torsion of the talus.

I find Lufler's study very interesting but flawed. I believe her conclusions are flawed for several reasons:

• Connective tissue in the living foot is very different in constituency than connective tissue in the postmortem foot. However, Lufler measured the PM Foot and then applied her findings to the in vivo foot
• The difference in the connective tissue constituency between the living and dead foot would obfuscate the apparent correlation between the relative rearfoot to forefoot position and talar torsion

A study that would definitively prove (or disprove) the correlation between talar torsion and the position of the embryological medial column of the foot would be:

Measure for the Primus Metatarsus Supinatus Foot structure (as described by myself and Cummings and Higbie).

Then take that same foot, after death, strip it down to the bony structure and measure the talar torson directly off the foot.

Compare your measurements. Do they correlate or not. That is, does one see an incomplete torsional development of the talar head and neck, or not.

For obvious reasons, this would be a very difficult study to conduct.

What exactly is forefoot varus and forefoot supinatus?

Podiatrists use these terms to describe connective tissue changes in the foot resulting from positional shifts.

• When the forefoot is positionally inverted relative to the rearfoot, they term it forefoot varus
• When the forefoot is positionally everted relative the rearfot, they term it forefoot valgus

However, one must keep in mind that these terms are used to describe symptoms (albeit positional symptoms), not primary pathology (etiology).

So, the question remains: what is the cause of forefoot varus or forefoot supinatus. All the explanations I have read to date (including some of the very complex biomechanical explanations) do not isolate primary causes, but instead, describe in great detail a series of interlinking positional shifts leading to the varus or valgus forefoot.

My first tenant in any therapy is to first isolate (determine) the cause of the symptoms. And then treat that cause directly.

If one treats symptoms (e.g., forefoot varus), the patient will end up in a life long process of pain management. Something that is very frustrating and expensive for the patient and should be avoided, if at all posssible.