Investigation of the podiatric model of foot biomechanics

I hear what everyone has said here, and recognise all that is said above but the phrase below says much.

From Dr LRCT2: "All I said on my post was “If it wasn't for Mert Root, Tom Scarlotta, John Weed, and Bill Orien and their research, publications, and lectures in the late 1960's and 70's there may not be a field called "biomechanics" as we know it today!"


You have to recognise that the world has moved on. when you refer to "their research and publications" that is fine, but they are not in journals that, frankly, cut the mustard today. Why are they not in Bone and Joint? Why are they not in The Journal of Anatomy? Why are they not in the various journals of orthopaedics and traumatology? JAPMA (and its anticedants) is a fine journal, but simply does not measure against those above (and others).

If we are to be taken seriously as a profession, we must publish in those journals that are utilised by those other professions judging us.

 

OK, Simon,

Before I begin any type of answer, lets find out where you stand.

1) Which of the Kirby statements about Root do you disagree with?

2) Do you have a Plato or Aristotle view of the "normal"? What is your opinion of the Root definition of the normal foot? (See his volume 1 for the definition - I am not asking about Root's criteria for normal)

3) Do you believe that a theory be proven right of wrong if instruments do not exist that can take measurements that the theory demand?

4) Do you you utilize any measurements described by Root in diagnosing foot abnormalities or prescribing shoe inserts? If so, which ones and why? If not, then would be you please direct me to the text where I can read all about your theory of foot function, and how to treat various foot dysfunctions.

5) Do you use the term "pronated" or "supinated" to describe any foot positions -- either clinically or academically? If so, what is your reference point?

6) If you have totally rejected all Root theory and practice, then can you assure me that you are getting better clinical results? How are you measuring your clinical results?

Once we've established the ground that you stand on (not the ground you're against) then we can try to find out what our true differences are and see if they can be bridged. It took me many many many hours of discussion with Dave Skliar (who is one of Dick Schuster's closest friends) before I began to find out what the true academic differences were and what was just name-calling.

Take care,
Daryl-

 

OK, Daryl I'll play along again

I'd already answered that (see previous posts)

I don't now what Plato's nor Aristotles definitions of normal were. I think Root's definition of normal foot is whatever he chose it to be, as I don't have a copy of volume 1 in front of me, perhaps you be so kind as to copy it here?

Theories are seldom "proven" nor "disproven" Daryl, but we can question the validity of theories when they are theoretically incoherent and/ or biologically implausable without necessarilly measuring everything with instruments.

The techniques of assessment which Root and his colleagues described in Volume 1, have been demonstrated to have poor reliability and repeatability and questionable validity. If we start using different tools to make the assessments that Root suggested we are no longer testing Root since we have to use the assessment as described by Root to be testing Root, so the argument becomes circular. If we follow this to it's logical conclusion, the theories of Root cannot be tested since the only one who can perform the measurements would be Root himself, and he's dead.

The weight of evidence from the studies which have been performed using the best available instrumentation appear to question the validity of much of Root's theories, the Jarvis study being the latest.

No, I don't use any of Root's measurements as far as I am aware. I guess the closest I could point you to as a theory that I employ as all encompassing would be that of quantitative genetics, you could try reading Falconer http://www.amazon.co.uk/Introduction-Quantitative-Genetics-Douglas-Falconer/dp/0582243025 My theory of foot function can thus be explained in one simple equation: P = G + E + (GxE) + i

Where:
P = foot function
G = Genotype
E = Environment (all non-genetic factors)
i = measurement error

I wrote about this in my PhD thesis.

I use the terms, but since Root is not the originator of these terms it is irrelevent to this discussion. Out of interest, what do you call the motion which generated axial position C in Nester's paper? Nester C.J., Findlow A., Bowker P.: Scientific Approach to the Axis of Rotation at the Midtarsal Joint. J Am Podiatr Med Assoc 91(2): 68-73, 2001

Again, since my ability as a practioner can be defined as

P = G + E + (G x E) + i

Where: P = clinical outcome for given patient

Then it becomes obvious that I cannot compare the results that I obtain with those of another clinician using a different model of practice. Moreover, I cannot compare my own results using different models in the same patient because: P = G + E + (G x E) + i is not a constant.

I use patient satisfaction as my main measure of success, along with pain scores and activity levels.

Who is name calling, Daryl? I've answered your questions so perhaps you could point me to the research evidence which has validated Root's theories so that we can see if there is a "baby" in the bath at all?


Bill, if you think there was no podiatric biomechanics going on in the UK pre-Root, can you explain to me what Hicks was up to at the Birmingham Accident Hospital in the 1950's and let me know what Gordon Rose was talking about in the early 1950's from his base in Oswestry?

 

To Rob Kidd and other "Podiatry Arena Veterans":
The answer to "Why R, W, S & O'R are not in Bone and Joint . . . The Journal of Anatomy . . . various journals of orthopaedics and traumatology" is quite simple, I think.
We all have to make choices about how we spend our time, how we want to contribute to society, and how we earn a living. At the time of R, W, S & O'R, podiatry had just emerged from the days of chiropody and still not recognized and accepted by many as a "science". As a result, it would most likely have been difficult for podiatrists to get anything published at the time in the types of Journals you mentioned.
In addition, writing and selling books was back then (and still is) often much more lucrative than publishing papers in journals, and surely more profitable than spending time on sites like this which, to me at least, smacks of the same old rivalries that have gone on amongst differing professions forever!
I, for example, could have chosen to write papers for journals; or instead, write and obtain United States and Foreign Patents (based on Root, et. al. theory, I might add); and subsequently, license my Patents to major branded footwear manufacturers from which I've been able to earn millions! Yes, that's right, MILLIONS! (You'd also be right if you accused me of having had issues with money most of my life - never thinking that enough was enough!) :>)
Another "Podiatry Arena Veteran" was quite correct when writing that "my choosing to exit these discussions was akin to picking-up my ball and taking it home"! Quite right! I Wish You All the Best in life and in pursuit of your choices! :>)

 

Louis you have ticked a lot of boxes in a few posts, good effort.

Enjoy your life , bye

 

BTW (and for the very last time, I promise!), I don't happen to have my copy of Volume 1 as it's been out on loan to my youngest Son, a third generation Podiatric Physician and Foot & Ankle Surgeon out in my old stomping grounds (S.F.); however, while Root's criteria uses the term "normalcy", I also believe it states somewhere in that text that "these criteria represent the 'ideal' foot" which is quite rare; and therefore, not the "norm"!

 

Which reminds me, there were a series of papers published in the chiropodist might have the 60's or 70's , if memory serves they were written by A.W. Swallow who I believe was a lecturer at one of the London Schools. Within these papers he was advocating something resembling what we might now call a tissue stress approach to podiatric biomechanics. I might have copies of these somewhere in a box in the garage, but if anyone can lay their hands on them without clearing out my garage, I'd appreciate it.

 

Or the Journal of Biomechanics. You don't see much work based on STJ neutral in the Journal of Biomechanics. A lot of podiatry students are surprised when they pick up that journal.

Eric

 

I'm not quite the historian as some are. So, I'm going to just talk about what I would keep from the teachings of Root, Orien and Weed. I don't know if they originated these ideas, but they found them useful.

Partially compensated varus and the influence of tibial varum. I am firmly convinced that this is a valid concept and can predict foot function. The STJ that is at the end of its range of motion in the direction of pronation is more likely to get sinus tarsi pain than one that is not.

The use of the intrinsic forefoot valgus post. An orthic with this modification will function differently than one without this modification.

At the extremes, a forefoot varus foot will function radically different from a forefoot valgus foot. ( A few degrees won't make any difference)

John Weed's description of attempting to place fingers under parts of the foot for assessing where the force is. Although this concept is a little separate from STJ neutral theory.

Casting with the forefoot loaded on the rearfoot. I beleive that when a foot stands on an orthotic casted with the forefoot dorsiflexed on the rearfoot, that the orthotic will help pre load the lateral plantar ligaments. When you look at positive casts that have been modified the consistent place where there is little plaster added is the plantar lateral aspect of the foot. I don't believe that the MTJ is "locked" but just pre loaded. So, I like their observation of what works, but I dislike their explanation of why it works. Of course, there is Ed Glasser, who may show that you don't need to dorsiflex the forefoot on the rearfoot.

Now, there are some things to discard.

The notion that forefoot to rearfoot measurement can be accurately measured. Calcaneal bisection. How hard do you load the lateral forefoot when taking the measurement. In describing how to take the measurement there is no mention of what to do with the medial forefoot. It is reasonable to expect that the passive position of the first ray will change from day to day and from time of day.

STJ neutral is the best reference point. Not pronated, not supinated definition could be applied to anywhere that wasn't maximally pronated nor maximally supinated. Why is STJ neutral a better reference point than the maximally pronated position?

There's more. However, we should have the discussion of what to throw out and why. A lot of this has been discussed on the arena before. However, I would like the chance to convince Luis that there are good reasons for discarding some of what the old guys did. Luis, you have the opportunity to convince some of us there is more valid stuff to be learned from Root et al.

Eric

 

Glad to see that we are all in agreement.:wacko:

Seriously though, I believe that we should give credit to Root for the pioneering work he, and his colleagues, did for podiatry. More than anything, his greatest contribution was he forcefully pushed the subject of biomechanics to the forefront for our profession in the 1960s and 1970s by lecturing continuously throughout the US and Canada, by publishing his three books and allowing his CCPM biomechanics lecture notes to be published in the Compendium.

Was there any other podiatrist who published as much information on foot and lower extremity biomechanics and foot function during that era? No. Was there any other individual in the world that published as much information on foot and lower extremity biomechanics and foot function during that era? I can think of only one: Verne Inman, MD, PhD. Being second place to Inman is no mean feat, in my book.

As far as not publishing in more prestigious journals than JAPMA or JAPA, as it was previously called, I consider that to be a non-issue since no podiatrists published papers in these journals in the 1960s and 1970s, to my knowledge. In addition, many of the current biomechanics journals weren't even in existence in that era.

Root seemed to be mostly interested in furthering podiatry and the knowledge of podiatrists at a time when biomechanics and podiatry were both developing by leaps and bounds here in the US. I believe Root chose to publish a few articles in the existing podiatry literature like his podiatric colleagues did. Anyone who suggests otherwise that Root was somehow remiss by not publishing in JBJS or the Journal of Biomechanics, I think is missing the point of what Root and his colleagues were trying to do for the podiatry profession here in the US: to try to elevate the level of knowledge of podiatrists in the growing field of biomechanics.

On the other hand, as you all may know, I have been a vocal critic of many of the postulates put forth by Root et al for the past 25 years. Are Root Biomechanics Dying?But, as some of you may not know, I was trained personally by Mert Root, John Weed and their colleagues/pupils, Ron Valmassy, Chris Smith, Lester Jones, William Sanner, Rich Blake and Rich Bogdan on "Root biomechanics". I even taught "Root Biomechanics" during my Biomechanics Fellowship. I did, though, greatly appreciate the knowledge these individuals imparted to me. Without the background in knowledge I gained from these individuals, I don't know if I could have accomplished what I have over the past 30 years since graduating from CCPM in the field of biomechanics and orthosis therapy.

However, Simon makes a very valid point about "Root biomechanics". Root was particularly dogmatic, in my opinion, and many of his pupils were afraid to question his ideas. In addition, many of his pupils accepted what he taught as gospel and have tended to ridicule those who did not the believe in "The Way" (i.e. Root's ideas).

This dogmatic approach, I believe, stifled creativity and curtailed independent thought in students. In addition, many students who "did not get it" became turned off to biomechanics in general since they were taught that STJ neutral and calcaneal bisections were "biomechanics", when, in fact, these were Root's ideas of how foot biomechanics should be taught. Nothing more, nothing less.

Unfortunately, I believe I am still fighting that fight here in the US against many of Root's ideas especially when I talk to podiatrists who have been around longer than I have. However, I do have help among my colleagues. Simon Spooner, Eric Fuller, Craig Payne, Simon Bartold and others here on Podiatry Arena have always thought independently and I regard them as valuable partners in trying to elevate the world-wide knowledge level among podiatrists in the subject of foot and lower extremity biomechanics.

Together, we have pushed podiatric biomechanics forward in, what I feel is, a positive direction. Whether we agree on how important Root was to all of us, is not particularly important to me. What is important to me is that we continue to use the best available scientific evidence and theories based on Newton's Laws to move our profession forward for the future generations of podiatrists and their patients with foot and lower extremity pathologies. That, I believe, is a worthy goal that should keep me going for the rest of my life.:drinks

 

In answer to the question what exactly is it that Merton Root was the first to describe, I would answer I don’t necessarily know and frankly, I really don’t care about it all that much! It is my understanding that Dr. Root defined 23 osseous conditions and deformities using his neutral position classification system. Here is an incomplete list of a few things I believe you can credit him with:

1. Defined the neutral position of the STJ

2. Developed a standardized heel bisection technique using palpation of the posterior medial and lateral margins of the calcaneus (Biomechanical Examination of the Foot, Vol. 1, pages 44-45)

3. Designed and developed the Forefoot Measuring Device to accurately measure ff to rf relationship (Biomechanical Examination of the Foot, Vol. 1, pages 72-75). He gave the patent rights and revenue rights to the company that manufactured it because he wasn’t doing it for profit but because he wanted to create the most accurate tool available for measuring ff to rf relationship. Since no tool existed, he created it. If you do not possess and use this tool, you don’t have the ability to measure ff to rf the same way Root did, so this creates variability from Root’s approach. Since they don’t manufacture it anymore due to lack of interest/demand, then I wonder how many of you own this tool and how many studies was it used in to validate Root's measurement technique? You can’t accurately measure ff to rf with a tractograph due to the distance and angular relationship between the heel bisection and the plane of the met heads and there is no other tool as accurate as the Forefoot Measuring Device. Variability is the product of inconsistent measurement technique largely due to lack of standardized measurement tools (sort of like using a laser or a ruler to measure the distance between two points that are a nearly a mile apart).

4. Developed a technique to measure the relative range of motion of the stj by measuring frontal plane motion of the bisection posterior surface of the calcaneus (Biomechanical Examination of the Foot, Vol. 1, pages 50-53).

5. Defined the perpendicular ff to rf relationship which is determined with stj in neutral and mtj fully pronated

6. Defined forefoot varus (an osseous position of ff inversion determined with stj in neutral and mtj fully pronated)

7. Defined forefoot supinatus (a soft tissue and potentially reducible inverted position of the ff determined with stj in neutral and mtj fully pronated)

8. Defined forefoot valgus (an osseous position of ff eversion determined with stj in neutral and mtj fully pronated)

9. Defined rearfoot varus (an inverted neutral position of the stj). As mentioned by Daryl, the terms varus and valgus were (and still are) used interchangeably to describe position or deformity. This creates significant ambiguity in communication. Root chose to use inverted and everted to describe position and varus and valgus to describe a condition or deformity. For example, consider an individual with a perpendicular ff to rf relationship with the stj in neutral and mtj fully pronated. If you invert the forefoot it is incorrect to say the individual has a forefoot varus since forefoot varus (as a result of Root’s neutral position classification system) is an inverted forefoot condition (i.e. osseous deformity). However it would be correct to say they have a “varus position of the forefoot” or that the “forefoot is inverted relative to the rearfoot”. This system of describing position is made possible only as a result of having a reference, which happens to be the bisection of the heel. Without bisection of the heel, there is no point of reference to differentiate an inverted forefoot position, condition or deformity from an everted forefoot position, condition or deformity.

10. Defined rearfoot valgus (an everted neutral position of the stj).

11. Defined the terms “plantarflexed 1st ray” and “dorsiflexed 1st ray” based on evaluating the rom of the 1st ray while the stj is neutral and while the mtj is fully pronated.

12. Developed a technique for measuring the range of ankle joint dorsiflexion while holding the stj in the neutral position.

13. Developed a technique to measure “neutral calcaneal stance position” and “relaxed calcaneal stance position” using heel bisections.

14. Defined hypermobility as “Any motion occurring in a joint, in response to gravitational force, at a time when that joint should be stable under such force” (Biomechanical Examination of the Foot, Vol. 1, page 24).​

Root’s neutral position classification system terminology is the basis of much of podiatric nomenclature. Many of Root’s critics use and must depend on the very terms they considered to be the result of a “flawed system” because they have no better alternative. They often criticize but have not or cannot offer a better alternative. For example, if you really don’t feel that the heel can be accurately bisected and that the forefoot to rearfoot relationship can be accurately measured, then it would seem you are obligated to abandon the use of all terminology (most of items listed above) that depends on heel bisection, the neutral position and measuring the ff to rf relationship with the stj in the neutral position and the mtj fully pronated. However, if you do, you will be unable to communicate coherently with your colleagues and many, if not most of the biomechanical textbooks and scientific articles that deal with foot biomechanics will be of limited or no use to you in your practice. Doesn’t this obligate you to publish, for your own benefit and for the benefit of others, a replacement to the 1970’s era work of Root, Orien, Weed and Hughes? I will be the first to purchase it!

My father saw a huge biomechanical void and attempted to address an educational and clinical need the best he could at the time. My father’s inspiration came in part from one of his professors who after my father asked some challenging functional anatomy (biomechanics) questions, his professor replied “Mert, you’re better off spending your time playing Bridge” (yes, the card game!). That sums up the level of interest of one of my father’s professors and it is a telling statement about the status of lower extremity biomechanics in chiropody school at the time. Some of you complain about the quality of education you received in Podiatry School, including “Root Theory”. My father never complained about or blamed his teachers, he simply set out to better his own education and understanding and tried to pass along the knowledge he gained so that other might benefit from it. He did not see it as a starting point or an end point. He saw it as “the best possible basis on which to make treatment decisions” at the time. By the time that statement was printed and the ink dried in volume II, he had probably already begun to question what might have already changed!

Once you are dead, you gain no egotistical satisfaction from your accomplishments. But after you are gone, if you have helped make the world a better place as a result of your contribution, then you have probably successfully fulfilled your obligation to society. I am no Root theory historian and will gladly leave that task to others and to those who wish to judge the value of his contribution. As an orthotic laboratory owner I patiently await the day all the new science and all the new theories markedly changes the way we examine and treat foot related pathology. I started off my reply by saying “In answer to the question what exactly is it that Merton Root was the first to describe, I would answer I don’t necessarily know and frankly, I really don’t care about it all that much!” because ultimately what is most important is what works, not who created it!

Jeff Root
jroot@root-lab.com

 

I started off my reply by saying “In answer to the question what exactly is it that Merton Root was the first to describe, I would answer I don’t necessarily know and frankly, I really don’t care about it all that much!” because ultimately what is most important is what works, not who created it!

Jeff Root

Jeff, Thanks for your input and hope your doing well. I for one, think that every generation needs to give credit and honor to those before them that have laid down the critical framework so others can build upon it.

Dr. Root was a brilliant forward thinker and I think our profession always needs to know not only his contributions but his undying passion that has ignited interest in furthering the study of Biomechanics.

Our bodies are nothing, for they are temporary but our spirit is everything and remembering the names of those that have made vast contributions keeps their spirit alive for us in this world.

Steven

 

You see this is where I get confused Jeff, a simple search of pubmed shows that the terms you propose were defined by Root such as rearfoot varus and valgus and forefoot varus and valgus shows that these terms were being employed in the literature before your father's publications. Indeed, Harry Hlavac published a paper entitled compensated forefoot varus in June of 1970 http://www.ncbi.nlm.nih.gov/pubmed/5444191 , your father didn't publish volume 1 until 1971.

 

One of the features of a profession is that it has its own specific body of knowledge and one of its roles is to put up barriers to keep that knowledge from others, ie to maintain its competitive advantage, to enhance its status, etc.

Podiatry doesn't have a body of knowledge that it can call its own and even if it did, has no way of keeping that body of knowledge to itself.

Having deserted any attempts to create a unique professional, scientific body of knowledge around its historical core areas of nails, corn and callus, 'Podiatric biomechanics' represents an attempt to develop and define an area of knowledge specific to the profession of podiatry.

Maybe we could learn from the past. We can quite easily create our own unique and, in practical terms, untouchable body of knowledge, by ensuring that all podiatry training is undertaken, and all podiatry texts are written, in Latin! Other than that if we could just go back a hundred years or more and hold hands with dentistry and have it written into the law that it is illegal for anyone other than a podiatrist to touch a person's feet it would be problem solved.


If I can help somebody as I travel on my way........

Bill

 

I would have thought that the structure/function relationship can only be anything other than absolute/100%, if there is such a thing as magic?

Bill

 

Simon,

Harry Hlavac was one of my father's students. My father had been teaching at the college since the early to mid 1960's. Virtually none of his original ideas, which he taught to his students, had been published at the time.

Jeff

 

Hlavac aside, there are multiple papers which used the terms forefoot varus and valgus and rearfoot varus and valgus which were published prior to your father. An example if you need it:

"There was a slight valgus deformity of the forefoot in two cases" A.J. Drew 1951 http://www.bjj.boneandjoint.org.uk/content/33-B/4/496.full.pdf html

 

As Jeff said, Harry Hlavac was one of the many students of Mert Root. Much of the Compendium contains Root's CCPM biomechanics lecture notes which had many of Root's ideas that had been previously unpublished. In fact, the push to publish the Compendium was based on the desire to bring Mert Root's ideas into wider distribution than just to the students of CCPM. In Hlavac's paper on "Compensated Forefoot Varus" in the Compendium, Hlavac openly states that this "foot type" was first described by Dr. Merton Root. Let's give credit where credit is due.

 

Bill,

I believe the term podiatric biomechanics is used because it is a better way of describing biomechanics when applied to treat lower extremity related pathology by a podiatric specialist. In other words, it means the application of biomechanics for podiatric purposes and does not necessarily mean that the basic biomechanical principles employed are exclusive to podiatry. When I go to my dental hygienist for my six month teeth cleaning, I don’t ask her why she doesn’t just call herself a hygienist since hygiene isn’t unique to the dental profession. I know it’s because her scope of practice focuses on the dental aspect of hygiene. Podiatric biomechanics is ultimately a foot related practice even though it involves areas of the body beyond the foot. Podiatric biomechanics simply implies focus/scope of practice.

Jeff

 

Simon,

He defined them based on the requirement that the foot must be placed in the neutral position in order to establish the presence of these conditions. I didn’t say he coined the terms. He better defined the terms by removing the variability of random positioning of the stj.

Jeff

 

And the mtj! If you randomly position the stj and the mtj, how can you tell if the subject has a ff varus or a ff valgus?

Jeff

 

OK sorry, I thought you said:

Which seemed to me to mean that if I use the term forefoot varus etc. then I am in some way employing your father's system. So what you are actually saying, since he didn't invent these terms, whether someone uses them or not actually has nothing to do with your dad's work. The caveat being that Root defined them as being measured with the foot in a certain position. Specifically in the position of "subtalar joint neutral" which was, according to Daryl, defined by Lovett and Cotton. A position which has questionable validity and poor within and between tester reliability when clinicians attempt to place the foot into this position; given this I'm not sure the variability due to the random positioning of the STJ was resolved by this technique.

What reference system was used to define whether a forefoot was in varus or valgus alignment to the hindfoot, prior to this?

 

Simon,

I bet most if not all of those papers used the term rearfoot varus to mean that the heel appeared to be in an inverted position and rearfoot valgus to mean that the heel appeared to be in an everted position. The problem that my father discovered was that made the terms useless for purposes of defining deformities (structural osseous conditions) such as rearfoot varus as we now think of it today. As my father wrote in his first book, we need terms to describe motion, position and structure. Using the terms interchangeably creates confusion. Supinated is a position, supination is a motion, and varus is a condition (osseous condition or deformity). You can use varus to describe position provided you also use another word such as a "varus position" of the heel which also means "inverted". But my father was attempting to create clearer and more efficient terminology so podiatrists could better communicate with each other. In addition, without heel bisection, it becomes more difficult to differentiate an inverted and everted heel position. So although there is an acceptable margin of error with heel bisection, most people feel we are better off with some reference rather than none.

Jeff

 

Good question! As I said in my other post, we need terms that can be used to describe and differentiate position, motion and structure.

 

Does anyone know which book this is from?
http://www.podiatryinstitute.com/pdfs/Update_2005/2005_42.pdf

 

Jeff, do you know what definition of stable was used when defining hypermobility? I don't feel that hypermobility is well defined. I don't know what measures your father used to decide that joint was hypermobile. Many people may be misusing the first ray range of motion measurement because that is a non weight bearing measure and the above definition requires weight bearing.

The recognition of the existence of supinatus is essentially and admission that forefoot to rearfoot cannot be measured accurately. If you don't have a method to accurately determine how much supinatus there is, at a given point in time, then you cannot accurately determine the true forefoot to rearfoot relationship. I don't believe that forefoot to rearfoot can be measured accurately and I have no problem using or understanding the terms. I don't see why I have to abandon the terms. I think there is a valid concept there, but it just cannot be measured accurately.

Another important teaching of Mert Root is that there are characteristics of feet that will make one foot behave differently than another foot. So, when you do a study that involves feet, the same intervention will create different effects in different feet. If you cannot identify what those differences are, your experimentation will not provide very consistent results. When evaluating the teachings that our predecessors have left us, it is important that we keep what is of value and discard what is not.

Eric

 

I have this book on my library shelf:

The Podiatry Institute, Update 2005: The Proceedings of the Annual Meeting of the Podiatry Institute, The Podiatry Institute, Tucker, Georgia, USA, 2005, pp. 221-225.

Every year, the Podiatry Institute publishes a book from their members which are given to those who attend their seminars here in the US during the year. This one was from 2005. I lecture nearly every year for Don Green's Podiatry Institute Seminar in San Diego.

 

I believe that our discussion here leads us to an even bigger question that I believe we need to answer as a profession:

Does the structure of the foot and lower extremity contribute toward determining the kinematics and kinetics of gait (i.e. walking, running, etc)? I believe the answer is a definite yes.

Now, assuming most of us agree with the above statement, and we agree that structure may be a contributing factor in determining the kinematics and kinetics of gait, how should we then go about classifying the structural variables of the foot and lower extremity in order to design scientific research so we can learn more about how much the structural variables inherent within the human foot and lower extremity do affect the kinematics and kinetics of gait?

Any ideas or suggestions?

 

Hold your horses there, Tonto... what did that study from that book chapter on your shelf conclude? I'm not saying that structure doesn't influence kinetics nor kinematics, but we really don't have a handle on how yet- which I guess is what Jarvis was investigating in her PhD. Modern 3d imaging provides the best data on structure, bone pin markers provide the best data on kinetics, force plate data in concert with in-shoe pressure provides the best data on kinetics.

 

Quote Simon Spooner.
Bill, if you think there was no podiatric biomechanics going on in the UK pre-Root, can you explain to me what Hicks was up to at the Birmingham Accident Hospital in the 1950's and let me know what Gordon Rose was talking about in the early 1950's from his base in Oswestry?

I wonder if our difference of opinion is largely based on semantics?

I consider that 'podiatric biomechanics' must include: the involvement of chiropodists/podiatrists in at least some related research and/or academic writing on the subject and/or practical use by podiatrists of the 'discoveries', ie just because something is foot related doesn't make it podiatric.

I would classify the work of John Hicks and Gordon Rose as foot mechanics or even orthopaedic mechanics but not podiatric biomechanic because there was no contemporary involvement of chiropodists/podiatrists and no use was made of their findings by chiropodists/podiatrists either at that time or for the next 20 to 30 years , ie it wasn't until the writings of R, W & O'R hit the British shore that the profession woke up to the idea of biomechanics in a meaningful way.

If, prior to the arrival of the R, W & O'Rs' texts in the UK, someone within the chiropody profession had taken the research of Hicks and Rose and used it to initiate or extend an existing theory of biomechanics within the UK profession I would be happy to talk about pre-Rootian podiatric biomechanics in the UK.

Bill

 

Slow down there, Lone Ranger!

Here is what I did ask:

Oh, and by the way, you are welcome for me taking the time out of my busy morning to get you that reference book you requested...

 

I think we are singing from the same song sheet.

In the UK at least, the advantage that the dental hygienist (through here association with a dentist) has, over the podiatrist is that here body of professional knowledge and its exploitation is protected. No on else can come along and start to clean teeth. Thus in practical terms dental hygienists have a body of knowledge that is peculiar to their profession.

As you say "hygiene is not unique to the dental profession" but 'dental hygiene' is. If podiatrists could say the same thing about 'podiatric biomechanics' or any other aspect of podiatry we would have a real profession.

Bill

 

Then I refer you to work of A.W. Swallow (who was a chiropodist) and wrote about biomechanics of the foot in the UK prior to the American invasion here, as I would also refer you to texts such as Hanby and Walker (1960) have a look, then tell me there is no biomechanics in that book.

And you know, that no chiropodist in the UK read or applied any of the work of Rose or Hicks or the countless others that were involved in biomechanics in the UK who were not chiropodists?

It's funny, I have many old UK textbooks that were given to me by my old boss- Lew Russell. I looked at Hanby and Walker today and saw diagrams of lever classification, there's even a picture of a flat foot with a tibial and heel bisection super-imposed on the photograph, theres a photo of a foot with a forefoot varus and reference lines showing the angular relationship twixt forefoot and rearfoot. I was under the impression Hanby and Walker was pretty much a standard text back in the day. Didn't anyone in the UK read Lake's book? Moreover, did anyone read JBJS?

 

Thank you for taking the time out of your busy schedule to find the reference to the book that I requested.

 

You are welcome.

Think it's time for me to step back from this discussion. Nothing positive seems to be coming from it. I'll let you all take it from here...

 

I'm not sure what you wanted me to say, Kevin? Agreed though, I'll step back and let those that believe that biomechanics began with Root's ideas and that these ideas still have value in 2013 continue with this discussion, since I don't (I trust I'm allowed that opinion?) and I've obviously offended you somehow in the process of defending my position. Same old stump. Interesting that no-one has discussed the finding of the Jarvis PhD yet, even though we're on page 3 of this thread about the Jarvis PhD... I guess were all too busy to read it, or just don't want to.

 

We should probably be using the term Lower Extremity Biomechanics or Gait Related Biomechanics rather than Podiatric Biomechanics. Podiatric Biomechanics is the practice of Lower Extremity Biomechanics. Ironically, we must also consider arm swing, upper body sway, head tilt, shoulder tilt, etc. so Gait Related Biomechanics is probably the best term but in either case, it really involves the entire body.

Jeff

 

Simon,

That is exactly the point. The terms were being used without any common meaning and standard definition. Dr. Root attempted to create one. Can you find anyone who defined these terms prior to Dr. Root? I believe that is precisely why he felt the need to create the definitions, which happened to be based on the neutral position as a reference point.

Jeff

 

Kevin,

A simple example of this is a medializing or laterizing calcaneal osteotomy. In the following link you can see how rearfoot relationship (indicated by lines on leg and heel) is used to educate the patient and to demonstrate how altering structure is used to change function.
http://www.footeducation.com/calcaneal-osteotomy

Jeff

 

And here is an example of "how the Root et al (1977) description of the movement of the normal foot during the gait cycle does not concur with that of feet classified as asymptomatic" and "that the measurements obtained from a static based biomechanical assessment of the foot cannot predict the movement of the foot during the gait cycle". http://usir.salford.ac.uk/29381/1/HannahJarvis_PhDThesis.pdf

Jeff, I could probably find definitions of the terms prior to your Dad, since clinicians were clearly using them and communicating these ideas within the literature for many, many years. The reality is, even in going to this effort it wouldn't change anyone's mind or opinions any more than the PhD thesis linked above will change the minds and opinions here; anymore than the chapter I found and linked to earlier which showed that forefoot to rearfoot alignment did not significantly influence rearfoot kinematics during gait will change anything; anymore than all of the studies which have tested the Root hypothesis and found it lacking will change anything. Some people are just not willing to change for the reasons Craig outlined 15 years ago in "past, present, future..."

Something to think about though before I take a break, and I take your point Kevin- what structural variables should we measure then?- right? But: two feet- both have identical subtalar joint (STJ) axial positions, both have same STJ neutral positions, relaxed calcaneal stance postions. In fact, both feet are identical in every respect to all of the variables defined as measurements in Root's books. The two feet and lower limbs are identical in every way, the people that these limbs belong to are in every way identical except that they show variation in the shape of their articular surfaces at the STJ (maybe like Janis Bruckner described here: http://www.ncbi.nlm.nih.gov/pubmed/18797028 ). We apply identical external and internal forces to both feet during a walking cycle/ running cycle via ground reaction force, muscles, ligament and tendon forces for whatever dynamic activity of daily living you care to think of- would we expect the feet to display identical kinematics at the STJ in response to the loading? So, unless we can measure clinically such variation in structure, we'll never get it; multiply this with the almost infinite variation in human structure and you are left with P= G + E + (G x E) +i and all of it's implications. Drawing lines on the back of peoples legs and feet and measuring static angular relationships is not going to be anywhere near enough to understand lower limb biomechanics. But then, we already knew that didn't we, which is why we have modern research using bone pins etc.

If the baby in the Rootian bath-tub is that he defined the requirement that the foot must be placed in the neutral position in order to establish the presence of conditions which had for many years previously been defined regardless, then it isn't much of a baby when we know that the neutral position lacks validity and repeatability and that these measures do not predict dynamic function. In fact, when there's nothing left of the "baby" and the bath is filled with so much sludge and debris from the dissolved remains of the baby expelled by the almost countless acid tests of science applied to it and found it wanting, it's high time that you drew a new bath, put a new baby in it and started again. If podiatrists read more widely, rather than focusing only upon publications in podiatric journals by podiatrists- we'd have realised all of this as a profession years ago.

Simon Spooner PhD, BSc, Podiatrist in clinical practice - hobbies: peeling babies and rolling them in salt.

Bye for now.