Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory?

Eric, certainly you have positioned patients for X-rays before. Have the subject stand in their angle and base of gait and watch to see that they don't sift their weight while taking the X-ray. This is all very standard stuff:
http://www.wikiradiography.net/page/Podiatry+X-ray+Positioning

 

Do you have an X-ray?

 

An X-ray of what? Do I order radiographs- yes. Do you? I didn't think you had any medical qualifications, Jeff- so are you allowed to order x-rays? Which one of those feet in the pictures "appears more normal to you", Jeff- they are your photo's? You are either being incredibly stupid or ignoring the obvious for fear of stating it here Jeff. I know you are not incredibly stupid...

 

Simon,

If there is ankle pathology, it must be determined by the clinician, not the lab. We don't write the Rx for the orthoses, the clinician does. Sometimes they send radiographs in when they want to discuss treatment options. We can learn a lot from
the patient's radiographs.

Jeff

 

Why are you asking me If I have an X-ray then? It's irrelevent isn't it, Jeff? Back to the plot- which of the feet in the photograph that you provided "appears most normal"? Is it so painful for you to state the obvious?

 

We can't tell from the photo!

 

:good:Absolutely:welcome:. And neither can we tell when a patient stands in front of us with criteria a) nor d) because applying comparison to the "biomechanical criteria for normalcy" does not provide us with the requisite information to make such judgements.

At last. Time for bed.

 

I have positioned patients before. When I've taken my own x-rays, I move around behind the lead screen and am not looking at the patient when the button is pushed. In an institutional setting like the VA, where Daryl works, the x-ray technician is in another part of the building. So, I think asking how he makes sure that the patient has their center of mass between the feet is a valid question.

Eric

 

Jeff, did yo look at the picture in the website that you posted. Their picture is certainly not in base of gait. The picture that daryl posted looks like a person with symetrical lower extremites leaning to one side. It also looks like someone with asymetrical lower extremities. We can't tell from the picture.

Eric

 

Admin, there is apparently an attachment that I'm having trouble seeing.
<http://www.podiatry-arena.com/podiatry-forum/attachment.php?attachmentid=6848&stc=1&d=1431024488>

Jeff, did you attach Daryl's picture to your post?

 

Eric,

If your point is we must have a properly trained technician who knows how to position the patient in their angle and base of gait to get an angle and base of gait film, then I agree. Many x-ray techs don't know how to position a patient in their angle and base of gait unless they have been trained on how to do it. That's why my father trained his techs to do it properly. Most x-ray techs, who don't work in a podiatry office or who aren't trained by a podiatrist who knows how to correctly position that patient, don't position the patient properly. That's why podiatrists shouldn't send patients out for x-rays, but should do it themselves or have it done by a technician who is under their direct supervision. Just another problem with how some practitioners practice podiatry!

Jeff

 

No, I just referenced it.

 

Actually Eric, I had only so much room in the picture. The full radiograph includes the full lower extremity, including the entire pelvis. This particular patient had quite a bit of hip dysplasia, and was definitely putting more weight on the left foot that the right foot. I can send you the full radiograph if you want, and you will see the pubis symphysis is shifted to the left side significantly. I have made a power point presentation on one of the patients showing all the things I look at, including the levelness of various points of the hip, knee and ankle as well as where the center of the hip is relative to the knees, ankles, etc. You can also detect with greater sensitivity the transverse plane rotations in the pelvis, much better than you can clinically detect it, and you can even conclude sagittal plane plane movement between the left and right innominate bones. If you've never ordered one of these studies, it's great. I've been doing more and more of them. I don't think I've begun to scratch the surface yet of how these exams may be utilized. What I haven't been able to do yet is to coordinate the radiology exam with the Fmat examination. Hope to do a lot more of such things when we get moved into our new hospital.

Again, I'm not stuck in the past of the way of doing things, I'm still looking for new ways of examining and understanding the lower extremity. I wish we could get Howard Dananberg to write a text book on interpreting the pedobarograph. Just got my new 3D camera 2 days ago, and I hope to see what we can do with that. Kevin knows from my Vancouver lecture that I use a durometer in my clinical exam of diabetics. Still waiting for delivery of my runScribe instrument, which has been delayed. And of course I continue to experiment with all types of goniometric measurements.

Thanks,
Daryl

 

Actually, Jeff, the whole angle and base of gait thing is one thing I've moved away from. The angle, I think can be basically equated between static stance and walking (I can discuss later the nuances that it is not exactly) but the base of gait is quite different between walking and comfortable static stance. I believe that comfortable stance still represents a significant evaluation of function because a great majority of people spend more time standing than walking. So standing itself is "function" So I try to get our X-ray techs (which aren't too far displaced from our exam rooms in our current facility, but will be in the new facility) to just get the patient to stand in their relaxed most comfortable position for all WB x-rays, including the leg-length study.

One of the things I always liked about Mert was that he took both relaxed angle and base of gait radiographs of the feet as well as neutral stance x-rays. Unfortunately all those x-rays are lost to time (as far as I know) for someone to evaluate and publish data, however I know that many ideas were formulated in his mind by doing these comparison x-rays.

I think if we really wanted to reproduce radiographs in angle and base of gait, they should be single support radiographs, and then we would have to try to position pelvic position to match what happens in midstance, which would be very difficult.

I believe the new technology is Curve-Beam, which is the 3D CT WB exam. I talked with our new chief of radiology yesterday about this, and he is much more amenable to considering putting this new technology into place in the new facility that our previous chief was. So we'll keep you apprised.

Have a good day,
Daryl

 

This is really off the subject, and it's not the same patient as the previous one, but I thought you'd be interested in a blowup of the pelvic region of a radiographic bone length study. How many asymmetries can you identify?

Talk more later,
Daryl

 

For all those interested in learning more about Tissue Stress Theory, the upcoming Biomechanics Summer School in Manchester, UK on June 19-20, 2015 will be devoted to Tissue Stress Theory. The title of the seminar is "The Tissue Stress Theory and Its Clinical Relevance".

http://biorthotics.com.au/biomechanics-summer-school/Summer_School_2015_Leaflet.pdf

I believe this is the first ever seminar devoted exclusively to Tissue Stress Theory with the following speakers giving lectures and workshops at the meeting:

Simon Bartold
Mark Gallagher
Ian Griffiths
Lee Herrington
Kevin Kirby
Geza Kogler
Chris Nester

The lectures I will be giving include "Tissue Stress Theory: Changing the Paradigm of Biomechanical Therapy for the Foot and Lower Extremity" and "Midtarsal Joint Biomechanics: Theory, Research and Clinical Applications". My workshop will be "Clinical Tests for the Modern Podiatrisits: The Three Methods of Subtalar Joint Axis Determination, Supination Resistance Test, Maximum Pronation Test, Functional Hallux Limitus Test, Orthosis Deformation Test, and Dorsal Drawer, Plantar Provocation and Taping for Plantar Plate Tears".

Should be a good meeting and I hope to see many of you there.

I tend to doubt that Root et al's "Biophysical Criteria for Normalcy" will be discussed any, other than in its historical context.

 

Here is the Lecture and Workshop Schedule for the 2015 Biomechanics Summer School in Manchester on June 19-20, 2015

 

No one is going to defend the joints needing to lie in the transverse plane. I'm trying to see how the STJ even lies in the transverse plane. Joint axes?



Eric

 

Continuing on with the criteria for normalcy

C. The subtalar joint rests at its neutral position

D. The bisection of the posterior surface of the calcaneus is vertical.

I don't see why these two criteria need to be separated.

There is no reason why the STJ must rest in any of the three definitions of neutral position.

In light of Kevin's paper on the anterior axial radiographic projection we can pretty much decide not to teach either of these criteria anymore. Debate?

Eric

 

Eric, the vast majority of those that have given this time and scrutiny have already come to the conclusion that it is invalid and undefendable; the only ones trying to defend it are those with a vested interest in it. When they have gone, we'll move on. But I honestly don't think that while such individuals are still alive, we'll be able to move on. We've been having these same discussions on social media for the best part of twenty years now. As long as the vested interest remains, those without the vested interest that choose to move on will move on, and those with the vested interest that don't, won't. It's now been 17+ years since Craig published: Past, present and future- for some the world has turned, for others it's still where it was. Craig neatly explained why that should be the case back then: http://www.slideshare.net/mdjimenez...d-future-of-podiatric-biomechanics-japma-1998

To be honest, from what I have gleaned from colleagues here in the UK, from my teachings in central Europe and from discussion with colleagues in the southern hemisphere- the rest of the world has already moved on (or never abided to the Root approach in the first place), it is only in the USA where the Rootian approach still has a hold on podiatric biomechanics. So, who's problem is this?

 

Simon,

The vested interest argument is a very weak argument, if one at all. Do those who advocate and promote Tissue Stress theory have a vested interest in Tissue Stress? You bet! Just look at the book sales, paid travel, honorariums, accommodations, meals, orthotic sales, personal recognition, ego gratification, teaching salaries, research related income and recognition, and the other perceived benefits of being in the Tissue Stress club. If a vested interest was sufficient grounds for dismissing a theory, then there would be no theories in biomechanics and podiatry. If you can't convince others of the validity of your position due to the competition of differing opinions, then perhaps you should take a look at the gaps and flaws in your own position like the desire to ignore the importance of variances in the osseous structure of the foot. In the states podiatrists (DPM's) need a model of foot function that can be the basis of foot surgery and orthotic therapy. You can't move on until you have somewhere to go! Yes, podiatry in the state has changed and advanced greatly but how do you base a surgical practice on tissue stress theory alone?

Jeff

 

I agree with the vested interest point. I believe that most people honestly believe what they believe. People should be able to make a reasoned argument for what they believe.

It would certainly be easier to make surgical decisions based on the tissue stress approach than on the criteria for normalcy. If you want to make the foot more normal do you choose to make the heel sit vertical or do you choose to put it into neutral position. For the vast majority of feet neutral position is markedly inverted. If we knew what the advantage of being in neutral position was, we could make some informed choices on which one of those two criteria was more important. Or we could figure out if those criteria should be used at all.

An example of tissue stress and surgical decision making. Patient has PT dysfunction and you want to do surgery to make it better. The patient has an everted heel bisection and a medially deviated STJ axis. If you chose to do a calcaneal osteotomy would you choose to make heel bisection more vertical or would you choose to slide the heel more medially to put more foot on the medial side of the STJ axis?

Why would making the heel bisection more vertical help? Why would sliding the inferior portion of the calcaneus more medially help? In tissue stress you are looking at what you can improve. You have an explanation of why you are doing what you are doing. Making it more normal is not really understanding unless you know why normal should be normal/ ideal.

Eric

 

Simon:

I would tend to agree with you. There has been an evolution of ideas over the past 30 years that I have been in practice and these ideas have not all come overnight. It has been a long, hard struggle to change the way people think but it seems now like we have a strong nucleus of older and younger podiatrists who can teach Tissue Stress Theory ideas for years to come and develop these ideas further for the international podiatric profession.

One thing I have noticed over the past 30 years of being in the thick of all this discussion is that there have been many theories that have come and gone during our talks on JISC Podiatry Mailbase and Podiatry Arena, but that Tissue Stress Theory seems to be the one that is growing in popularity, rather than fading into obliviion. I have found also that most intelligent and experienced podiatrists in countries that I have lectured in (UK, New Zealand, Australia, Spain, Canada) seem to gravitate toward Tissue Stress Theory more than any other theory.

Unfortunately, here in the US, most podiatrists are simply not interested enough in biomechanics to be concerned about any new biomechanics theories. Therefore, for the US podiatrist, they will tend to believe what they were taught in school (i.e. Root theory) since they don't want to burden their intellect with learning basic biomechanics and engineering principles that will conflict with what they "already know".

All in all, it has been an interesting last three decades. We have made considerable advancement toward learning more about foot and lower extremity biomechanics, the biomechanical etiologies of many injuries and the biomechanics and function of foot orthoses during that time. I expect we will continue to increase our knowledge as long as we keep our minds open to new ideas and are willing to dispose of many of our long-cherished myths that are theoretically incoherent or are unsupported by the research literature.

Here's to progress!:drinks

 

It wasn't tissue stress theory that allowed me to solve the mystery of growing pains in children and then connect it to RLS in adults. It was my 'going back to the basics', ie., Root Theory, that allowed me to successfully treat these, string together a series of successes, and then broaden my perspective to write about it. Since I concluded that pilot study, I've had a LOT of successful treatments...one right after the other.

 

Just for the record you have not sorved any mystery re Growing Pains Matt you just claim to have.

 

Jeff, your response is a series of "straw-men" and logical fallacies

Could you point me to where I said that advocates of tissue stress theory don't have a vested interest in that theory? You can't because I didn't say that.

Again, I didn't say that vested interest was sufficient grounds for dismissing a theory- did I? It is certainly not a strong reason to hold onto a theory either.

This is a straw-man, Jeff. The tissue stress approach does not ignore structural variation.

We have somewhere to go, and you can base a surgical practice on tissue stress theory alone since part of tissue stress theory is applied structural mechanics, and part of orthopaedic foot surgery is applied structural mechanics. Hence they share a common foundation.

 

Btw, one of the best books ever written appears to being reprinted- I picked up a brand new copy of kinesiology of the human body under normal and pathological conditions by Arthur Steindler from Amazon UK for £30. This book was talking about tissue stress and rotational equilibrium at the STJ when it was first published in 1955. If you have an interest in lower limb biomechanics and gait you should own a copy of this book- it was my favorite book in the podiatry library at Plymouth School of podiatry.

 

I'd forgotten what a beauty this book is: on p. 378 he proposes a three axis approach to the MTJ, Nester subsequently employed this approach a few decades later.

On page 385, he describes movement at the STJ to occur about "a succession of instantaneous axes". Remember this book was published in 1955.

I've only had chance to quickly flick through this book to reacquaint myself with the gems it contains, but I can remember already why I used to have it on almost perminant loan from the library.

 

Cos you weren`t paid enough, as a lecturer, to buy a copy?

 

"For the record", Mike? The record now indicates you're misguided in your adherence to "what used to be"...whatever that was. Please explain your problem(s) with the hypothesis, because I have an opinion from a highly regarded podopediatrician that is contrary to yours, not to mention dozens of patient treatment successes that flies in the face of your position.

 

Which `record` is that Dr Hunt? Where can I access it? Or is this your opinionated conjecture?

Opinion, opinion, op-inyon = a belief or judgment that rests on grounds insufficient to produce complete certainty.

In scientific objective levels of evidence, personal "op-inyon" and "my patients think I`m great" rank below the lowest level of `panel of expert` op-inyon.

 

When did I write that my patients "think l'm great"? Project much? Considering that the "best" approach proferred by the Aussie and Euro Pods appears to be that I should've used "placebo" orthotics, (whatever those are), in my study, your
concerns fall flat. We've already read a response by Dr. Fisher whom has tried my approach to treat not only himself, but several of his patients with RLS successfully, yet you remain steadfast in your disbelief. All we ask is for Podiatrists to examine their patients with the hypothesis in mind, and we have asked for nothing in return. That's right....nothing. It really doesn't take too long to initiate and implement my approach, or even perform a cursory examination, yet you're more interested in denigrating the process instead of testing the content. Do your patients think you're great, considering your dogmatic approach? Do you still tell the patient's parents that "they will grow out of the pain"? Tsk, tsk.

 

Couldn't get it to buy then, it was out of print.

 

Technically you didn't, but you implied it when you said

So please tell me who here doesn't have a vested interest? You?

So what did you really mean? Did you mean to say was that those with a vested interest in their respective theories will continue to use and/or advocate for their respective theories? So what is wrong with that? Why did you need to mention a vested interest? What value dose it contribute to the discussion? What has that got to do with the validity or not of "Root theory" or "tissue stress theory"? The answer is it has no bearing either theory.

Jeff

 

Doogle,

Let me ask you this. Do you think it is possible that maximum pronation of the STJ could be a cause of growing pains?

Jeff

 

My "concerns" are your lack of scientific approach or acknowledgement - nothing more, nothing less.

You obviously don`t understand the term `tissue stress` "theory" as you like you call it, if your straw-man argument is that we advise parents that their kids will `grow out of pain`...hint; clue is in the name?

 

Jeff,

I couldn`t possibly answer your question unless you define "Growing pains".

John.

 

Since we were specificLly discussing your fathers criteria for normalcy, I was referring to those with and without a vested interest in Rootian biomechanics in my original post. Vested interest is one of the factors discussed by Kuhn in relation to "holding-on" to theories despite scientific evidence which shows such theories to be flawed, so it is relevent here. As I said, I did not say that those who were proponents of tissue stress theory did not have vested interest in that theory too.

My honest opinion is that the only country this debate is relevent to is the United States, since as I said, the rest of the world has either moved on, or didn't get on board in the first place.

 

[Face-palm] OMG...it's not as though the last 192 years of research papers in re to GPs haven't been sufficient enough to define the problem.

 

John,

I don't believe there is a singular definition of growing pains. However, growing pains are typically described as a symptom or clinical condition characterized by aches, pains or cramping, most commonly in the lower legs, that occur in the evening or at night and affect children typically between the ages of about 3 to 12. It is often described as a non-articular condition.

Jeff