Brian, Howard and Colleagues:
Brian wrote:
<< The issue I believe that needs to be discussed is as follows: My
research [and collaborated by other research teams, as cited in my paper]
defines a foot structure in which When the STJ is in joint congruity [my
definition of neutral position], the medial column of the foot
[specifically the 1st metatarsal, proximal phalanx and hallux] are off the
transverse plane [elevated relative to the lesser metatarsals]. Do you
believe this paradigm is valid or not.>>
Kevin replies:
Are you basing your "paradigm" on the simple observation that when the foot
is placed into neutral calcaneal stance position that some feet have the
plane of their metatarsal heads inverted from the supporting surface? I
think this is quite old information. Root et al and Sgarlato described this
type of foot thirty years ago. They thought that this type of observation
could occur with certain deformities such as rearfoot varus deformity or
forefoot varus deformity. How is your "paradigm" any different than that
described by the above authors thirty years ago?
In addition, how exactly do you determine where the position of joint
congruity is for the subtalar joint (STJ)? Are you palpating the
talo-calcaneal joint margins, palpating the talo-navicular joint margins,
putting the foot through range of motion and determining the "flat spot",
observing skin lines over the sinus tarsi, observing the curves inferior and
superior to the lateral malleolus, or have you invented some other
technique? How do you know that the joint surfaces of the talo-calcaneal
joint are congruent, without some sort of computerized radiographic or MRI
scanning technique?
Brian continues:
<<If you dismiss this paradigm as being invalid, then of course you could
never understand the medial column system and its rational in therapy.>>
Kevin replies:
Dismissing a "paradigm" as being invalid has nothing to do with not being
able to understand a concept. One may understand all of what you do in a
clinical setting, but could not agree with it based on their own prior
knowledge of the biomechanics of the foot and lower extremity and the need
to do no harm to the patient. For example, if your "paradigm" was that in
order to control pronation of the foot, that thumb tacks should be placed
under the first metatarsal head, then I would find this "paradigm" not only
invalid, but would also find it irrational. That doesn't mean that I
couldn't understand the superficial logic behind the concept, but I would
consider it ill-conceived, based on concepts that are invalid, and also
would consider that it was developed without taking into consideration the
potential negative side effects to the patient.
Brian continues:
<<However, I feel the embryological record speaks very loudly for this
concept, and in fact, I have seen various talar bones from adult feet
demonstrating different amounts of talar supinatus [twist in the head of
the talus on its surgical neck].
Once talar supinatus is accepted as a valid entity in the adult foot,
my paradigm in treatment is difficult to ignore. A very simple test to
prove/disprove my theory is as follows: Take, say, 10 patients who are
moderate hyperpronators. In a standing position, place the left [or right]
STJ in joint congruity [using motion-palpation technique]. Evaluate the
position of the 1st metatarsal relative to the ground. If my paradigm is
correct, the 1st metatarsal will be OFF the ground [Refer to Fig 6 page 4
in my paper]. If my paradigm is INcorrect, the 1st metatarsal will be ON
the ground. A very simple and quick way to resolve this issue.>>
Kevin replies:
It is hard for me to believe that you seriously think that just because the
first metatarsal head is off the ground when the foot is placed in neutral
calcaneal stance position that this indicates "talar supinatus". Don't you
also consider that other factors may be causing this elevation of the first
metatarsal off the ground such as soft tissue adaptation of the medial
column at the talo-navicular joint, navicular-first cuneiform joint, and
first cuneiform-first metatarsal joint? Also, how does the presence or
absence of elevation of the first metatarsal head off the ground either
prove or disprove the presence or absence of your "talar supinatus" you
describe? Not only could this clinical observation be described by any
number of other factors of osseous, ligamentous or muscular origin, but it
would certainly also not be a "simple and quick way to resolve this issue".
Brian, before you can expect the almost 400 members of the podiatry mailbase
to accept your beliefs as a "paradigm", then you will most likely need to
provide much better evidence for this "paradigm" than what you have provided
above. I, for one, am anxiously awaiting such information. Also, I suggest
that you try publishing your papers in either the podiatric medical or
orthopedic medical literature if you truly want to have your ideas become
accepted as a "paradigm" within the podiatric or orthopedic medical
community. If you can't get your paper published in a peer-reviewed
podiatric or orthopedic journal, then I, for one, would find it hard to
accept it as a true "paradigm" of treatment of foot pathology.
Happy holidays,
Kevin
********************************************
Kevin A. Kirby, DPM
Assistant Clinical Professor of Biomechanics
California College of Podiatric Medicine
Private Practice:
2626 N Street
Sacramento, CA 95816 USA
Voice: (916) 456-4768 Fax: (916) 451-6014
E-mail: [log in to unmask]
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