Stan;
how do I subscribe to the podiatry management listserv again. what
about the other list that was popular until the Dr. sold it? Anyone else?
Sincerely;
Bruce
----- Original Message -----
From: "Dr. Stanley Beekman" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, January 25, 2005 8:50 PM
Subject: Re: EVA vs Plastic/Carbon Fibre FFO's: Discuss
> Bruce,
>
> As long as you are adding material under the center of the calcaneus, you
> are raising the heel. The way to add a wedge without a lift, is to add
half
> the amount on the side you want to wedge, and reduce the opposite side by
> the other half. This way, there will be no change to the heel height.
>
> Regards,
>
> Stanley
>
> At 07:28 AM 1/25/05 -0600, you wrote:
> >Stanley;
> > I have found that on occasion if I make use of a heel skive (medial
or
> >lateral) or a RF post, that this will often act somewhat as a heel lift
as
> >well. Would you agree?
> >Bruce
> >----- Original Message -----
> >From: "Dr. Stanley Beekman" <[log in to unmask]>
> >To: <[log in to unmask]>
> >Sent: Monday, January 24, 2005 7:45 PM
> >Subject: Re: EVA vs Plastic/Carbon Fibre FFO's: Discuss
> >
> >
> > > Bart,
> > >
> > > It is nice of you to join the discussion.
> > >
> > >
> > > >I have to concur with Kevin and Eric that kinetics (=kinematics or
> > > >movement plus dynamics or the interplay of the acting forces) are
> > > >the essence of the play in biomechanical world.
> > > >Most of us are trained to look at movement (and the resulting
> > > >position), but research is more and more pointing to the importance
> > > >of understanding how forces and force moments affect the function of
> > > >lower joints. Most of the times orthotic correction does not result
> > > >in a significant change of motion or position, but rather in
> > > >dynamics. The problem is that dynamics (forces and pressures) are
> > > >very difficult to estimate by eye or by conventional video while
> > > >motion and position can be well appreciated by rather simple means.
> > >
> > >
> > > Again we are brought to the leap of faith. Orthotics that do not move
the
> > > position of a foot, and forces and pressures that are very difficult
to
> > > estimate (let alone measure).
> > >
> > > >But in the future of podiatric practice, in my view, it will be
> > > >compulsory to use some advanced technology in order to observe and
> > > >understand the dynamics of the game.
> > >
> > > When we have this technology, I will be first in line.
> > >
> > > >One cannot ignore that
> > > >mechanical overload and resulting injuries , most of the times, are
> > > >not due to excessive motion or position by itself, but rather to
> > > >excessive stress (loading forces) on the soft tissues (tendons,
> > > >ligaments etc...) and also on the bony contact areas of the joint.
> > >
> > > Just so you don't ignore position regarding joints, Sammarco (this
was at
> > > the North Lake conference in 1975) talked about the centers of motion
in a
> > > joint, and how injury changes this. He also talked about about how
there
> >is
> > > normal gliding in the middle range of a joint. So if the position is
too
> > > far in one direction or the other, there will be degenerative changes.
In
> > > regards to the first mechanism (injury) he was unable to give a
treatment.
> > > So we are only able at this time to affect a joint by limiting its
> > > position. It is far easier to see the change in the position than to
> > > calculate immeasurable moments.
> > > Another thing position takes into account that the moment theory
doesn't
> >is
> > > strength-length relationship curves, as it applies to the posterior
tibial
> > > tendon.
> > > Basically I agree with what you are saying about loading forces, but
lets
> > > use ligaments as an example. We are going to far on inversion of the
> >ankle.
> > > The anterior talo fibular ligament has some force on it that is
injuring
> > > it. So we can use our immeasurable moments and calculate that a
correction
> > > should reduce the forces, or we can evert the foot a few degrees and
know
> > > with certainty that there is 0 force on the ligament.
> > >
> > >
> > > >Today I had a nice example where an orthotic correction will
> > > >alleviate pain without necessarily affecting motion.
> > > >A patient with an excessive plantar flexed 1st ray (7mm) showed
> > > >excessive reaction of her peroneus longus, enough to keep the
> > > >calcaneus in a more or less vertical position, but at the cost of
> > > >chronic pains. Inserting a everting valgus wedge did not
> > > >necessarily push the calcaneus in a more everted position, but it
> > > >will help the peroneus to balance the inverting action from to
> > > >plantar flexed 1st ray. So the net result is no real change in
> > > >position, but balancing all moments of force to net zero requires
> > > >less force of the peroneus as the valgus wedge is taking over part of
> > > >the load. So the overloaded peroneus may feel more relaxed now and
> > > >the pain subdued.
> > > >So if one looks to position only , one is likely to miss the point.
> > > >But fortunately, the happy patient will not care how it worked and
> > > >consider you still to be a good podiatrist.
> > >
> > > Let me see if I understand what you are saying. The calcaneus is
vertical
> > > because the moments are balanced (which may or may not be at an end
> >range).
> > > The moments are the plantarflexed 1st ray causing supination, and the
> > > peroneal muscles causing pronation moments. (and maybe the subtalar
joint
> > > which I can assume is not the case, because if the joint was stopping
the
> > > supination moment, then the peroneals would not have to fire
excessively).
> > > Now you add a valgus post to assist the peroneal pronation moments. If
we
> > > have an asymmetrical pathology, and you have a foot that has a
> > > plantarflexed ray, and the peroneals are firing excessively, you
should
> > > look for a short leg. I would measure for a shortage (because it is
> > > measurable), and know if I need to apply the correct amount of lift,
or if
> > > I should focus exclusively on the foot. The beauty of what you are
doing
> >is
> > > that since you are not affecting position, you do not have much to
worry
> > > about how you are affecting the sacroiliac joint or the lumbar spine.
The
> > > problem is that if you do not balance the body correctly, you will end
up
> > > with a recurrence when the activity level increases. In other words,
it
> > > seems that the concept of moments causes you to limit your therapy.
> > >
> > > Regards,
> > >
> > > Stanley
> > >
> > >
> > > >My two pence ...
> > > >
> > > >Well, rest me to lay may brain asleep before early morning is
catching
> >up.
> > > >Good night,
> > > >Bart
> > > >
> > > >>Hello Kevin,
> > > >>
> > > >>I am glad to see that you are well. You have been missed.
> > > >>
> > > >>
> > > >>At 08:30 PM 1/23/05 -0800, you wrote:
> > > >>>Stanley, Eric and Colleagues:
> > > >>>
> > > >>>Stanley wrote in response to Eric:
> > > >>>
> > > >>><<So you believe that people walk around maximally pronated to
prevent
> >ankle
> > > >>>sprains. You also believe maximally pronated is not bad. You have
> >mentioned
> > > >>>that since 60-99% of the population is maximally pronated, it is
> >normal, so
> > > >>>we shouldn't treat it. Now I understand why you are content in
making
> > > >>>orthotics that do change the moments and not the maximally pronated
> > > >>>position.>>
> > > >>>
> > > >>>Kevin responds:
> > > >>>
> > > >>>Foot orthoses alter the location, magnitude and temporal patterns
of
> > > >>>reaction forces acting on the plantar foot. In so doing, they will
> >alter
> > > >>>the moments acting across the subtalar joint (STJ), midtarsal joint
> >(MTJ)
> > > >>>and other joints of the foot and ankle. In order for the orthosis
to
> >take
> > > >>>a foot out of the maximally pronated position of the STJ, they
**must**
> > > >>>cause an increase in STJ supination moment. However, not all
orthoses
> > > >>>that cause an increase in magnitude of STJ supination moment will
cause
> > > >>>the STJ to supinate out of its maximally pronated position.
> >Individuals
> > > >>>that understand the concept of STJ rotational equilibrium and STJ
> >kinetics
> > > >>>will easily understand this fact.
> > > >>
> > > >>
> > > >>Kevin, this sounds wonderful, so tell me how you measure the moments
> >that
> > > >>you change on the STJ and MTJ and the other joints of the foot (Lis
> > > >>Franc's, I assume) and the ankle with and without orthotics?
> > > >>Eric already explained the nutcracker theory. I still think it is
better
> >if
> > > >>you get the nut.
> > > >>
> > > >>>
> > > >>>Just because a clinician doesn't know what a moment is and how
their
> >foot
> > > >>>orthoses affect the moments across the STJ, MTJ and other joints of
the
> > > >>>foot and ankle, this doesn't mean that these moments aren't changed
by
> >use
> > > >>>of their foot orthoses. You will find few, if any, references to
STJ
> > > >>>moments (i.e. torques) before 1987 in the podiatric medical
literature,
> > > >>>not because these moments weren't present in the human population
> >before
> > > >>>1987, but because podiatrists didn't understand the mechanical
> > > >>>significance of moments, rotational equilibrium and kinetics.
> > > >>
> > > >>
> > > >>By the way, I wrote an article for Current Podiatry in 1976. In it,
I
> > > >>mentioned the pronatory torque at heel contact (using Plato Schwartz
as
> >a
> > > >>reference). I can see the significance at heel contact. But it seems
to
> >be
> > > >>more like window dressing at midstance.
> > > >>
> > > >>>Now, there are an increasing number of podiatrists who understand
foot
> > > >>>mechanics throughout the world with much more clarity since they
> > > >>>understand why it is so important to discuss moments acting across
> >joint
> > > >>>axes, and not just discuss position and motion as was taught in the
> > > >>>earlier days of podiatric biomechanics. This discussion of moments
> >that
> > > >>>we are having in this forum, is not a fad, it has replaced and is
> > > >>>replacing the older ways that podiatric biomechanics is being
taught
> > > >>>around the world because it is more biomechanically accurate and
> >explains
> > > >>>the mechanical etiology of pathologies with much greater clarity
than
> > > >>>could have been explained before.
> > > >>
> > > >>Kevin, I am not sure you can say the concept of moments is replacing
> > > >>position and motion. It seems that the only additional information
that
> >can
> > > >>be gotten from moments is when there is no movement. This is why the
> > > >>maximally pronated position is so important to you. It is at this
> >position,
> > > >>that you can analyze the situation with greater clarity. Those that
look
> >at
> > > >>position, will try to move the foot away from this. For instance,
sinus
> > > >>tarsitis (your favorite condition). You will look at the decrease in
> > > >>moments at this maximally pronated position and be able to determine
> >that
> > > >>there is 50% less force of the talus hitting the calcaneus. I, on
the
> >other
> > > >>hand in my simple approach would say that the talus should not hit
the
> > > >>calcaneus, so we should move it a few degrees away from maximally
> >pronated.
> > > >>This way there will be 0 force. At this point we do not have to make
> > > >>calculations as to how much we have to decrease the force to make
the
> > > >>patient asymptomatic. I would be spending my time looking at the
equinus
> > > >>that is the main causative factor, and by the position of the foot
know
> >how
> > > >>much of a heel lift is required to eliminate this extrinsic factor,
so
> >my
> > > >>orthotics can supinate the foot.
> > > >>
> > > >>>
> > > >>>Stanley also responded to Eric:
> > > >>>
> > > >>><<The difference between kinetics and kinematics, is you can change
the
> > > >>>moment without effecting movement. To me, it seems like a lot of
> > > >>>superfluous information, and the more information that is not
> >important,
> > > >>>the more confusing it becomes. Your point is that what I consider
> > > >>>unimportant, you consider to be very important. This is because you
are
> > > >>>comfortable with a patient that is maximally pronated.>>
> > > >>>Kevin responds:
> > > >>>
> > > >>>Understanding kinetics is crucial to understanding the production
of
> > > >>>mechanical pathology in the foot and lower extremity. Kinematics
is
> >also
> > > >>>important but kinematics does not have the potential to explain
> >mechanical
> > > >>>pathology since it does not include a discussion of forces or
moments
> > > >>>(forces and moments are the things that actually produce mechanical
> > > >>>pathology in the foot and lower extremity, not motion or lack of
> > > >>>motion). Kinetics is only "superfluous information" if you don't
need
> >to
> > > >>>understand (1) how a mechanical pathology is produced, (2) how one
may
> > > >>>best treat that pathology and (3) why certain mechanical
interventions
> > > >>>work better than others. Personally, I have kinetics during my
> > > >>>Biomechanics Fellowship and afterwards so I could better understand
> >#1-3.
> > > >>
> > > >>Clinically, when we talk about the Q angle, we are talking about
> >position.
> > > >>When we talk about SI dysfunction, we are talking about position.
When
> >we
> > > >>are talking about leg length, we are talking about position. When
most
> >of
> > > >>podiatry talks about the foot, they are talking about position. When
you
> > > >>talk about the foot, you are talking moments. It would seem to me
that
> > > >>moments is the exception, not the rule when we talk about pathology.
> >There
> > > >>are times that I will talk about the forces causing pathology, for
> >instance
> > > >>how an equinus causes a posterior displacement of the center of
gravity,
> > > >>and how this increases the tension to at heel off. But the bottom
line
> >is
> > > >>that I use dorsiflexion range of motion to determine my treatment,
not
> > > >>moments.
> > > >>I think you need to explain how you measure these moments, and how
this
> >is
> > > >>used to treat a foot. I have read about the two finger push up test,
is
> > > >>this what you use? Do you quantify it? Or go by feel?
> > > >>
> > > >>>
> > > >>>On another note, feet that are maximally pronated at the STJ are
very
> > > >>>common. However, I don't know of any research that suggests that
over
> >50
> > > >>>% of the population is maximally pronated at the STJ. You must
> >remember,
> > > >>>unless you are measuring the asymptomatic population and not just
those
> > > >>>that come into your office for treatment, you will probably
> >overestimate
> > > >>>the number of maximally pronated feet in the human population.
> >However, I
> > > >>>do think that over 50% of the population is within 2 degrees of
being
> > > >>>maximally pronated at the STJ. Not all these maximally pronated
feet
> >are
> > > >>>symptomatic and not all of these patients require treatment.
> > > >>>
> > > >>>I hope that no podiatrist recommends treatment for asymptomatic
> >patients
> > > >>>simply because they are maximally pronated at the STJ. One must
> >remember
> > > >>>that maximally pronated feet may also have symptoms (e.g. lateral
ankle
> > > >>>instability) caused by excessive STJ supination moments.
> > > >>
> > > >>I don't think any knowledgeable podiatrist will recommend treatment
for
> > > >>asymptomatic patients. Regarding ankle sprains, you say that on
> >maximally
> > > >>pronated feet, there is a supination moment that causes it. I can
see if
> > > >>the moments are different at different parts of the gait cycle, but
> > > >>otherwise this is contradictory. I was wondering if you are familiar
> >with
> > > >>Articular Deafferentiation as the etiology for chronic ankle
sprains.
> > > >>
> > > >>Moments, like anything new, seems like it is the entire answer, and
as
> >time
> > > >>goes on, it eventually finds its proper place. I think it is good to
> > > >>explain some of the pathology, but clinically, in midstance
position,
> > > >>movement seems more important.
> > > >>
> > > >>Respectfully,
> > > >>
> > > >>Stanley
> > > >>
> > > >>-----------------------------------------------------------------
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> > > >
> > > >--
> > > >*******************************************************************
> > > > Bart Van Gheluwe
> > > >Laboratory of Biomechanics
> > > >Vrije Universiteit Brussel -Fac. LK
> > > >Vakgroep BIOM
> > > >Pleinlaan 2, 1050 Brussel, Belgium
> > > >Tel.: 02/629.27.33 (31)
> > > >Fax: 02/629.27.36
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