Evidence In Podiatry Practice: An Interview With The Run Research Junkie Himself – Craig Payne


Evidence In Podiatry Practice: An Interview With The Run Research Junkie Himself – Craig Payne

Craig Payne likes to describe himself as a University lecturer, runner, cynic, researcher, sceptic, forum admin, woo basher, clinician, rabble-rouser, blogger and dad. He blogs at Run Research Junkie http://www.runresearchjunkie.com and It’s a Foot Captain, BuPayne_print.jpgt Not as You Know It http://www.itsafootcaptain.com/ ; is the admin at Podiatry Arena http://podiatryarena.com/index.php and runs the Clinical Biomechanics Boot Camps http://podiatrycpdacademy.com/clinical-biomechanics-boot-camp/ .

Simon Bartold recently stated in an online interview with Ted Jedynak that “just because the research isn’t there doesn’t mean we should be chucking out the therapy”. Do you agree with this statement and do you believe that modalities with limited research such as kinesiology taping and Foot Mobilization Techniques should be practiced without that research?

Of course I do, but you also have to be very careful making such statements as the promoters of pseudoscience and woo use the same logical fallacy. If you do not want to be tarred with the same brush as them, then you need to be careful how you phrase it. There is a lot more to it than just the strength of evidence for an intervention; there is also things like biological plausibility and theoretical coherence. It also must be consistent with the available evidence. If it is not theoretically coherent nor consistent with all the available evidence, then you need to modify the theory or model that underpins the intervention.

When writing a research article there is potential for many mistakes to occur, from analysis of data to misinformed or inappropriate data collection and the conclusions deducted from that data. Where do you believe most people tend to go wrong when developing and writing a research article?

The biggest issue that I have blogged about several times and called papers and jour
nal editors out several times on is the use of a within groups rather than a between groups analysis. It can lead to the wrong conclusion and has several times. That is not a minor issue, it is significant. I produced a video on it here: http://www.itsafootcaptain.com/within-group-vs-between-groups-analysis-of-trial-data-and-the-way-too-many-studies-get-it-wrong/

The other problem you see a bit of is the over-exaggerated claims that get made by authors (and University press release departments) for the importance of their results when there are issues in the study. The study may well have been good, but might have been done on,
for eg, healthy female undergraduate students – how representative are they of the total population or the population of interest to clinicians with problems?

Bias can occur in a number of ways when it comes to research including; pre-conceived ideas, a desire to achieve a specific outcome, commercial finding and conflict of interest. Do you feel these issues regularly affect the outcome of research and does it happen very often in that which effect podiatry as a profession?

I don’t. I am a bit different than many others on this one. Yes there are preconceived biases, commercial funding and conflicts of interest. I tend to be more trusting of the integrity of researchers than others (even though there are glaring examples of research fraud that are rare). For eg if there is a conflict of interest and/or commercial funding, but everything in the study was done with adequate blinding, then what is the problem? Where I do tend to see these as being a problem is the “tone” of writing or “spin” put on the results by the authors that may reflect the biases and vested interests, but that is why you focus on the actual study design and results and not necessarily the wrote up.

As patient management becomes more individualized do you believe there is potential to be a further disconnect between research and clinical relevance?
The opposite should be happening. What I see as an issue is the understanding by clinicians and researchers about the role that research plays in clinical practice and that is often misunderstood and misused. Life in general and clinical practice in particular is based on belief systems, model or theories – there is no escaping that. What matters is how consistent the belief system, model or theory that is used is with the body of evidence. If there is evidence that contradicts your belief system, model or theory then you need to either find a good compelling reason why that research is fatally flawed or move or adapt your belief systems, model or theory. Dismissing research that does not fit your belief systems, model or theory is fraught with danger. That is what those who promote junk, pseudoscience and woo do. We shouldn’t.

With Evidence Based Medicine being highly promoted within the medical and allied health industry, do you believe there is an increased risk of stepping on the toes of each other’s professions? How would this be best avoided?

To be honest I really don’t give a ‘f’’! All professions are trying to expand their scopes of practice to do work traditionally done by other professions while at the same time defending their professions from encroachments from attempts to extend the scope of other professions. This has been going on for as long as I have been around and the world still has not ended. You can’t have it both ways. We all in it for the patient and to make them better.

I often try not to necessarily identify myself as a “Podiatrist”, but often as a “Clinician” in the “foot orthotic industry”. I interact with, teach and learn from all the professions and players with a foot in the “foot orthotic industry”

Where do you see podiatry heading as a profession in the future? What will we have to defend against, where will we stand out and how will be portrayed on a world stage?

Just doing what we do well.
The biggest problem we are facing is the claims made in social media that patients read that are not supported by or even contradicted by the evidence. That is why I started my blog, to get the actual evidence based approached out there.
Jackson McCosker
Director/ Chief Editor

The Devil in Heels: Exploring the Risk of High Heels


The Devil in Heels:
Exploring the Risk of High Heels

Fashion dictates! Whether you’re attending a sweet sixteenth, day to day work or a corporate soiree, high heels still seem to be a number one choice of footwear among females in metropolitan areas. Fashion, confidence and power are all given reasons of why individuals feel they need to wear high heels, but there are significant reasons why health practitioners warn against such footwear.shutterstock_94554937.jpg

The most obvious is falls! Even the most well seasoned stiletto tittering fashionista has their moments; an unsuspected stone, curb or bump in the carpet can deliver them to the ground in a less than elegant manner with the end result usually consisting of hobbling around the office with a ice pack attached to their ankle for the next two days. However, there are more chronic conditions that can develop outside of the embarrassing stack.

Bunions and Toe Deformities: A bunion can be caused by a number of reasons but footwear seems to be one of the more prominent risk factors. The tight toe box of the heels places increased pressure on the 1st or “large” toe causing it to move laterally, putting increased pressure on the joint and the other structures of the foot.
Placing the feet into an angled position above 2.5cm can cause the foot to slide forward, cramming it into the toe box of the footwear and the lesser toes to curl leading to hammer, claw or mallet formations.

Osteoarthritis: Increased pressure on the structure of the feet can lead to unnatural joint movement and trauma leading to the development of Osteoarthritis.
Some studies have shown the most people have the beginnings of osteoarthritis at the big toe joint by the age of 30.

Muscle Pain: The design of high heels places increased demand on the muscles of the body. The calf muscles are placed into a shortened position and the quads and anterior leg muscles are used to stabilize the body while moving. This can lead to overuse injuries or general muscle soreness as well as more significant injures such as plantarfascitis and achillies tendonopathy.

Neuritis/Neuroma: As previously discussed the forefoot can be placed in a compromising position in high heels. Neuri.tis is the inflammation of nerve tissue leading to burning, tingling or pins and needles with in the foot

When looking for a high heel that is less likely to cause significant trouble, look for a lower heel, wider toe box and soft insoles to reduce stressors upon the foot.

Development of a Childs Foot


Development of a Childs Foot

As a recently new father, I now know the pressures and desires to give your child the best start in life and wanting to do the impossible of getting everything right the first time. The ideals of having a flat foot being bad for you has seemingly imbedded itself into not only the medical world but pop culture as well – ever since Root Theory was established in the 1970’s. The retail world has gained a lot from offering “supportive” footwear to patients or up-sell products such as generic insoles or padding devices for those who have been scared into believing that something is wrong with them based on visual observations, despite that fact of having nil pain. Therefore, seeing that your newly upright and walking son or daughter has flat feet can send alarm bells ringing for an emergency appointment with the GP or Podiatrist. To make things a little easier on you, the parents, lets touch on the basics of foot development to reduce those fear.shutterstock_100165070

A child’s foot is not the same as an adult’s foot. A fully matured adult has 26 bones, 33 joints and over 20 muscles. A child’s foot has many more pieces of bone due to the foot not having reached full maturity and bone ossification. With so many joints within the foot, it is no wonder a child’s foot is so flexible. It has been found that the development of the medial longitudinal arch is associated with the age of the child, with quite rapid development occurring in the initial 5 years of life. Obviously, this is encompassing of the time where a child will learn to walk, strengthening the bones, muscles and connective tissues to for a mighty spring which can attenuate pressures and direct elastic energy in a useful way. Additionally, the child’s heel will begin to straighten slightly with the increase in strength from the generally accepted everted position (we will touch on the idea on straight feet in an upcoming article).

Most children will begin walking somewhere between eight and eighteen months and will tend to in-toe as they continue to learn this new phenomenon. Children shoe be allowed to play barefoot, whenever it is safe to do so as there are many benefits to barefoot play. Not only does it help to strengthen the child’s foot, but it also promotes proprioceptive feed back to the child which helps with balance and body awareness. Shoes should only be worn by a child when protecting their feet from dangers. When identifying the best possible footwear for child to wear, the following criteria is a great summary of what to look for:

  • Wide toe box (all five toes should be able to spread out easily)
  • Both foot length and width should be measured
  • Flexible/ FLAT shoes
  • Laces (elastic laces will allow better fixation if the child cannot tie them their self)

So we have looked at the fact that in general, it is normal for a child to have flat feet. With everything in life, there will always be an exception to the rule. So now let’s dive a little deeper into what constitutes a flat foot, the difference between flexible flat feet and inflexible flat feet, red flags to keep an eye on and what management plans may be put in place in addressing your concerns.

Root theory was established by Root et al 1971, suggesting that a vertical heel position provided more optimal biomechanics, however in recent years’ different models have been proposed to challenge the idea that a vertical heel is normal. The first is known as the Tissue Stress Theory and focuses on the individual tissues and their ability to cope with the stressors which they are being placed under – indicating that orthotic or offloading prescription does not necessarily have to target the rearfoot but be more specific to the area of concern. As discussed above, most children displaying a visually flat foot, will generally do so due to increased flexibility.

Flexible flat foot is generally seen as a physiological implication where as a rigid flat foot is seen to be pathological. The primary factor which looks to differentiate the too observations is the Jack’s Test; where the 1st toe is passively pulled into extension to plantarflex the first ray and produce the windlass mechanism. A foot which is able to achieve the windlass mechanism while in a relaxed position is seen to be normal, whereas a foot which can be placed into talar-neutral and achieve the windlass mechanism is treatable. A rigid foot at such a young age is never a normal finding and surgical opinion should be sort.

The feet are designed to create a stable base for bipedal movement, although it is a part of natural development for a child to lose balance at times, regular tripping, falls and complaints of pain should be taken seriously. Children tend to respond poorly to structured exercise but when disguised as a game can find prescribe activities quite fun. Additionally, in-shoe offloading if done correctly can be beneficial in helping to develop habits and strengthen proximal muscles to address underlying weaknesses. Other treatment options include; varying footwear choices, night stretch splints and cast orthotics in extreme cases. The evidence for the use of orthotics in children with no signs or symptoms of discomfort is becoming clearer and clearer with two RCTs published finding no evidence for the use of foot orthotics, either generic or custom, in asymptomatic children.

Hopefully, the information displayed helps calm the nerves of some of the parents out there that have been worried about what their children’s feet look like. Although there can be major issues in a child’s development, very little is actually associated with flat feet. In fact, in many cases it is actually the opposite. Of course if you have any issues you are still not sure about, please make contact with your local podiatrist.  Keep an eye out in our coming articles where we delve deeper into the orthotics argument and the increase in foot specific training for rehabilitation, prevention and even performance.

Until Next Time,

Jackson McCosker
Director/Chief Editor

 

References

Children’s Feet. (2016, July 28). Retrieved from Better Health Channel: betterhealth.vic.gov.au

Evans, A., & Mathieson, I. (2010). Pocket Podiatry: Paediatrics. Adelaide: Churchill Livingston.

 

 

Moving Freely With MSK Therapy: Combining Evidence Based Medicine and Clinical Evidence


 

Shaun Brewster and Caroline Cleary are the founders and directors of Continuing Education Australia (CEA), a professional development seminar business educating manual and exercise therapists. Shaun is a musculoskeletal therapist, exercise physiologist, and running coach (www.brewstersrunning.com) with a passion for ultra-marathons. Caroline is also a musculoskeletal therapist and a sports physiotherapist, she’s also an ex-elite netball player and worked for many state/national sporting teams over the past 16 years.

  1. Continuing Education Australia supplies great continued professional development classes to allied practitioners around treatment modalities which seem to have limited supportive evidence but very compelling theory. What do you perceive to be the limitations of evidence based medicine? Is it a case that researchers are not spending enough time designing appropriate methods or is it that some interventions need to so individualized and the current system doesn’t allow for this to be taken into account?

Manual therapy involves the consideration of a multitude of patient variables and due to the nature of evidence based research it’s often very difficult to conduct research that provides clear and concise treatment and management protocols. While there has been some great advancements in EBM in our field, our profession is still largely guided by clinical based evidence, our goal is to marry EBM and clinical evidence to produce innovative and patient centred assessment and treatment methodologies.shutterstock_377153422 The limitations in our opinion are monetary, including in part practitioners working in a research capacity; spending many hours each week practicing as a clinician, possibly teaching in higher education (if you’re that way inclined), and finding the time and avenue of working in a  research capacity is all quite taxing and time consuming. Australia needs to make it more accessible for intelligent and hardworking clinicians to spread their time into research. Also, agreeing with your statement above that for research to be quantifiable it’s usually very specific, which is great, but makes it somewhat hard to extrapolate the information out to the mainstream and into treatment techniques manual therapists’ use.

  1. The method of cupping has recently been highlighted to the general public by the display of bruising on prominent Olympic athletes. Can you explain, in reasonably simple terms, the theory behind cupping and more specifically the “functional release cupping” that your business teaches?

Traditionally (Eastern medicine) would describe the markings left behind from the cupping in diagnostic terms, in that the colours would indicate particular types or levels of energy or blood stagnation in the body. Western myofascial cupping however, views the markings simply as minor damage to superficial blood vessels which occurs as a result of the strong vacuum created by the cups. The goal of myofascial cupping is to create a sustained drag on muscle and connective tissue which in turn changes the resting state of that tissue to create improved functionality locally. Functional release cupping (FRC) is the unique combination of myofascial cupping, kinetic chains, and functional movement. FRC seeks to create a more three dimensional and dynamic model for creating faster and more individualised changes in functional movement patterns – whether these be occupational, sporting, or other.

  1. Before cupping was made prominent at the 2016 Olympics in Rio, London introduced us to kinesiology taping (popular referred to by brand name ROCKTAPE) do you see benefits in this taping technique and how would you tend to use this intervention in consults?

Yes we regularly use and teach kinesiology taping and use it to support other therapeutic interventions post treatment. It is a fantastic pain reducing tool, it has been shown to improve lymphatic flow and also to increase the neuromuscular facilitation during sport or rehabilitation exercises.

  1. Acupuncture has been used by alternative medicine sources such as Chinese
    Medicine and Naturopaths’ for centuries/decades, however, allied health professions are restricted in the use of the word acupuncture and must refer to treatment as dry needling. Are you able to describe the differences between the two ideas and how each modality is theoretically supposed to work?

Acupuncture is based on the traditional Chinese medicine (TCM) model of energy flow (Qi) along meridian pathways. Acupuncture involves inserting fine needles into specific acupuncture points along these meridians to assist in the stimulation or balance of the flow of Qi. Dry needling was developed within the last 80 years and is based on a western medical model underpinned by the concept of myofascial trigger points. Myofascial trigger points develop in the body as a result of unwanted stress, excessive load, poor posture, and other factors. Trigger points produce a large percentage of the muscular based aches and pains that we experience from day to day. Dry needling uses needles very similar to acupuncture needles, but these are inserted at the site of the trigger points specifically to eliminate pain and to improve movement.

  1. Continuing Education Australia offer a Mobilisation With Movement course to allied health practitioners, which focuses on the use of mobilisation techniques and the promise of arthrokinematics. Are you able to describe this treatment modality to us, who it is most suitable for and how it can benefit an individual?

Mobilisation with movement (MWM) is an excellent tool for any allied health practitioner that deals with painful or restricted movements coming from incongruent/dysfunctional joints. MWM’s utilises anatomical motions in conjunction with arthrokinematic glides to improve joint functionality with less effort on the behalf of the practitioner. One of the unique tools that we use with this method is the MWM treatment belt which is a thick webbing strap with a high load buckle used to create more specific force with greater leverage.

  1. Where do you see the direction of Allied Health professionals going in the future? How will we reduce the chances of stepping on each other’s toes with the use of EBM and continued professional development expanding practitioner scope of practice?

We see allied health as becoming first contact practitioners more so than ever before. With the growing population of allied health practitioners we see each and every modality becoming more specialised to the general public, along with this there is likely to be an increased expectation around the level of education undertaken by allied health practitioners. Rather than trying to avoid stepping on each other’s toes, we believe the future lies in an integrated multi-modal approach to patient care which encourages and supports a high level of respect and collaboration between the various professions.

To end, if we as health practitioners focus first and foremost on the needs of the patien
t and all components of that person and the presentation, then our clinical decisions will be guided toward a treatment plan that provides the most holistic and individualized approach, regardless of our own personal and professional biases.

If you would like further information on Continuing Education Australia’s up-coming courses you can find it here at: www.ceaustralia.com

Until Next Time

Jackson McCosker
Director/ Chief Editor

Cycling Shoes and Orthotics


Cycling Shoes and Orthotics

The activity of bike riding has been present for centuries, a skill once taught and never forgotten. With all activities, there is the prospect of being able to complete said task; and then there is being able to do it well. As mentioned in the previous blog, the foot is a very unstable structure of 26 bones and 33 joints, in the sport of cycling – whether for elite sportspeople or the average weekend punter, the body, and in particular the lower limb is shutterstock_221925682asked to move more like a machine than the multi-directional and dynamic creature it is.
In true road cycling, where the foot is latched to the pedal via cleats or a strap and both a push and pulling motion is created in conflict to the opposing limb, the legs are asked to act as levers or pistons to generate optimal force upon the small area of contact. With the foot being a highly manoeuvrable item, the ability to act as a stiff lever is difficult while cycling. Certain cycling shoes do have a carbon fibre sole which is in place to stiffen the shoe itself, however, this does not account for the movement inside the shoe which can then affect the angles of the knees, hips and body as a whole.
The foot is a very unstable structure. Despite the carbon fibre sole of the shoe attempting to stiffen it to act as a lever, the millimetres of room available in the shoe still allow for the natural movements of the foot which are trying to be prevented for best transfer of energy. There are a number of items available out there for cyclists but the better quality devices are those which are rigid, supportive and able to advance the locking mechanism of the subtalar joint by pronating the rearfoot and supinating the Midfoot to created a stiff ever and reduce movement of the foot. Creating a stiff lever in theory will help increase power output during cycling.

Complaints such as “hot foot”, knee pain, ankle pain and metatarsal head discomfort can all be addressed with the use of an insole off-loading device or adjustment to bicycle set-up.
When trying to design a custom orthotic for a cyclist which is not affiliated with a particular specialist brand, it should be recognized that the foot adjustments will have the greatest effect where the foot makes contact with a surface. In the case of road cyclists this is limited to a 20-50mm point of contact, unlike traditional orthotics which operates in a way which facilitates natural motion and reduces pathological movements at the foot through the full range of gait.

Challenging Footwear Perceptions: An Interview With Tim Brandson


  1. There has been a recent slide of practitioners away from the use of orthotics.

Do you believe orthotics have a place in lower limb health?

Short answer is Yes. But to dig deeper.. what is your long term plan to get your client out of orthotics?

If you determine a need to support and alter the function of multiple joints.. What is your plan to return full strength and function to those same joints?

Not all feet can be returned to being Powerful Workhorses and not all people are willing to put the work in for this to be achieved.. But if you build a clinic around Strengthening and Training optimum foot function the motivated clientele will be the majority rather than the exception.

  1. Can you give an overview/outline of your theory or beliefs when it comes to foot strength and orthotic use?

Each foot has 20 Muscles + 33 movable Joints.. Plus 13 more muscles in the leg that attach into each Foot. There is incredible untapped potential in these joints and muscles to function efficiently and be Strong Powerful SPRINGS.. But only if you and your client are willing to invest in a true solution to their dysfunction.

Orthotics CANNOT strengthen feet.. It is physiologically impossible to use artificial support and restriction of movement to attain increased strength as an outcome. But orthotics can de-load tissue to allow healing.

My StrongFeet Program aims to restore lost Mobility, Coordination, Balance and Proprioception, and then layer Strength on these solid foundations. If I use orthotics to de-load injured tissue or accommodate a true foot deformity I will still use the principles of StrongFeet to improve function and create less reliance on the artificial support.. removing the orthotics altogether when possible.

3.The evidence for particular conditions such as knee OA and HAV prevention is reasonably strong for offloading devices is this still a condition you would look to use orthotics for?

Yes, orthotic therapy can be used to de-load damaged tissue in both knee OA and HAV.. But I will still go after improving foot, leg and torso function to improve a client’s ability to stand, walk and run.. whenever possible.

  1. In today’s society many people are looking for a quick fix, your practice in particular has patients which may be more determined to complete strength and conditioning as a primary modality of rehab…what would be your suggestion to other practitioners?

Ask yourself who your 3 favorite clients are. Dig deep into why these people are your 3 favorite clients. Then set about filling your clinic with more of these people. For me, my 3 favorite clients are all awesome humans first and foremost.. They have all achieved what others told them they could not.. And they are dominating life while others around them marvel at their achievements. The crazy thing is they do not understand what is so special about what they are doing.

Many practitioners think they cannot control who walks through their clinic door. Until you change that mindset you are absolutely correct. And if you are happy working with weak, lazy, unmotivated clientele wanting a quick fix, that is fine also. I choose not to work with these people as they do not inspire me and I cannot help them become truly awesome.

5.There has been a rise in barefoot debate since 2005, what are your thoughts on barefoot running and the athletic footwear market?

The athletic footwear industry is structured on sales and marketing, as all businesses should be. Just as fast food companies are not truly concerned with what food products are the best option for long term health, I believe athletic footwear companies are not very concerned (or perhaps educated) on long term foot health.

Their job is to be one step ahead of their competitors in marketing the latest greatest unnecessary piece of “technology”.. generally sold as a miraculous performance enhancing wondrous savior.

And just like making good food choices is not always easy in our fast paced convenience above hard work society, the same can be said of footwear design. It is about a magic pill or quick fix rather than truly helping feet work better.

If the mainstream athletic footwear industry truly cared about our feet the widest point of their shoes would be the toes. It seems pretty obvious that shoes, especially athletic shoes, should be the same shape as our feet. But they make them pointed at the toes.. More like a triangle than our actual rectangular shaped shoes. And yes, this has a HUGE influence on foot and leg function.

As for Barefoot Running I actually do not care if you run barefoot or not.. But I do care that nearly every runner I have ever treated has incredibly WEAK Feet. Strong Powerful Feet should be the primary aim for every runner.

While I do not suggest everyone should be barefoot running I am a HUGE fan of Barefoot LIVING! Ditch the big clumpy pointy high heeled shoes you wear to work (that includes you men) and start using your feet the way they were intended.

  1. If that is the case why do you believe the top athletic shoe developers such as; Brookes, ASICS, NIKE, NB, Mizuno and Adidas use a similar last design?

It makes money. Not many people wear gloves that are a different shape to their hands. They don’t squeeze the tips of their fingers into pointy mittens. But we as consumers accept this is okay for our toes to be squished and squashed into pointy shaped running shoes.

If companies who made real “foot-shaped” shoes like Lems, Skora, Topo Athletic, VIVOBAREFOOT, etc. actually put a dent in the market the big brands would either buy them out.. or make the same shoe, stick a swoosh on it and probably put them out of business.

Reliability and Validity of Lower Limb Biomechanical Assessments: Can You Trust Someone Else’s Work?


Reliability and Validity of Lower Limb Biomechanical Assessments: Can You Trust Someone Else’s Work?

The use of lower limb assessments in podiatric practice is an essential element when determining contributing factors to a current complaint and when monitoring the success of an individual’s management plan. What we were taught during our educational years through university and subsequent CPD courses gives a solid base on how “best” to subtract information from patients through open and closed ended questions and which tests/assessments are most appropriate. But what do these figures mean?
And in a world where there is an increasing number of practitioners working across multiple practices through contracting, locum and employment based agreements; how accurate can this number be when re-measured by a colleague?
In this article we look at a number of commonly performed assessments by podiatrists and their reliability, validity and inter-practitioner measurements.

Ankle Range of Motion
The assessment of ankle joint ROM is primarily completed in a weight bearing position, “knee to wall test”. In a research project by Bennell et al 1998, four practitioners of varying experience were tasked with measuring thirteen health individual’s ankle joint ROM. The two measurement being assessed were; distance of the first toe away from the wall when performing a lunge (knee touch wall) and the angle of the fibula in relation to vertical.

Inter-rater Reliability: There was no significant difference in the mean measurement of centimetres from the wall by raters. However, there was a significant
difference in the measurement of angle (p=0.001) between one rater and the other three, a mean difference of 4deg.

Intra-rater Reliability: There was no significant difference between raters for either the measurement to wall or measurement of angle between raters.

Conclusion: The weight-bearing lunge test can be complete reliably by the same practitioner or multiple practitioners with confidence of receiving comparable results.

Pronation
The use of the word pronation has been thrown around a lot in the past and was largely based on the idea of a sub-talar neutral foot position brought to light by Root et al in the 1970’s. Since that time the education system has brought in changes to the base biomechanics discussed in that article by adding measurement tools such as the Foot Posture Index which was utilized in pointing out that very few people meet Root’s criteria of what constitutes a normal foot type and that majority of people are slightly pronated.

Conclusion: There is no agreed method in the measurement of pronation. Those which have been tested for reliability have shown inter-reliability to be poor – moderate at best. Additional questions need to be evaluated as to whether static foot posture can be correlated to dynamic gait as current evidence is not supportive of this theory. Similarly, the mindset behind the movement of pronation has been shifted as we begin to understand the individual’s tolerance to body stressors in contrast to a once evil motion.

3D Gait Analysis
Although very much still specific to laboratory testing 3D gait analysis is beginning to make its presence felt in both the public and private sector of the allied health fraternity. However, measurements and diagnosis made on account of those measurement are only useful if they display adequate reliability. One of the primary issues with the use of a 3D gait analysis system is the protocol which is required and the human error which takes place. One such error is the positioning of markers on identified anatomical land marks.

Conclusion: 3D gait analysis has a high reliability for the kinematic parameters in the sagittal and frontal planes of the ankle, knee and hip. However, poor reliability is seen when viewing the hip and knee in the transverse plane and the pelvis in all three planes.

Biomechanical Assessment
The biomechanical assessment as a whole is used within both private and public health systems. The assessments which take place in these identification tasks have not been completely agreed upon. However, many of those which are used have been found to have quite poor reliability between assessors. Although these assessments are considered to be mainstream within the podiatry community, one must ask the question that if this continues and no protocol or substantial evidence is produced to contradict these findings then how long will these assessments be considered acceptable in an evidence based medicine society.
Below is a summary of the findings regarding the most common biomechanical assessment tools.
Limb Length Discrepancy
      =          Good Reliability
Angle of Gait                          =         Good Reliability
Base of Gait                            =          Good Reliability
Manual Muscle Testing         =          Good Reliability
Ankle Laxity                            =          Good Reliability
STJ Positions                           =          Poor Reliability
STJ Neutral                             =          Poor Reliability
First Ray ROM Qualitative     =          Poor Reliability
First Ray ROM Quantitative  =          Poor Reliability
FF to RF Relation Goniometer=         Poor Reliability
FF to RF Relation Visual         =          More Reliable

Physiological Assessment
In addition to Biomechanical Assessments, Physiological Assessments also take place in a podiatry consult and are most important in developing a management plan. This is especially important in the treatment of patients with chronic lifestyle disease such as Type 2 Diabetes or Peripheral Vascular Disease. Many of the Neurological tests have been found to have a fair inter-rater reliability, more specifically tests of sharps processing, vibration processing and joint position sense. Both Ankle Reflex Assessment and Monofilament testing have been found to have moderate inter-rater reliability.
Pedal Pulses Palpation have been found to have fair to substantial inter-rater reliability. It should be noted that all these test have potential to change how reliable they are based on the time available to a practitioner. If more reliable assessment protocol was developed there may be justifiable circumstances to extend consult times in order to provide more meaningful assessment results.

Until Next Time

 

Jackson McCosker
Director/Chief Editor

 

 

References

Bennell, K., Talbot, R., Wajswelner, H., Techovanich, W., & Kelly, D. (1998). Intra-Rater and Inter-Rater Reliability of a Weight Bearing Lunge Measure of Ankle Dorsiflexion. Australian Physiotherapy, 175 – 180.

Griffiths, I. (2012). Overpronation: Accurate or Parachronistic Terminology. SporteX.

Jarvis, H., Nester, C., Jones, R., Williams, A., & Bowden, P. (2012). Inter-Accessor Reliability of Practice Based Biomechanical Assessment of the Foot and Ankle. Journal of Foot and Ankle Research.

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