Negative Model Production

I much prefer the terminology of Negative Model Production than casting or negative casting. In order to make a foot orthotic, then some sort of volumetric model is needed of the foot. There are so many legitimate ways to do this these days as opposed to in the past when we mostly just had the traditional plaster cast. Some of these other methods are old, but are gaining in popularity (eg foam box casting) and some have come about with advances in technology (eg digital scanning). I also like to include the term 'eye balling' as a method of negative model production, as this is the modelling that we do before using a prefabricated foot orthotic.

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Manipulation of the foot

The use of manipulation of the foot within podiatry comes in two forms:

1) It a philiosophy that the practice is based on. There are a number of podiatrists who use this as a predominant treatment in their practices and claim good success with it. They are sort of like chiropractors of the foot treating subluxations (see: Manipulation).

2) It is a useful treatment modality that is just one of many approaches that can be used (see: Cuboid Manipulation).

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Posterior tibial tendon dysfunction

This is the primary cause of acquired flat foot in adults. Essentially the underlying pathomechanics is that the posterior tibial tendon and muscle just give up - they can no longer do their job. Why do they give up? My understanding and experience is that all that all those with posterior tibial tendon dysfunction have a medially located subtalar joint axis. If this is the case, then it means that the posterior tibial tendon will have a much shorter lever arm to the joint axis. This would mean that in these people the muscle would have to work substantially harder than if the tendon had a longer lever arm if the subtalar joint axis was closer to a more normal or average position. After a life time of having to work so much harder, no wonder the tendon and muscle complex just give up. This is becoming more common in runners who start forefoot striking.

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How common is heel pain caused by gout?

This is something that I almost never see, but I have seen others claim that it is common. I recently did a liteature search on 'gout heel pain' and found next to nothing. The best I could find being to use colchicine for a few days as a diagnostic aid.

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Are MBT Shoes Helpful?

Masai Barefoot Technology or MBT shoes are shoes that have been on the market for a while now and have a rocker bottom that is supposed to simulate the natural gait of walking barefoot that is modeled on the Masai people from Africa. The MBT company do make a lot of claims for the benefits of the shoes. They even used to make cliams about treating cellulite (but recently stopped that one). There is some limited evidence to support the claims about helping some people with postural porbalme, but there is not enough to support the wide range of claims made. Do MBT shoes work? Based on what i have read and what I understand, I think the shoes are beneficial in certain subpopulations, I would just prefer to see some better clinical trials to guide us as to how to better identify these people.

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Podiatry and Twitter

Do you even know what Twitter is? Have you caught up on all the fuss and what its about. There are many podiatrists and Podiatry related organisations on Twitter. See this search for podiatry. For example, Podiatry Arena has its twitter page. For those who have no idea what this is all about there is some good information I found on Twitter.

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iPhone tool for biomechanical measurements

For those who still do measurements as part of your biomechanical assessment (I stopped doing this a long time ago, except for measuring the tibial angle for the lunge test) and you have an iPhone, have you seen the iHandy Carpenter Tool (search for it at iTunes). It’s a cool way to do your measurements. It works really well for the Lunge Test.

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Jones fracture

I came across this little gem from 1902:

"SOME months ago, whilst dancing, I trod on the outer sideof my foot, my heel at the moment being off the ground. Some-thing gave way midway down my foot, and I at once suspected arupture of the peroneus longus tendon. By the help of a friend I managed to walk to my cab, a distance of over 300 or 400 yards.The following morning I carefully examined my foot and dis-covered that my tendon was intact. There was a slight swelling over the base of the fifth metatarsal bone. I endeavored to obtainc repitus and failed. A finger on the spot gave exquisite pain. Body pressure on the toes, even the slightest, was painful; butwhen the pressure was deviated to the outer side the pain wasstill greater. Extension of the ankle and flexion of the toes wereimmediately felt at the base of the fifth metatarsal."

This was Sir Robert Jones talking about his fracture that became known as a Jones fracture.

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Barefoot Running

I am not opposed to the barefoot running movement. It just some of the promoters of barefoot running that I have a problem with. They are like religious zealots that are fanatical about the whole concept of barefoot running. They use nonsensical non-scientific mumbo jumbo to support what they do. They twist research to make it sound like it supports their cause. They dismiss research that is anti-barefoot. They take any research that is anti-running shoe as evidence that proves running barefoot is better (huh?).

At the end of the day, there is no evidence that running barefoot is even ideal, let alone beneficial. There is also no evidence that its not. I blogged about this here and see Podiatry Arena: Barefoot Running for a balanced discussion on the pros and cons of barefoot running. For a bit a fun check out the zealotry on some of the running forums when it comes to discussing this. Trying to be rational with these people is like trying to argue a religion - not going to win that one.

I have no doubt that the research will show that there will be some benefits to running barefoot; I have no doubt it will also show that there will also have some risks. What we need is better evidence of who and when it should be used. I have no doubt that barefoot running should be a part of a balanced running program for all those who can tolerate it, but it should be used in moderation.

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MASS Foot Position Theory for Foot Orthotics

MASS foot orthotic position theory has been proposed by Ed Glaser, DPM from Sole Supports Inc. MASS stands for Maximum Arch Subtalar Supination. It is a position of the foot that is much more supinated than the traditional subtalar joint neutral position, but also maintains the forefoot on the ground (no varus or valgus captured). Ed advocates the use of semi-weightbearing foam box as opposed to plaster (though it is not difficult to reproduce the position non-weightbearing with plaster bandage). The position results in a very different foot orthotic shape that is what is traditionally used. For more see comments on the Boot Camp site: MASS Foot Position Theory and the threads on Podiatry Arena tagged with MASS position theory (they do get a little heated).

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Laser treatment for toenail fungus

This is an interesting one to blog about, but has everything to do with innovation and bringing products to the market. The laser treatment for toenail fungus (onychomycosis) is a recent innovation. The clinical trials by the company, PinPointe, are underway and no results are yet available. However, many clinics are beginning to widely use and tout this treatment. All the evidence for it is the testimonials and unsubstantiated claims. There are many clips on You Tube about it. Its not cheap and costs a lot of money. My interest in this was piqued when this marketing of a product before the evidence comes in as to its efficacy is lacking. This is a pattern that has been repeated many times in the history of the profession. More often than not, the use of the product dies off as the evidence come in. Don’t we ever learn by our mistakes?

(See this on Podiatry Arena: Nail fungus laser treatment; Laser treatment for nail fungus)

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The MOSI Foot Orthotics

If the foot is abnormally pronating and causing problems, there is only one way it can be stopped. It has to be stopped by the use of a force on the medial side of the assumed subtalar joint axis. While this makes intuitive sense, the problem arises as the position of the axis varies substantially. There are clinical tests that can tell us where the axis is, so we can work out where the force from a foot orthoses has to be applied.

When the axis is located more medially located, the problem comes that there is very little room on the plantar surface medial to the joint axis for that force to be applied. To apply the force various orthotic design parameters have been developed. There is the DC Wedge, Kirby medial skive, the the Blake Inverted foot orthotic.

Recently a unique design, the MOSI foot orthotic has been proposed by Paul Harradine, and Simon Collins., Chris Webb , Lawrence Bevan. The MOSI orthotic stands for medial oblique shell inclination. The aim of this design is to incline upwards the shell of the orthotic on the medial side of the subtalar joint axis. It is an interesting innovative design that makes good theoretical sense.

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a.k.a. Parish and Bell

Just an update on the previous post on Parish and Bell and all the dissatisfied "patients" that were left in no-mans-land with the bankruptcy and no one was held accountable for the duty-of-care.

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Bad research

In the most recent issue of the Journal of the American Podiatric Medical Association is this paper: Robert Fridman, Jarrett D. Cain, and Lowell Weil, Jr: Extracorporeal Shockwave Therapy for Interdigital Neuroma: A Randomized, Placebo-Controlled, Double-Blind Trial. J Am Podiatr Med Assoc 2009 99: 191-193. This was a randomised controlled trial comparing shockwave therapy for mortons neuroma to a placebo.

The purpose of a RCT is to determine how much more effective an intervention is compared to a placebo. To do this the correct way to analyze a RCT is to compare the outcomes BETWEEN the intervention and placebo groups (I could cite some references here, but every book on clinical trials says that, so take your pick).

The authors in this study did a WITHIN groups analysis which is the wrong way! They found a statistically significant difference between baseline and outcome in the shockwave group and no difference in the placebo group. Doing a WITHIN groups comparison, you have no way of knowing how much of the change in the shockwave group was due to the placebo effect which is why you do a BETWEEN groups comparison. On the basis of the analysis that the authors did, they concluded that: “Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton’s neuroma” and made recommendations for its use.

In the paper the authors tabulated the individual results for each participant. I put those numbers into a stats program and did a BETWEEN groups comparison and got a p value for the difference of 0.27 – not even close to being statistically significantly different! The authors actually showed that shockwave therapy for neuromas was no better than a placebo! – the opposite of what they claimed!

Not to mention that this research was also very underpowered and there were dropouts in the placebo group that should have been included in the analysis (look up ‘intention to treat’).

I seriously question how this publication made it past the journal’s review process. Comments here: Shockwave therapy for Morton's neuroma.

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Podiatry site claims of good search engine rankings

Two things caught my eye today.

First there was this blog post from Podiatrists.com:
"the Internet’s leading online directory of podiatrists is now ranked on page one organically on the worlds leading search engine Google as well as; Yahoo.com, MSN.com and AOL.com under the key search queries ”Find a Podiatrist”, “Podiatrist”, Podiatrists” and “Find a Foot Doctor”. Elysium Internet CEO Scott Gallagher commented, ” We’re pleased to deliver our members page one access to search engines that cover 97.3% of all online searches in the US "

and then there was this newsletter from Podiatry Exchange:
"pleased to announce to its readers and vendors that the Exchange is listed as #1 on GOOGLE key word search PODIATRY CLASSIFIEDS. PODIATRY EXCHANGE ranking on GOOGLE key word search under PODIATRYPODIATRY CLASSIFEDS) #1 out of 50,300 listed in that category(PODIATRY CODES) #3 out of 157,000 Listed in that category"

So I did a bit of looking around. According to Overture and Wordtracker (who measure what terms users put into search engines when searching for stuff), no one actually uses the terms "Find a Podiatrist", "Podiatry Classifieds", or "Podiatry Codes". However, from what I understand, a few people will probably use these terms, but it so few that it does not register at Overture or Wordtracker.

The claims made by these two sites are right - they do rank well for these terms, but what is the point in ranking well for them if no one actually searches using the terms! Are they making the claims to impress potential advertisers? Hope none of them fall for it.

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Linkvana Reviews on how to promote a site in the search engines.

Tea Tree Oil

Tea Tree Oil is an 'alternative' medicine. Its seems to be popular amoung Podiatrists in the UK and some in Australia and NZ, but not used widely in the USA (why is that?). It has been shown to be no better than a placebo for the treatment of onychomycosis, yet so many still use it (why is that?). The EU have expressed safety concerns about it, yet many still use it (why is that?) (see: Tea tree oil faces ban over health fear). See these discussions:
Whats your Gold Standard for onychomycosis?
Is there a place for tea tree oil in foot care?
I just can not understand the rationale of those that use it (...there is always the argument that "I used it and got some good results" -- BUT, according to the evidence, a placebo would have got the same results).

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Parish & Bell

Parish and Bell are a foot orthotic clinic in the UK that advertise nationally, apparently use high pressure sales and marketing techniques as well as charge what appear to be extortionist prices for foot orthotics. They recently went bust leaving a lot of disgruntled patients and numerous threads on a number of forums. The one on Podiatry Arena is most interesting as Les Bailey from Parish and Bell tried to rationalise what happen by blaming everyone else for their demise and claiming that the criticism were just Podiatrists being jealous. See the Parish and Bell thread and see the reactions from Podiatrists and patients -- judge for yourself.

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