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I need help with orthosis subject

Posted by Dr. Zuckerman on 7/30/02 at 20:40 (091049)

Does anyone know of any article or study that proved that orthosis are effective for plantar fasciitis and or heel spur.

Re: I need help with orthosis subject

Carole C in NOLA on 7/30/02 at 22:47 (091063)

Nope, I don't really know much about podiatry and I haven't run across that sort of article online. Now, if you merely wanted anecdotal evidence, I could provide that to you from my own experience!

Carole C

Re: try these

elliott on 7/30/02 at 23:46 (091069)

They're of somewhat varying quality and usefulness, but some sound pretty good:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11949663&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11563570&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11415628&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11272297&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797213&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10349286&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10229276&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9735623&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8886778&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1897659&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1920106&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1999801&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2189536&dopt=Abstract

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Re: I need help with orthosis subject

Dr Dennis Kiper on 7/31/02 at 19:23 (091209)

Hi Dr Zuckerman, my name is Dennis Kiper, DPM. One of my patients pointed me to your inquiry here. There are several articles and studies done about orthotics. Not too long ago the American Orthopaedic Board did a comparative study between traditional (rigid and semi rigid) orthotics and over-the-counter types. They actually found that the over-the-counter in most cases worked better. The truth is that any study done regarding this matter is a poor one because it is based on an antiquated biomechanical system.
Traditional orthotics in and of themselves have been a bane to the medical profession and patients for a long time. In my opinion it is because the mechanics of a device that tries to 'control' the way a foot works is illogical. I have found that the foot needs to be 'guided' efficiently though the footstep in order to slow down and reverse years of accumulated inflammation, tension and spasm. As you know, PF is like the 'common cold' of the foot, the #1 most common foot problem in the world. It is secondary to repetitive excessive motion of the arch with every step. By the time a patient first realizes the 'problem', they don't equate that with the underlying condition of the mechanics that has been present since their first footstep on the ground. For some it is easy to reverse their pain by simply minimizing the excessive repetitive motion of the foot we call pronation and overpronation (this can be done even with a wad of toilet paper). This is what every generic, over-the-counter type orthotic does. That is why they faired so well in the 'study' by the Orthopods. Unfortunately for most an OTC support is not precise enough. Custom traditional orthotics on the other hand, while they are customized to the patients foot, does not mean they fit the way that foot works, hence all the failures and semi-satisfactory results. A traditional support is too rigid, it locks the foot up and in most cases is uncomfortable and in many cases the patient finds dissatisfaction in their results and maybe even ripped off by the cost.
What is strange is that while there are many products, and therapeutic modalities, they all ONLY address to the symptoms of PF. Only an orthotic addresses the underlying mechanical cause. Until one finds a proper fitting orthotic that can be changed as the architectural position of the foots alignment to the floor changes, then you will have a difficult if not impossible 'cure'. But cure is possible in my practice. I devote myself to guiding the patient through an adjustment process whereby the fit is easy and comfortable to wear and the intrinsic muscles of the foot accept a new way of walking and become retrained to forget what it was like being misaligned and feeling the difference of being aligned. This is not an easy process, because regardless of whether the patient is chronic, complex and severe, most patients unless they hit the lottery with instant satisfaction are prone to becoming frustrated and disappointed when they don't get the results they hoped for in a more acceptable time frame to themselves.

Re: I need help with orthosis subject

Dr. Zuckerman on 7/31/02 at 20:47 (091214)

Here is another way to look at the problem of plantar fasciitis. It is my
opinion that pf /heel spur is caused by repetitive injury to the plantar fascia at the insertion. Yes there may be pronation but the patient has injuried the area either by standing too much usually on cement or hard surfaces. So you have same tears. The body tried to heal the tears. No luck there is too damage to the micro circulation and we have what I call a mal-union of the soft tissue. The patient is limping. It is my opinion that at this stage no orthosis is going to help. You need ESWT or surgery and ESWT has so many benefits when compared to foot surgery.

So what causes pf? Biomechanics maybe contribute hard surfaces or injury yes. There are thousands of patients with abnormal biomechanics that have pain free feet .

Re: try these

Dr. Zuckerman on 7/31/02 at 20:55 (091215)

Thanks

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 07:30 (091248)

I agree and yet have to challenge your remarks. While there certainly can be micro-tears resulting in scar formation(which may be the cause of the most chronic and difficult cases we see), standing on hard floors and cement is not necessarily the cause. Standing on any surface causes the foot to absorb incoming shock. This is the repetitive process of pronation and overpronation. It is this underlying condition which produces the problems. To say that an orthosis will not help in my opinion is incorrect, because while this particular case may and probably will require something more radical i.e. ESWT , and lastly surgery, only an orthotic addresses the underlying root of the pronatory forces.
You must support the foot in its healing process. Otherwise it's like adding insult to injury.
Your statement that there are thousands of people with abnormal biomechanics that are pain free. What is 'abnormal biomechanics'? Do you mean conditions such as pes cavus, rocker bottom, coalitions etc? Or do you mean pronation?
What is poorly understood is that everyone 'overpronates'. The foot stretches with every step as far as necessary to absorb incoming shock. And it is this repetitive (normal) motion that over time takes it's toll. People who are pain free are rare. In my experience of over 30 years, many people are so used to their discomfort and feel there is nothing that can be done about it, forget, they are not pain free. For those individuals who are truly pain free, you have to wait until the end of their life span to ask 'have you been totally pain free'. The remainder of people who are pain free otherwise have died before they had pain develop.
This is the nature of things.

Re: I need help with orthosis subject

paula on 8/01/02 at 09:44 (091262)

dr kiper. welcome to this board. we have good pods who help us here and give us very useful information. another doc is very welcome. hope you stick around and can offer your expertise to us many sufferers. good to see a doctor dialogue with varying opinions. this will help us all i am sure. what is your opinion of posterior tibial tendon dysfunction. do you have any words of wisdom for me? i have very flat feet. other docs jump right in as well.

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 10:41 (091267)

Thank you for your welcome. PTT dysfunction is like any other biomechanical problem in that it stems from excessive repetitive motion of the arch with every step. The problem has taken your lifetime to form, until you feel it.
The difficulty with PTT is that it is a long term injury. Like any tendon, it receives a diminished blood supply. Coupled with the fact that you still have to get up everyday and perform your daily activities, you are constantly antagonizing the very thing you're trying to rest. So it's two steps forward and one back.
The mechanism of this injury is overpronation, the tendon glides through the surrounding tissue (called fascia) with a greater degree of friction and irritation because the 'track' of the tendon is inefficient. To resolve this, an orthotic that meets the criteria of a precise fit (comfort, fullness and stability on the floor) will in fact reverse the inflammatory buildup and you would become pain free. If finances are a problem for a custom orthotic any OTC support will help to at least minimize your overpronation and at least start you on the road to some recovery. Some of the OTC products work better for different people. It becomes a matter of trial and error. If you wind up buying as many OTC that exist, you'll wind up spending as much or more for a custom fit.
If you've tried custom supports before and failed, at the risk of sounding like a salesman you may want to review my site drkiper.com I have something different that you may want to consider at some time in the future. At the very least you MUST look at the stretching exercises for the lower extremity. Stretching is a key component in resolution and maintaing flexibility for quality of life.

Re: I need help with orthosis subject

paula on 8/01/02 at 12:49 (091280)

i will review your site. but i think i've beent there before and i didnt see exactly what your orthotic is about. is it all silicone or is there silicone in specific areas? i have already shelled out another load of money on a ucbl because a dr gere here mentioned that i think. i have to go pick it up. if it doesnt work i may call you.

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 13:24 (091285)

What it's about can be quite lengthy, but it is silicone fluid NOT gel. It moves with the motion of your arch as if it were part of your foot. This makes it easy and comfortable to wear including around the house in slippers or sandals. Yet it limits overpronation which is what an orthotic is supposed to do. The scientific principles of the sdo go back over 2000 years to Archimedes and Pascal (you can find those principles under their names even in your dictionary). You can also see the scientific evidence under my link to 'computer tests'. One of the major problems with traditional supports is that it locks up the foot in a pre-set position so the foot step is 'static' rather than 'dynamic'. Now if it's comfortable and it works, that's the bottom line. The silicone let's your foot work naturally, and guides it through the foot step, so it feels like your own foot. I hope the one you've already been custom fit for by dr gere, fits the way you walk. If not and you want to give me a try (I hate sounding like a salesman), remember my offer is risk free. If you're not satisfied by 6 months you're not stuck with another set of orthotics, give them back.

Re: not to butt in on this dialogue between Drs

elliott on 8/01/02 at 17:55 (091319)

but I believe that study to which you refer comparing custom orthotics to OTC ones finding the OTC ones better is in one of the links I gave to Dr. Z (click below):

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10229276&dopt=Abstract

What you didn't point out is that, as the title there suggests, this was for 'initial' treatment only of proximal PF, not a general all-encompassing conclusion. But, as previously pointed out by Dr. Ed Davis, DPM, everyone fails to mention this. (Sort of reminds me of Jim Fixx, where every sedentary potato couch seems to know that the legendary promoter of running died of a heart attack while running, but never seem to know that he had a genetic heart defect that caused it and which could have been detected had he gotten checked as his family history had warranted.) (Could it be you're both right, but that your OTC orthoses are targeting an earlier PF stage, Dr. Z's ESWT a later one?) In addition, I believe Dr. Ed stated (but I could be wrong) that this study was funded by (you guessed it) some pre-fab OTC orthotic company. Regardless, once you look past the initial treatment at longer-term sufferers, maybe traditional orthotics would make a comeback. In fact, yet another link I supplied Dr. Z,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

probably including longer-term patients, suggests that traditional orthotics (and night splints) got all the way back to 'no statistical significance' between them and OTC orthotics! A lot better than being negative. :-)

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Re: regarding sounding like a salesman...

elliott on 8/01/02 at 18:04 (091324)

Here's an idea: Would you agree, by any chance, to giving out a number of free OTC orthotic samples (e.g. 10) to members of this board, maybe through Scott R (the board host) or someone else, who can do the followup and publish the results. We see how well it worked, and if a high number of them get cured or much improved, you stand to gain tremendously. (Such a thing was tried before.) And then we won't have to see all those 'just go to Dr. Kiper!!!!' posts. So there's something in it for everyone. :-)).

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Re: regarding sounding like a salesman...

Dr. Zuckerman on 8/01/02 at 19:59 (091342)

Now we are talking elliott. ITs called place your money where you mouth is.

Re: regarding sounding like a salesman...

Pauline on 8/01/02 at 23:10 (091358)

Elliot,
I appreciate your point about repetitive advertisment, but in Rons defense please tell me what is the difference between Ron posting about calling Dr. Kiper for help or Dr. Z posting about contacting his office for ESWT treatment?

Personally I think they are both the same except one is a doctor offering his services and the other is the satisfied patient of a doctor telling posters about a Doctor who carries a product that helped him.

Both Dr. Z office and Dr. Kiper's orthotics are already carried on this web site in other locations and probably neither need to be mentioned as often as they are, but sometimes it appears to this reader it's more about territory than treatment or product.

We are fortunate now to have many doctors that visit this board. I suspect all of them offer good treatment whether it be ESWT or orthotics and could also use a plug, but none of the others including Dr. Kiper, until Ron's enthusiast post, which brought on suspicion, advertises their practice or products on this site.

In fact, I remember Dr. Joe pointing out this fact in one of his posts saying he didn't advertise his practice on the site. I'm not sure we really know where Dr. Joe practices. I don't know where and I don't know Ron and I don't know Dr. Kiper except from his recent postings and Ron's posts about him.

To me advertisement is advertisement whether it's enthusiast Ron or enthusiast Dr. Z. After the man is check out for spam and found not to represent Dr. Kiper I think he should be left alone to speak about what helped him. If it provides conservative help for someone why not?

I would simply ask Ron not to plaster each reply with it, the same as everyone else.

Re: regarding sounding like a salesman...

Dr Dennis Kiper on 8/02/02 at 07:49 (091379)

Just about like most things, not every OTC product is good for everybody.
You'd do best by trying them one by one until you found what works best for you.

Re: To Dr. Kiper regarding sounding like a salesman...

Pauline on 8/02/02 at 08:59 (091395)

Dr. Kiper,
I'd like to also welcome you as others did to this web site especially since your orthotics got here before you did. I hope that you will continue to be a sourse of information for posters by expression your opinion on all the varous questions they ask.

I think it's a privlidge to be able to gather answers and ideas from so many doctors on one site.

Certainly your orthotics sound unique, and because they are part of a conservative approach to treating P.F. surely a welcomed approach to treatment before people consider surgery.

I along with others will look forward to your participation on this site.

Re: do I take that as a "No"? :-) (nm)

elliott on 8/02/02 at 09:14 (091400)

.

Re: since you asked, here's the difference

elliott on 8/02/02 at 10:14 (091404)

Dr. Z just about always responds only to questions about 1) ESWT or 2) what alternatives are left before surgery. In fact, I did a search for the month of July, and every one of the 5 times Dr. Z answered with his email address for info, it was in response to one of these two types of question. By contrast, Ron P pops up everywhere unprompted, in fact 30 times over the month of July (this excludes the posts where he responded to others querying him or his few posts about Birks, and together that's all he's posted about). That is the key difference. The equivalent behavior would be if Ron P, or Dr. Kiper himself, responded when someone asked for an orthotic that works or (if appropriate) alternatives to surgery.

There are other things worth pointing out too. We're human, so the number of posts does matter. 30 in one month is a lot. I'm not sure what you mean by check someone out for spamming. How do you do that? I know Scott R is the POWER, but even he would have trouble ascetaining with certainty whether someone has a financial incentive to post about a product. And it can even be a real person who got cured, but he can still be a spammer. Regardless, whether Ron P is a spammer or not, he sounds like one. All his posts are the same variation of the same 3 or 4 lines ('Have PF? Why not call Dr. KIPER? 800...Silicone! Really helped me! Web site/email too! Call now!'). Sound like a spammer and you turn people off. You'd think they would realize that. Contrast that with me, a poster with good intentions who gets on some people's nerves. I tried an orthotic by a company recommended by Dr. Ed, with the mold taken by a pod in my state. In four months, it brought my foot back from near-crippled to being able to walk. Not sure it will save this foot from surgery in the future (there's a bone issue to be dealt with), but it is doing what an orthotic was designed to do, and doing it well. I posted once or twice raving about it, almost nobody believed me, and then I moved on to other things. That fits a more typical profile, rather than someone coming on to post about nothing but. Again, we're human, so we make such evaluations on people. You can also throw in that Dr. Z gains more credibility by answering other questions. Maybe Dr. Kiper, if he has time, will do the same.

All that said, your point is well taken about anyone promoting their products, including Dr. Z, and some can view what he's doing too as shameless promotion. I feel a little uncomfortable about it, but only a little. And that doesn't mean I believe everything he says either. (I for one will admit that I am still doubtful about claims of 90% success rates with ESWT. Time will tell for sure. I'm leaning more towards 50%, which still has a lot of merit. Newer machines no doubt will improve the figure too.) While there are wide-ranging views on perceived advertising here, the general consensus is that we'd like at least some exposure to new products and treatments, and letting their promoters respond, within reason, is the way to get it. We're trying to get better here but without being taken for a ride.

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Re: since you asked, here's the difference

paula on 8/02/02 at 13:40 (091431)

the way i look at advice here is if the medical professional answers questions that have nothing to do with his making a profit. then if he also stands behind his method that makes him money that is not a problem for me. but if he only answers or mostly only answers to promote his thing then i start discounting everything said. that's how i look at it. i have been helped very much by docs here on topics that they were never going to make a penny on. long detailed thougtful answers too. taking time to help and heal

Re: since you asked, here's the difference

Pauline on 8/02/02 at 15:14 (091443)

Since Dr. Kiper is new to this site, I think we have to wait to see if he will continue to answer questions like the rest of the doctors that post here. I think he will.

Personally, I think he's being judged solely on Ron P's postings and not on his merit or committment to helping people. I don't think you can compare a new arrival with yourself who has been here for some time solely based on the number of questions answered. We have no way of knowing if he lacks commitment. It's too early to tell.

He and Dr. Joe and possibly Dr. Ed are the only doctors posting that I know of that could be considered 'outsiders' meaning not belonging to your ESWT group. Maybe Dr. Ed does too. I don't know. I believe you mentioned you have 35 doctors now, yet none of the others coming here including Dr. Wander ever ask people to contact them but they still continue to answer many questions for posters. I think they are just as committed to helping people as you are.

Your points are well taken , but I don't think we should or can honestly judge what Dr. Kiper is about. Time will tell all of us loud and clear.

Re: since you asked, here's the difference

Dr. Zuckerman on 8/02/02 at 20:38 (091463)

Hi Elliott. I appreciate your effort and time with postering.

The claim of 92% Average reduction in pain from ESWT during the one year follow up.with the epos is FACT. This was taken from the FDA multicenter studies. CAll the FDA . Look up the study.. Its all there. I didn't make the Claim up . Dornier reports their claim and the FDA confirms it .

Re: relationship of faulty biomechanics to PF

Ed Davis, DPM on 8/03/02 at 14:30 (091485)

There are too many variables and our ability to measure those variables too limited in order to accuarately relate the relationship between biomchanical deficits and symptomatology. We can make generalizations.

Both Drs. Z and K are on the right track but their emphasis is different. I have proposed a 'treatment triad' here previously in order to remind posters to avoid over-emphasing any one of the 3 'legs.' The legs include biomechanics, inflammation and tissue quality. Control of biomechanics alone may or may not be adequate for a cure. Control of tissue quality alone is unlikely in my mind to effect a long term cure despite our inability to use biomechanical info. to accurately forecast or predict symptoms.

In response to Dr. K, most would consider 'functional' foot orthotics to be dynamic in nature. I can see how the SDO's would be able to decelerate the rate of subtalar joint pronation, thus providing a good benefit. I am uncertain of their effect on midtarsal joint function which may be a signiticant factor for many. I would appreciate Dr. Kiper's assessment on this.
Ed

Re: since you asked, here's the difference

elliott on 8/03/02 at 22:51 (091513)

I just want to doublecheck that the 92% means that a random patient going in will have a 92% reduction in pain coming out, and not something like, if it works, it will bring about on average a 92% reduction in pain.

I haven't been keeping count, but I get the impression that our board's experience has been nowhere close to this. Any explanation?

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Re: since you asked, here's the difference

Dr. Zuckerman on 8/04/02 at 07:57 (091526)

My understand is that is was those patients treated in the FDA study after one year had a 92% average reduction in pain . No one on our board is post one year ESWT

Re: I hope you're right

elliott on 8/04/02 at 23:12 (091590)

I wouldn't mind seeing the detailed study, though. The FDA seems to have removed the page on Dornier Epos efficacy from its web site. In an extensive web search, I couldn't find any such figure quoted. The only one I did find was 60%, quoted in the article below:

http://atlanta.bizjournals.com/atlanta/stories/2002/04/29/focus12.html

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Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/05/02 at 11:42 (091632)

First I'd like to address 'faulty biomechanics'-this is an innacurate way to describe someone with a problem'. It is 'normal' biomechanics.
The function of the biomechanics is to allow locomotion and absorb the incoming shock to our system. It is wear and tear of our normal biomechanics that produces the problems. Not everyone is affected the same way. PF is the most common problem, but almost all lower extremity injuries are the result of the same repetitive excessive motion of our arches as we walk, including hip and low back pain. The functional shortage of one side (that has come into vogue in the last couple of years)
is also a function of 'normal' biomechanics. Our two feet while they look the same are not identical in their measurements (same as two cars coming off an assembly line). The brain recognizes this difference as we begin to walk and slowly makes the adjustment in our hips that produces the (FS) 'functional shortage' (I wrote an article about this for a running magazine and it describes how you can examine yourself for this FS) at my http://www .
Couple all this with the variables of bone development (anteversion, and antetorsion-(twists and angles) and it becomes more complex for some people
If there are vitamin deficiencies (e.g rickets), there will be changes in our bone shapes. It goes on and on. All this leaves us with our own normal biomechanics for the way we're built and the way we're shaped.
While all orthotics including generic (OTC) are functional (just diffences in precise fit) I do not consider all orthotics to be 'dynamic'. Our foot and leg muscles do help to decelerate pronation, but the problem in my opinion with traditional orthotics is that the end of the range of motion (of pronation) is terminated abruptly. This is not the motion that the foot itself makes, but rather a fluid motion. In addition the position of the orthotic locks the foot into that position. If the foot likes it and it's comfortable and it works, then you're going to have good results. But I have found in 30 years of practice that most feet do not like traditional orthotics because it is not comfortable and the pre-set position of a traditional orthotic is not tolerated. Hence, non-compliance and poor results.
The SDO that I work with is very different. It moves with the foot as if it were part of it. It helps the muscles in decelerating the motion of pronation and allows the end of range of that motion to be cushioned rather than stopped abruptly. Yet it does what it is supposed to do, in that it limits the amount of overpronation which is the injurious effect of that repetitive motion. It just doesn't do it in the conventional way as a traditional orthotic by holding and trying to control the subtaler joint. Rather than control the foot from behind to front. It is a retrograde effect of disallowing max pronation at the middle of the foot, thereby disallowing the rearfoot (sub taler joint) from rotating out further allowing greater pronation (overpronation).
I'm sure that most of the people at this site are better educated to biomechanics than most (not including runners), and the SDO flies in the face of those traditional theories. Well, I have simply found another way to 'skin the cat.'

Re: I hope you're right

Dr. Zuckerman on 8/05/02 at 20:10 (091679)

I have the one year follow up report in a graph form . This is from the company dornier. Will Scott post this ??. Be very happy to provide this for the site if Scott wants to post this for the viewers to see

Re: Dr. Kiper

elliott on 8/05/02 at 22:20 (091707)

Seems to me whether you call crappy feet normal for that individual or faulty is just a matter of semantics, but I'll let Dr. Ed answer for himself. I had some other things on my mind to ask you. I looked at your web site. (I will say that your six-month guarantee does offer credibility.) There it is claimed that the SDO cure rate for PF is essentially 100% (albeit with different healing/marked improvement times, ranging from a week to 2-3 years to 6-10 years). Given the complex nature of the human body, as well as variation from human to human, I was wondering if you could explain that 100% a bit. I mean, what if someone's PF is a hair away from rupture (or even did rupture; an MRI often has trouble detecting even this). What of those cases that happen to have entrapment of the first branch of the lateral plantar nerve but are impossible to definitively diagnose? What if someone's obesity is contributing to the problem? (If obesity is completely 'normal', then pass the chips. :-)) What about heel irregularities, and not just spurs thought not to be the culprit. The list goes on. It's not all about an individual's 'normal' pronation. I gather you screen candidates, but even so, exact diagnosis of causes for each and every patient is impossible, hence no one technique should be expected to offer 100% success, yet yours does. Please explain.

A few other questions about orthotics. Why aren't OTC versions of SDOs, as sold elsewhere in California, good enough when combined with, say, a well-fitting running shoe controlling for pronation? Also, many custom orthotics on the market today do give a little at the arch when the foot weight-bears in the gait. Why isn't this good enough? Thanks.

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Re: relationship of faulty biomechanics to PF

BG CPed on 8/05/02 at 22:24 (091708)

This is all very interesting. There are many opinions on why an orthotic works or fails. My opinion is that many devices that are rigid with a high arch also lack proper rear foot control. If you have tight heel cords/gastroc and over pronate the eversion of the hind foot will create more mid stance to late stage pronation, which puts a very strong traction pull on the fascia.

Simply putting a 'lump' or a medial arch under the midfoot, w/o dealing with the hind foot can put more tension on the fascia as well as making the device uncomfortable. Most pf pt that pronate will say that upon rising they walk on the outside of the foot to reduce pain, this is a compensation that reduces the pull on the fascia.

This may be over simplified but in a case of ptti or pf some Dr will put the pt in a hard cast for several weeks. They dont cast them in pronation or wt bearing since that does not reduce the pull on the fascia. Many times the pain is reduced very soon but if the causative factors are not dealt with the pf can return after cast is removed.

With the heel cords and hind foot controled meaning wedging and heel elevation via insert and footwear I feel that symptoms will reduce much sooner than a lump in the arch that functions as a damper in a shock absorber.

Regards to the study that claimed the pre fabs over custom? If that was the one done near San Fran that studay was flawed imho. First the lab for the customs used was very good. The casts were taken by several different people, this is like doing a study on the best pizza and haviong it made by 5 different people, that methodolgy creates too many variables.

the other flaw was that the study was funded by a heel cup company. Once the results were released the wire services just printed 'study done heel cups better than custom orthotics'

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 07:38 (091719)

I don't believe I use the word 'cure' on my web site. It's taken me close to 5 years to put my site together, so if the word 'cure' is there, please point it out. I say this because I am aware 'cure' is a nebulous word in medicine. We are always vulnerable to problems exacerbating, because the underlying condition is always present. I repeat that our problems are a result of wear and tear over time. An orthotic does not 'arrest', it merely minimizes and slows down the condition. If the problem is not felt, and you want to say 'cured', I guess that's OK, I'm not sure.
As for the total success of relief from PF I do say that it takes up to 6-10 years to reverse the health of the tissues (microscopically) the way they were 10-30 years ago. This is because everyday that we are getting better, we continue to antagonize the very problem we are trying to get better, so it's always two steps forward and one back.
Chronic, complex cases do present a more difficult situation. The most complex cases have had repeated injections (cortizone) and/or surgical intervention. What I do say here is that an orthotic may not be totally effective by itself, but regardless, should be wearing an orthotic to address the underlying condition of repetitive excess motion (overpronation). In fact my philosophy is that everyone should be wearing a foot orthotic because prevention is the issue, not just pain. After all most of us brush our teeth not because we have a cavity, but we're trying to prevent them. I'm sure that all or most of my colleagues (as well as others in allied fields concerned with orthoses), would disagree. That's because it's so hard to find an orthotic that fits everyone. This is what is so unique to the silicone orthotic, it can fit anyone. It's just a matter of finding the correct volume of fluid that supports, maintains balance/alignment and is comfortable that is necessary without controlling the subtalar joint. This does not mean you can never get a problem in your life, it simply means that wearing an orthotic can slow down and minimize your vulnerability to injury (same comparison to brushing ones teeth).
Your cases of a PF about to rip, if it's going to rip, it's going to rip.
Obesity? Compounds the problem, not necessarily cause the problem, after all there are many thin people who get the same problem, right? It's a matter of wear and tear of that person's normal mechanics over time.
Entrapment of the lateral plantar nerve, well if that's the case, the patient should still be wearing an orthotic. The variations in complexities are just that and an orthotic alone is not always the only answer, I never said it was.
As for OTC versions of the SDO, they are available through 'Sharper Image' catalog. The major difference is that the volume of fluid in those are generic. Besides the template size of a foot, the key to a prescription is the precise volume of fluid that fits the individual. It feels and works differently than the OTC ones.
Semi-rigid orthotics as you discuss do give a little, but they do not 'flow' in their motion akin to the human foot. They still hold the foot (albeit with some flex) to a pre-set position and terminate the end of the range of motion (pronation/overpronation) abruptly . As I've said before, if it feels comfortable and it works, then that's the bottom line. You have an effective orthotic.
I know that my writings are controversial. I'm not here to argue about it. I let my results speak for themselves, I offer the 'risk free trial'. With nothing to lose, what else is there? My failures are due primarily to patients who are frustrated and diasappointed that they did not have results within the trial period and they did not want to take a chance that they would lose more money than they already have with several others.
But the sdo fit them according to my criteria, which means that they were working, just not quickly enough for the years of accumulated damage as far as the patient was concerned.

Re: relationship of faulty biomechanics to PF

Carole C in NOLA on 8/06/02 at 08:24 (091723)

Thank you for a fascinating post. I always learn a lot from your posts, and this is one I can really relate to due to your discussion of the need for rear foot control rather than a lump under the arch. My feet agree with you 100% at present, although my PF is essentially gone.

You mention hind foot wedging and heel elevation via insert and footwear.

What shoes (if any) come to mind that provide some heel wedging? Are there OTC inserts that provide a heel wedge?

Or were you referring strictly to custom orthotics?

Carole C

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/06/02 at 10:12 (091731)

A 'lump under the arch shows a lack of understanding. There are two arches:
1-medial arch
2-longitudinal (which should include the 'lateral arch' or be a seperate entity.
A lump under just the medial arch would be an undercorrection of a precise alignment fit.

Re: Dr. Kiper

elliott on 8/06/02 at 11:19 (091738)

Appreciate your response; interesting. The word 'cure' does appear on your site, but not in a context which detracts from what you're saying. I used it to save words, clarifying it myself later in the same sentence.

The problem with 6-10 years (or even 2-3) is that in order to judge the value added from the SDO, we'd have to compare it to other orthotics, as well as other conservative means (which supposedly 'cure' 90% of PF anyway), difficult if not impossible to do, although that's not your fault.

Not sure I accept the toothbrush analogy: we weren't meant to be eating all the junk we do, but since we do, brushing is good. Also, after a minute, you put the brush away, as opposed to using orthotics the entire time you walk. Increased risk without them? Don't ride in a car or fly in a plane either. Orthotics aren't risk-free either, e.g., they've been known to cause medial plantar nerve entrapment in runners, although it makes sense yours might not give such problems.

I must say, though, that your money-back guarantee six months forward is very fair, and if for no other reason I hope some of the longer-term PF sufferers here give it a try so we can observe how much they improve. The only problem is, then they'll be flooding this site with 'just call Dr. Kiper!!!' :-)

Thanks.

Re: since you asked, here's the difference

mary on 8/06/02 at 13:14 (091746)

you have too much time on your hands

Re: since you asked, here's the difference

Dr. Zuckerman on 8/06/02 at 13:31 (091748)

Lets see I run a practice which sees forty patients a day. What I have is a computer sitting at my desk that is a DSL. Speed is what I have !!!

Re: relationship of faulty biomechanics to PF

BGCPed on 8/06/02 at 14:43 (091755)

I am not sure if you are reffering to my term lump under the arch. It was used to illustrate the type of devices I see every day that are 3/4 shell, shallow heel cups and lacking proper hind foot control. I think it is safe to assume in laypersons terms that the 'medial' or inside arch is the most obvious arch I am talking about. If we really want to be correct there are actually 3 not 2 archs. The transverse metatarsal arch is also a factor.

Re: re: eliot

paula on 8/06/02 at 15:56 (091761)

where do i get over the counter sdo s from? i'd like to try them

Re: Since you asked...

Mahatmelissama on 8/06/02 at 17:20 (091770)

http://drkiper.com/ for custom ones...

I myself am trying these, only been wearing them since 07/31/02.

Dr. Kiper says 'As for OTC versions of the SDO, they are available through 'Sharper Image' catalog'

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/06/02 at 17:25 (091771)

Now you got me. I'm not sure what you are referring to. 'term lump'?
I understood you to refer to the efficacy of the orthotic by putting a 'lump' under the arch.
As you notice I did mention the lateral arch as a possible seperate entity(your reference 'transverse metatarsal')

Re: re: eliot

Dr Dennis Kiper on 8/06/02 at 17:53 (091772)

The OTC type are from 'Sharper Image' catalog. Actually, they are not a fluid like the SDO, but rather a gel. I've had patients try them before they stepped up to the SDO and the response was favorable.

Re: since you asked, here's the difference

Dr Dennis Kiper on 8/06/02 at 17:55 (091773)

I'm just efficient.

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 18:21 (091777)

Let me clarify the time parameters of the healing process. I expect that in plain old PF (usually less than 1 year's onset), a positive response is noted within 60-90 days (anything from 20%-100%). Presuming the orthotics fit properly and are comfortable, this would indicate we are on the healing track. On average (in my experience), most patients feel 60-90% better by the end of the first year (sometimes two). Many feel 100% better, BUT there is still a level of microscopic inflammation that I am talking about that still takes years to reverse (even though the patient might feel pain free). Generally any remaining pain by the end of the first Rx change is usually resolved within another 6 mos-a year (in most cases). Some chronic patients who are lucky can go through this healing even quicker, just the luck of the draw.
My analogy to the damage accumulated over a lifetime is 1 mile in a car for every foot step, so if you count from the time you started walking on the planet to the time you first experience the problem (not counting the cases who are chronic, through neglect, unsuccessful treatment and worst, injections and surgery)), your feet are like cars with 300,000-500,00 miles.
How quickly do you think it should take to reverse this kind of damage?
Now consider that even with your pains you have to perform your daily life activities, hundreds to thousands of footsteps/day, for runners it's worse.
It's easy to become frustrated and disappointed when you are not getting relief. It's worse when your orthotics are uncomfortable. BUT, when an orthotic meets 3 criteria
1-feel support/fullness
2-comfort
3-stability on the floor
then those orthotics fit correctly and are working. It then is no longer a matter of 'if' it works, but 'when'.
My time frame of 6-10 years for total reversal of tissue health is really
not one substantiated, I only use that to help the patient understand that there is a very timely process involved here. Sometimes flare ups can occur, sometimes one seems to stagnate in their healing process. I always remind them of the time frames of the healing process, to be patient (as long as the criteria of the orthotic fit is met) and to be patient.

Re: Dr. Kiper

paula on 8/06/02 at 18:36 (091779)

i went to sharper image online and could not find the sdo s

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 19:36 (091783)

I checked it out (gel insoles), you're right I didn't see it either. You might try e-mailing their customer service dep't. It's possible that they don't carry it anymore. I heard good things about it, but it still was not any better than a generic OTC support (precision of fit is key).
Do stay away from the magnets and magnet orthotics, if you want a OTC referral I would recommend 'Spenco' 3/4 length or 'Superfeet'.

Re: Lets put the Kiper orthosis to the test

Dr. Zuckerman on 8/06/02 at 19:39 (091784)

All of this sounds very professional so lets do a study. Would you be willing to have a study of say ten to fifteen heelspurs.com heel pain patients . We could track the results/ This has been done before by Scott Roberts. How does this sound to you . How does this sound to the board

Re: Lets put the Kiper orthosis to the test

Dr Dennis Kiper on 8/06/02 at 20:25 (091786)

What you're asking is a lot of work. I don't personally feel I need to do this study, because a study of 90-100 patients has already been done by a physical therapy group in San Jose (not me). If you want those stats I can get them for you and the group.
The 'real' study would be to have those people who have been suffering with lower extremity injuries take the 'risk free offer' and at the end of the 6 months those who wanted their money back could post their results and be none the worse for it. Those that were helped and wanted to keep their orthotics would be getting their money's worth and the opportunity to be pain free and they could post their results.

Re: Dr. Kiper

paula on 8/06/02 at 21:17 (091789)

thanks, i'll look into the superfeet.

Re: Lets put the Kiper orthosis to the test

Dr. Zuckerman on 8/06/02 at 22:28 (091798)

That sounds pretty fair to DR. Z.

Re: innacuracies

Ed Davis, DPM on 8/06/02 at 22:59 (091802)

Dr. Kiper:

Studies at Univ. of Pennsylvania showed more of a deceleration of the rate of pronation as opposed to a direct effect on the amount of overpronation. The foot moves aginst the orthotic thus no hard stop to pronation applies.

I don't want to nit pick semantics but biomechanics that lead to actions creating pathology is basically a definition of pathomechanics or 'abnormal' biomechanics. I would consider biomechanics to be abnormal if the end results are stresses or strains on tissues of significant magnitude to cause pain or dysfunction.
Ed

Re: relationship of faulty biomechanics to PF

Ed Davis, DPM on 8/06/02 at 23:18 (091805)

BG:

I too am a bit dissapointed that Dr. Kiper refers to a study that is badly flawed and had a political agenda.

That aside, I welcome his input here. New ideas are refreshing but I feel an obligation to respond when controversial ideas are introduced. The obligation based on what I percieve is a need to give readers a broad but critical perspective.

Their is motion between the foot and a (non-fluid) orthotic so the type of rigid 'stops' and control that some suggest really is not there. Even the best made orthotics will not work for all so I am cautious when basic concepts of orthotic design are criticized --- failures will exist due to limitations of any modality.

Plantar fasciitis treatment involves our ability to control biomechanics, inflammation and tissue quality. I referred to three 'legs' but I failed to mention that those three legs or factors are rarely equal and can vary drastically from patient to patient. It is easy to fall into a 'trap' as a provider, by focusing on the 'leg' that we have the most control over -- biomechanics is the leg we work on the most, physical therapists -- inflammation and tissue quality is being addressed now by ESWT. Failure to cure PF is too often viewed from the perspective of one 'leg', ie. orthotics can never be a assured 'cure' for PF, they can only be a treatment for the abnormal biomechanics that can start and exaccerbate PF.
Many times biomechanics alone can effect a cure, but often it cannot even when expertly and perfectly applied.
Ed

Re: guys, I thinks she means me

elliott on 8/07/02 at 00:08 (091810)

Mary, how fortunate you are I have time on my hands so you can be the beneficiary of my eternal wisdom. :-)

---

Re: Dr. Kiper

Julie on 8/07/02 at 01:57 (091812)

Dr Kiper, your thoughts on the generous 6-10 year time frame for the healing of PF ('total reversal of tissue health') make great sense to me. I've suspected from the beginning that those who interpret cessation of symptoms as 'cure' are in for trouble in the form of future recurrences if they stop doing whatever 'worked', i.e. caused the pain to disappear.

If something, or a group of somethings, helped to bring one to an asymptomatic state, whether orthoses of any type, or Birks, or not going barefoot, or stretching, it would seem to make sense to continue doing/wearing whatever it was that helped, and not abandon self-treatment when the pain goes.

Anyway, that's my take on this business of 'cure', so although I was virtually pain free almost two years ago, and have been totally pain free for about a year, I stick to what helped: my feet are never (well, almost never) out of my trainers with orthotics (not yours, but they've worked for me) or my Birks.

Whatever the 'cause' of someone's PF, the result is damaged tissue, so it has to be a good idea to be vigilant long after symptoms disappear. 6-10 years sounds like a reasonable time frame to me.

Re: relationship of faulty biomechanics to PF

BGCPed on 8/07/02 at 09:28 (091820)

My reference to a 'lump' was not intended to support that theory. I was talking about the many non functioning devices that put too much focus on just medial arch support and not dealing with the foot as a whole. Again the 'lump' term was not used in a positive context

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/07/02 at 09:49 (091824)

When you refer to 'non-functioning' devices, are you referring to generic supports?
It is my contention that anything, even wads of cotton or toilet paper placed under the foot is 'functional'. The reason being that anything that minimizes the action of overpronation is helpful. In my opinion the foot functions around an 'optimal' position rather than to a 'neutral' position.
Anything that can put the foot closest to that architecturally aligned position to the ground is going to make the foot and lower extremity more efficient. If you accomplish that, then you have balance and 'control' (I really hate that term).
The more precise you get the foot to its optimal position the better everything is going to work and be more comfortable . I feel that 'rigid' and 'semi-rigid' control has gotten too complex. Furthermore I don't think the foot likes to be 'controlled', it's a dynamic organ that moves across a plane to locomote. The infrastructure of the foot is twisting and turning to accomplish this. Simply support that infrastructure so that it can feel and behave as natural as possible and you've got it.

Re: innacuracies

Dr Dennis Kiper on 8/07/02 at 09:54 (091825)

I am aware that the muscles designation to decelerate the pronation motion, but once it hits the end of the range of allowable motion (constrained by the position of the rigid-semi-rigid) it is abruptly stopped.)
As for only abnormal biomechanics being painful, what do you refer to that patient's biomechanics 1-5 years prior to his/her ever having the first symptoms?

Re: innacuracies

BGCPed on 8/07/02 at 21:08 (091898)

If I may contribute my .02 The patients biomechanics 1 to 5 years prior to ever having symptoms would still be considered abnormal (assuming they are)just asymptomatic. A good anaology would be high bp, cholesterol and tryclicerides when you are 35 and one day at age 39 you are shoveling snow and boom you suffer cardiac arrest and die. You had improper vascular function but didnt get symptoms till later. They are both a result of a pathology that may take 40 years or 10 years to emerge. I would say we can all agree that the majority of pf patients we see they all have some biomechanical and or footwear/adl issue that drives it.

How oten do you get a pf pt that is normal wt, has normal foot function ,proper footwear and gets bad case of pf? I would say only hi milage runners would present like that. Again just another view

Re: relationship of faulty biomechanics to PF

BGCPed on 8/07/02 at 21:12 (091899)

Many devices that rely on too much or just a lump in the arch fail. Yes a cotton ball and a rock or a golf ball could be also called functional. They wouldnt be very comfortable but I assume you mean anything that will alter the foots path.

If you get a pt with grade 2 or 3 ptti do you use this device and get same results? I would assume since it seems to be the answer to most problems compared to most other devices it would work great for those applications. Please if you will explain your theory for higher degree pronation or supinated foot and how your device works so well for both
thanks

Re: innacuracies

Dr Dennis Kiper on 8/08/02 at 09:03 (091934)

So how do you determine 'normal' biomechanics?

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 09:32 (091941)

The fact of the matter is that anyone with poor alignment characteristics, requires the use of an orthotic, even if it doesn't help their symptoms. You have to address the underlying condition of excessive repetitive motion (overpronation) as well as any other therapeutic modalities to get the injury resolved. Then it's a matter of time. Keeping in mind that every footstep that individual takes in their daily life activities is antagonistic to the problem itself, not to mention athletic activities which most athletes try to play or run through. Then they wonder 'why is it taking so long to get better?'

As for the pronator vs the supinator, both overpronate. The available range of motion intrinsic to that foot is normal. Whatever amount of motion is necessary to absorb the incoming shock is maximum, and that maximum amount is the excessive repetitive motion (that every foot has available to it) that produces the injury over time. Certainly there are other variables. But whatever it is, supporting the foot in its optimal position allows the most efficient use throughout the lower extremity.

The difference with the SDO is that as soon as you change the fluid volume, the architectural position of the alignment changes due to the principle of 'fluid mechanics'. The problem with a traditional support is that you can't effectively change the architectural position once it's cast.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 10:27 (091948)

i found it interesting that both pronators and supinators over pronate. i am a supinator with severe flat foot. can you or the other medical professionals here explain the mechanics of this. how does pronating create supination?

Re: relationship of faulty biomechanics to PF

elliott on 8/08/02 at 10:43 (091951)

A supinator does not overpronate; he just pronates, less than most.

In reading your posts, there is one question I just can't get out of my mind: why didn't God make us all with silicone orthotics attached to our feet? I don't mean to sound cynical, but you seem to be saying that ideally everyone should be wearing orthotics, and I find that hard to accept; God made us with walking in mind. Also, it is not lost that your argument is conveniently self-serving in a financial sense. People may want to believe, but they're suspicious of yet another product claiming to solve a large chunk of the world's foot problems.

---

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 10:52 (091954)

If you have 'severe' flat feet you are a pronator, you cannot be a supinator.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 10:55 (091956)

Why weren't we born with contact lenses, hearing aids, dentures, prothetic limbs?
All prosthetics and orthotics are designed to compensate for our human frailty.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 11:04 (091960)

You have every right to be skeptical and cautious. That's why my offer is risk free. You have nothing to lose. If you don't win, I don't win.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 11:09 (091961)

then why do i have more pain on outside of feet than inside and why do i keep twisting outside of ankles? it is very confusing cause i also tilt inward at the arch. and yet my shoes all get worn down at the outside heel.

Re: Why? Because...

elliott on 8/08/02 at 11:50 (091967)

most people don't need it, certainly not right away, and many will never need it. And you never know, but if they wore from day one something they never needed, they might get into trouble.

---

Re: I agree about the risk-free offer

elliott on 8/08/02 at 11:52 (091969)

It seems very fair. I wish you'd talk sometimes about foot issues not connected to the SDOs.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 12:31 (091971)

Because your orthotics are 'overcorrecting' you (supinating). They are pushing you up and over to the outside. This also makes you more injury prone to the ankle.

Re: I agree about the risk-free offer

Dr Dennis Kiper on 8/08/02 at 12:37 (091975)

I'm sorry, but there are no issues not connected to a proper fitting orthotic. Your additional post of some and many not needing an orthotic is also incorrect. Everyone needs a proper fitting orthotic. The issue is prevention first. The problem is that so many orthotics fail, that my profession would be a laughingstock if we promoted that.
If you wear a proper fitting orthotic (silicone, rigid or semi-rigid),
you cannot get into trouble. You will be less vulnerable to trouble and may even be fortunate enough to stay out of trouble.

Re: LOL! (nm)

elliott on 8/08/02 at 13:51 (091983)

.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 16:24 (092002)

i have no orthotics , i'm talking about just walking without orthotics

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 16:43 (092007)

You have a high arch. You are a supinator, so there is some slight pronation.

Re: pala

elliott on 8/08/02 at 23:11 (092037)

With very flat and unstable feet and associated problems, it is not uncommon to see arch collapsing inward, compensating leg putting undue pressure on outside of ankle/foot is common. A good doc should not find this mysterious and should be able to help you.

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Re: relationship of faulty biomechanics to PF

Andrue on 8/09/02 at 06:24 (092044)

I don't think Dr. Kiper is saying that everyone should wear orthotics because we all have bad feet.

Our feet have evolved to do their job without shoes, on softish surfaces and probably for only three or four decades. If you don't like the word 'evolved' then substitute 'God made our feet to do their job...' instead. Whatever - it's the same thing. Neither results in feet that are particularly well suited to their current usage.

We are now using them for longer (in years) but with less exercise and on less forgiving surfaces and wearing shoes. It's not too surprising if some people's repair mechanisms are unable to keep up. In fact you could say it was surprising that relatively few people do have serious problems with their feet.

In lieu of as all going back to walking on grass and soil and dying when we reach middle age it might be that orthosis are a reasonable alternative.

Re: pala

pala on 8/09/02 at 09:34 (092052)

i've had lots of doctors. would love to find a good doc. how do i do that?

Re: innacuracies

Ed Davis, DPM on 8/11/02 at 12:09 (092199)

'Normal' biomechanics would refer to a range of values which results in function that does not lead to pathology under normal circumstances. Coming up with numbers requires research -- something most would agree is needed. One available database is the one that Langer Biomechanics used when programming their electrodynagram.
Ed

Re: I need help with orthosis subject

Carole C in NOLA on 7/30/02 at 22:47 (091063)

Nope, I don't really know much about podiatry and I haven't run across that sort of article online. Now, if you merely wanted anecdotal evidence, I could provide that to you from my own experience!

Carole C

Re: try these

elliott on 7/30/02 at 23:46 (091069)

They're of somewhat varying quality and usefulness, but some sound pretty good:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11949663&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11563570&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11415628&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11272297&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797213&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10349286&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10229276&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9735623&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8886778&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1897659&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1920106&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1999801&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2189536&dopt=Abstract

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Re: I need help with orthosis subject

Dr Dennis Kiper on 7/31/02 at 19:23 (091209)

Hi Dr Zuckerman, my name is Dennis Kiper, DPM. One of my patients pointed me to your inquiry here. There are several articles and studies done about orthotics. Not too long ago the American Orthopaedic Board did a comparative study between traditional (rigid and semi rigid) orthotics and over-the-counter types. They actually found that the over-the-counter in most cases worked better. The truth is that any study done regarding this matter is a poor one because it is based on an antiquated biomechanical system.
Traditional orthotics in and of themselves have been a bane to the medical profession and patients for a long time. In my opinion it is because the mechanics of a device that tries to 'control' the way a foot works is illogical. I have found that the foot needs to be 'guided' efficiently though the footstep in order to slow down and reverse years of accumulated inflammation, tension and spasm. As you know, PF is like the 'common cold' of the foot, the #1 most common foot problem in the world. It is secondary to repetitive excessive motion of the arch with every step. By the time a patient first realizes the 'problem', they don't equate that with the underlying condition of the mechanics that has been present since their first footstep on the ground. For some it is easy to reverse their pain by simply minimizing the excessive repetitive motion of the foot we call pronation and overpronation (this can be done even with a wad of toilet paper). This is what every generic, over-the-counter type orthotic does. That is why they faired so well in the 'study' by the Orthopods. Unfortunately for most an OTC support is not precise enough. Custom traditional orthotics on the other hand, while they are customized to the patients foot, does not mean they fit the way that foot works, hence all the failures and semi-satisfactory results. A traditional support is too rigid, it locks the foot up and in most cases is uncomfortable and in many cases the patient finds dissatisfaction in their results and maybe even ripped off by the cost.
What is strange is that while there are many products, and therapeutic modalities, they all ONLY address to the symptoms of PF. Only an orthotic addresses the underlying mechanical cause. Until one finds a proper fitting orthotic that can be changed as the architectural position of the foots alignment to the floor changes, then you will have a difficult if not impossible 'cure'. But cure is possible in my practice. I devote myself to guiding the patient through an adjustment process whereby the fit is easy and comfortable to wear and the intrinsic muscles of the foot accept a new way of walking and become retrained to forget what it was like being misaligned and feeling the difference of being aligned. This is not an easy process, because regardless of whether the patient is chronic, complex and severe, most patients unless they hit the lottery with instant satisfaction are prone to becoming frustrated and disappointed when they don't get the results they hoped for in a more acceptable time frame to themselves.

Re: I need help with orthosis subject

Dr. Zuckerman on 7/31/02 at 20:47 (091214)

Here is another way to look at the problem of plantar fasciitis. It is my
opinion that pf /heel spur is caused by repetitive injury to the plantar fascia at the insertion. Yes there may be pronation but the patient has injuried the area either by standing too much usually on cement or hard surfaces. So you have same tears. The body tried to heal the tears. No luck there is too damage to the micro circulation and we have what I call a mal-union of the soft tissue. The patient is limping. It is my opinion that at this stage no orthosis is going to help. You need ESWT or surgery and ESWT has so many benefits when compared to foot surgery.

So what causes pf? Biomechanics maybe contribute hard surfaces or injury yes. There are thousands of patients with abnormal biomechanics that have pain free feet .

Re: try these

Dr. Zuckerman on 7/31/02 at 20:55 (091215)

Thanks

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 07:30 (091248)

I agree and yet have to challenge your remarks. While there certainly can be micro-tears resulting in scar formation(which may be the cause of the most chronic and difficult cases we see), standing on hard floors and cement is not necessarily the cause. Standing on any surface causes the foot to absorb incoming shock. This is the repetitive process of pronation and overpronation. It is this underlying condition which produces the problems. To say that an orthosis will not help in my opinion is incorrect, because while this particular case may and probably will require something more radical i.e. ESWT , and lastly surgery, only an orthotic addresses the underlying root of the pronatory forces.
You must support the foot in its healing process. Otherwise it's like adding insult to injury.
Your statement that there are thousands of people with abnormal biomechanics that are pain free. What is 'abnormal biomechanics'? Do you mean conditions such as pes cavus, rocker bottom, coalitions etc? Or do you mean pronation?
What is poorly understood is that everyone 'overpronates'. The foot stretches with every step as far as necessary to absorb incoming shock. And it is this repetitive (normal) motion that over time takes it's toll. People who are pain free are rare. In my experience of over 30 years, many people are so used to their discomfort and feel there is nothing that can be done about it, forget, they are not pain free. For those individuals who are truly pain free, you have to wait until the end of their life span to ask 'have you been totally pain free'. The remainder of people who are pain free otherwise have died before they had pain develop.
This is the nature of things.

Re: I need help with orthosis subject

paula on 8/01/02 at 09:44 (091262)

dr kiper. welcome to this board. we have good pods who help us here and give us very useful information. another doc is very welcome. hope you stick around and can offer your expertise to us many sufferers. good to see a doctor dialogue with varying opinions. this will help us all i am sure. what is your opinion of posterior tibial tendon dysfunction. do you have any words of wisdom for me? i have very flat feet. other docs jump right in as well.

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 10:41 (091267)

Thank you for your welcome. PTT dysfunction is like any other biomechanical problem in that it stems from excessive repetitive motion of the arch with every step. The problem has taken your lifetime to form, until you feel it.
The difficulty with PTT is that it is a long term injury. Like any tendon, it receives a diminished blood supply. Coupled with the fact that you still have to get up everyday and perform your daily activities, you are constantly antagonizing the very thing you're trying to rest. So it's two steps forward and one back.
The mechanism of this injury is overpronation, the tendon glides through the surrounding tissue (called fascia) with a greater degree of friction and irritation because the 'track' of the tendon is inefficient. To resolve this, an orthotic that meets the criteria of a precise fit (comfort, fullness and stability on the floor) will in fact reverse the inflammatory buildup and you would become pain free. If finances are a problem for a custom orthotic any OTC support will help to at least minimize your overpronation and at least start you on the road to some recovery. Some of the OTC products work better for different people. It becomes a matter of trial and error. If you wind up buying as many OTC that exist, you'll wind up spending as much or more for a custom fit.
If you've tried custom supports before and failed, at the risk of sounding like a salesman you may want to review my site drkiper.com I have something different that you may want to consider at some time in the future. At the very least you MUST look at the stretching exercises for the lower extremity. Stretching is a key component in resolution and maintaing flexibility for quality of life.

Re: I need help with orthosis subject

paula on 8/01/02 at 12:49 (091280)

i will review your site. but i think i've beent there before and i didnt see exactly what your orthotic is about. is it all silicone or is there silicone in specific areas? i have already shelled out another load of money on a ucbl because a dr gere here mentioned that i think. i have to go pick it up. if it doesnt work i may call you.

Re: I need help with orthosis subject

Dr Dennis Kiper on 8/01/02 at 13:24 (091285)

What it's about can be quite lengthy, but it is silicone fluid NOT gel. It moves with the motion of your arch as if it were part of your foot. This makes it easy and comfortable to wear including around the house in slippers or sandals. Yet it limits overpronation which is what an orthotic is supposed to do. The scientific principles of the sdo go back over 2000 years to Archimedes and Pascal (you can find those principles under their names even in your dictionary). You can also see the scientific evidence under my link to 'computer tests'. One of the major problems with traditional supports is that it locks up the foot in a pre-set position so the foot step is 'static' rather than 'dynamic'. Now if it's comfortable and it works, that's the bottom line. The silicone let's your foot work naturally, and guides it through the foot step, so it feels like your own foot. I hope the one you've already been custom fit for by dr gere, fits the way you walk. If not and you want to give me a try (I hate sounding like a salesman), remember my offer is risk free. If you're not satisfied by 6 months you're not stuck with another set of orthotics, give them back.

Re: not to butt in on this dialogue between Drs

elliott on 8/01/02 at 17:55 (091319)

but I believe that study to which you refer comparing custom orthotics to OTC ones finding the OTC ones better is in one of the links I gave to Dr. Z (click below):

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10229276&dopt=Abstract

What you didn't point out is that, as the title there suggests, this was for 'initial' treatment only of proximal PF, not a general all-encompassing conclusion. But, as previously pointed out by Dr. Ed Davis, DPM, everyone fails to mention this. (Sort of reminds me of Jim Fixx, where every sedentary potato couch seems to know that the legendary promoter of running died of a heart attack while running, but never seem to know that he had a genetic heart defect that caused it and which could have been detected had he gotten checked as his family history had warranted.) (Could it be you're both right, but that your OTC orthoses are targeting an earlier PF stage, Dr. Z's ESWT a later one?) In addition, I believe Dr. Ed stated (but I could be wrong) that this study was funded by (you guessed it) some pre-fab OTC orthotic company. Regardless, once you look past the initial treatment at longer-term sufferers, maybe traditional orthotics would make a comeback. In fact, yet another link I supplied Dr. Z,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11266478&dopt=Abstract

probably including longer-term patients, suggests that traditional orthotics (and night splints) got all the way back to 'no statistical significance' between them and OTC orthotics! A lot better than being negative. :-)

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Re: regarding sounding like a salesman...

elliott on 8/01/02 at 18:04 (091324)

Here's an idea: Would you agree, by any chance, to giving out a number of free OTC orthotic samples (e.g. 10) to members of this board, maybe through Scott R (the board host) or someone else, who can do the followup and publish the results. We see how well it worked, and if a high number of them get cured or much improved, you stand to gain tremendously. (Such a thing was tried before.) And then we won't have to see all those 'just go to Dr. Kiper!!!!' posts. So there's something in it for everyone. :-)).

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Re: regarding sounding like a salesman...

Dr. Zuckerman on 8/01/02 at 19:59 (091342)

Now we are talking elliott. ITs called place your money where you mouth is.

Re: regarding sounding like a salesman...

Pauline on 8/01/02 at 23:10 (091358)

Elliot,
I appreciate your point about repetitive advertisment, but in Rons defense please tell me what is the difference between Ron posting about calling Dr. Kiper for help or Dr. Z posting about contacting his office for ESWT treatment?

Personally I think they are both the same except one is a doctor offering his services and the other is the satisfied patient of a doctor telling posters about a Doctor who carries a product that helped him.

Both Dr. Z office and Dr. Kiper's orthotics are already carried on this web site in other locations and probably neither need to be mentioned as often as they are, but sometimes it appears to this reader it's more about territory than treatment or product.

We are fortunate now to have many doctors that visit this board. I suspect all of them offer good treatment whether it be ESWT or orthotics and could also use a plug, but none of the others including Dr. Kiper, until Ron's enthusiast post, which brought on suspicion, advertises their practice or products on this site.

In fact, I remember Dr. Joe pointing out this fact in one of his posts saying he didn't advertise his practice on the site. I'm not sure we really know where Dr. Joe practices. I don't know where and I don't know Ron and I don't know Dr. Kiper except from his recent postings and Ron's posts about him.

To me advertisement is advertisement whether it's enthusiast Ron or enthusiast Dr. Z. After the man is check out for spam and found not to represent Dr. Kiper I think he should be left alone to speak about what helped him. If it provides conservative help for someone why not?

I would simply ask Ron not to plaster each reply with it, the same as everyone else.

Re: regarding sounding like a salesman...

Dr Dennis Kiper on 8/02/02 at 07:49 (091379)

Just about like most things, not every OTC product is good for everybody.
You'd do best by trying them one by one until you found what works best for you.

Re: To Dr. Kiper regarding sounding like a salesman...

Pauline on 8/02/02 at 08:59 (091395)

Dr. Kiper,
I'd like to also welcome you as others did to this web site especially since your orthotics got here before you did. I hope that you will continue to be a sourse of information for posters by expression your opinion on all the varous questions they ask.

I think it's a privlidge to be able to gather answers and ideas from so many doctors on one site.

Certainly your orthotics sound unique, and because they are part of a conservative approach to treating P.F. surely a welcomed approach to treatment before people consider surgery.

I along with others will look forward to your participation on this site.

Re: do I take that as a "No"? :-) (nm)

elliott on 8/02/02 at 09:14 (091400)

.

Re: since you asked, here's the difference

elliott on 8/02/02 at 10:14 (091404)

Dr. Z just about always responds only to questions about 1) ESWT or 2) what alternatives are left before surgery. In fact, I did a search for the month of July, and every one of the 5 times Dr. Z answered with his email address for info, it was in response to one of these two types of question. By contrast, Ron P pops up everywhere unprompted, in fact 30 times over the month of July (this excludes the posts where he responded to others querying him or his few posts about Birks, and together that's all he's posted about). That is the key difference. The equivalent behavior would be if Ron P, or Dr. Kiper himself, responded when someone asked for an orthotic that works or (if appropriate) alternatives to surgery.

There are other things worth pointing out too. We're human, so the number of posts does matter. 30 in one month is a lot. I'm not sure what you mean by check someone out for spamming. How do you do that? I know Scott R is the POWER, but even he would have trouble ascetaining with certainty whether someone has a financial incentive to post about a product. And it can even be a real person who got cured, but he can still be a spammer. Regardless, whether Ron P is a spammer or not, he sounds like one. All his posts are the same variation of the same 3 or 4 lines ('Have PF? Why not call Dr. KIPER? 800...Silicone! Really helped me! Web site/email too! Call now!'). Sound like a spammer and you turn people off. You'd think they would realize that. Contrast that with me, a poster with good intentions who gets on some people's nerves. I tried an orthotic by a company recommended by Dr. Ed, with the mold taken by a pod in my state. In four months, it brought my foot back from near-crippled to being able to walk. Not sure it will save this foot from surgery in the future (there's a bone issue to be dealt with), but it is doing what an orthotic was designed to do, and doing it well. I posted once or twice raving about it, almost nobody believed me, and then I moved on to other things. That fits a more typical profile, rather than someone coming on to post about nothing but. Again, we're human, so we make such evaluations on people. You can also throw in that Dr. Z gains more credibility by answering other questions. Maybe Dr. Kiper, if he has time, will do the same.

All that said, your point is well taken about anyone promoting their products, including Dr. Z, and some can view what he's doing too as shameless promotion. I feel a little uncomfortable about it, but only a little. And that doesn't mean I believe everything he says either. (I for one will admit that I am still doubtful about claims of 90% success rates with ESWT. Time will tell for sure. I'm leaning more towards 50%, which still has a lot of merit. Newer machines no doubt will improve the figure too.) While there are wide-ranging views on perceived advertising here, the general consensus is that we'd like at least some exposure to new products and treatments, and letting their promoters respond, within reason, is the way to get it. We're trying to get better here but without being taken for a ride.

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Re: since you asked, here's the difference

paula on 8/02/02 at 13:40 (091431)

the way i look at advice here is if the medical professional answers questions that have nothing to do with his making a profit. then if he also stands behind his method that makes him money that is not a problem for me. but if he only answers or mostly only answers to promote his thing then i start discounting everything said. that's how i look at it. i have been helped very much by docs here on topics that they were never going to make a penny on. long detailed thougtful answers too. taking time to help and heal

Re: since you asked, here's the difference

Pauline on 8/02/02 at 15:14 (091443)

Since Dr. Kiper is new to this site, I think we have to wait to see if he will continue to answer questions like the rest of the doctors that post here. I think he will.

Personally, I think he's being judged solely on Ron P's postings and not on his merit or committment to helping people. I don't think you can compare a new arrival with yourself who has been here for some time solely based on the number of questions answered. We have no way of knowing if he lacks commitment. It's too early to tell.

He and Dr. Joe and possibly Dr. Ed are the only doctors posting that I know of that could be considered 'outsiders' meaning not belonging to your ESWT group. Maybe Dr. Ed does too. I don't know. I believe you mentioned you have 35 doctors now, yet none of the others coming here including Dr. Wander ever ask people to contact them but they still continue to answer many questions for posters. I think they are just as committed to helping people as you are.

Your points are well taken , but I don't think we should or can honestly judge what Dr. Kiper is about. Time will tell all of us loud and clear.

Re: since you asked, here's the difference

Dr. Zuckerman on 8/02/02 at 20:38 (091463)

Hi Elliott. I appreciate your effort and time with postering.

The claim of 92% Average reduction in pain from ESWT during the one year follow up.with the epos is FACT. This was taken from the FDA multicenter studies. CAll the FDA . Look up the study.. Its all there. I didn't make the Claim up . Dornier reports their claim and the FDA confirms it .

Re: relationship of faulty biomechanics to PF

Ed Davis, DPM on 8/03/02 at 14:30 (091485)

There are too many variables and our ability to measure those variables too limited in order to accuarately relate the relationship between biomchanical deficits and symptomatology. We can make generalizations.

Both Drs. Z and K are on the right track but their emphasis is different. I have proposed a 'treatment triad' here previously in order to remind posters to avoid over-emphasing any one of the 3 'legs.' The legs include biomechanics, inflammation and tissue quality. Control of biomechanics alone may or may not be adequate for a cure. Control of tissue quality alone is unlikely in my mind to effect a long term cure despite our inability to use biomechanical info. to accurately forecast or predict symptoms.

In response to Dr. K, most would consider 'functional' foot orthotics to be dynamic in nature. I can see how the SDO's would be able to decelerate the rate of subtalar joint pronation, thus providing a good benefit. I am uncertain of their effect on midtarsal joint function which may be a signiticant factor for many. I would appreciate Dr. Kiper's assessment on this.
Ed

Re: since you asked, here's the difference

elliott on 8/03/02 at 22:51 (091513)

I just want to doublecheck that the 92% means that a random patient going in will have a 92% reduction in pain coming out, and not something like, if it works, it will bring about on average a 92% reduction in pain.

I haven't been keeping count, but I get the impression that our board's experience has been nowhere close to this. Any explanation?

--

Re: since you asked, here's the difference

Dr. Zuckerman on 8/04/02 at 07:57 (091526)

My understand is that is was those patients treated in the FDA study after one year had a 92% average reduction in pain . No one on our board is post one year ESWT

Re: I hope you're right

elliott on 8/04/02 at 23:12 (091590)

I wouldn't mind seeing the detailed study, though. The FDA seems to have removed the page on Dornier Epos efficacy from its web site. In an extensive web search, I couldn't find any such figure quoted. The only one I did find was 60%, quoted in the article below:

http://atlanta.bizjournals.com/atlanta/stories/2002/04/29/focus12.html

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Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/05/02 at 11:42 (091632)

First I'd like to address 'faulty biomechanics'-this is an innacurate way to describe someone with a problem'. It is 'normal' biomechanics.
The function of the biomechanics is to allow locomotion and absorb the incoming shock to our system. It is wear and tear of our normal biomechanics that produces the problems. Not everyone is affected the same way. PF is the most common problem, but almost all lower extremity injuries are the result of the same repetitive excessive motion of our arches as we walk, including hip and low back pain. The functional shortage of one side (that has come into vogue in the last couple of years)
is also a function of 'normal' biomechanics. Our two feet while they look the same are not identical in their measurements (same as two cars coming off an assembly line). The brain recognizes this difference as we begin to walk and slowly makes the adjustment in our hips that produces the (FS) 'functional shortage' (I wrote an article about this for a running magazine and it describes how you can examine yourself for this FS) at my http://www .
Couple all this with the variables of bone development (anteversion, and antetorsion-(twists and angles) and it becomes more complex for some people
If there are vitamin deficiencies (e.g rickets), there will be changes in our bone shapes. It goes on and on. All this leaves us with our own normal biomechanics for the way we're built and the way we're shaped.
While all orthotics including generic (OTC) are functional (just diffences in precise fit) I do not consider all orthotics to be 'dynamic'. Our foot and leg muscles do help to decelerate pronation, but the problem in my opinion with traditional orthotics is that the end of the range of motion (of pronation) is terminated abruptly. This is not the motion that the foot itself makes, but rather a fluid motion. In addition the position of the orthotic locks the foot into that position. If the foot likes it and it's comfortable and it works, then you're going to have good results. But I have found in 30 years of practice that most feet do not like traditional orthotics because it is not comfortable and the pre-set position of a traditional orthotic is not tolerated. Hence, non-compliance and poor results.
The SDO that I work with is very different. It moves with the foot as if it were part of it. It helps the muscles in decelerating the motion of pronation and allows the end of range of that motion to be cushioned rather than stopped abruptly. Yet it does what it is supposed to do, in that it limits the amount of overpronation which is the injurious effect of that repetitive motion. It just doesn't do it in the conventional way as a traditional orthotic by holding and trying to control the subtaler joint. Rather than control the foot from behind to front. It is a retrograde effect of disallowing max pronation at the middle of the foot, thereby disallowing the rearfoot (sub taler joint) from rotating out further allowing greater pronation (overpronation).
I'm sure that most of the people at this site are better educated to biomechanics than most (not including runners), and the SDO flies in the face of those traditional theories. Well, I have simply found another way to 'skin the cat.'

Re: I hope you're right

Dr. Zuckerman on 8/05/02 at 20:10 (091679)

I have the one year follow up report in a graph form . This is from the company dornier. Will Scott post this ??. Be very happy to provide this for the site if Scott wants to post this for the viewers to see

Re: Dr. Kiper

elliott on 8/05/02 at 22:20 (091707)

Seems to me whether you call crappy feet normal for that individual or faulty is just a matter of semantics, but I'll let Dr. Ed answer for himself. I had some other things on my mind to ask you. I looked at your web site. (I will say that your six-month guarantee does offer credibility.) There it is claimed that the SDO cure rate for PF is essentially 100% (albeit with different healing/marked improvement times, ranging from a week to 2-3 years to 6-10 years). Given the complex nature of the human body, as well as variation from human to human, I was wondering if you could explain that 100% a bit. I mean, what if someone's PF is a hair away from rupture (or even did rupture; an MRI often has trouble detecting even this). What of those cases that happen to have entrapment of the first branch of the lateral plantar nerve but are impossible to definitively diagnose? What if someone's obesity is contributing to the problem? (If obesity is completely 'normal', then pass the chips. :-)) What about heel irregularities, and not just spurs thought not to be the culprit. The list goes on. It's not all about an individual's 'normal' pronation. I gather you screen candidates, but even so, exact diagnosis of causes for each and every patient is impossible, hence no one technique should be expected to offer 100% success, yet yours does. Please explain.

A few other questions about orthotics. Why aren't OTC versions of SDOs, as sold elsewhere in California, good enough when combined with, say, a well-fitting running shoe controlling for pronation? Also, many custom orthotics on the market today do give a little at the arch when the foot weight-bears in the gait. Why isn't this good enough? Thanks.

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Re: relationship of faulty biomechanics to PF

BG CPed on 8/05/02 at 22:24 (091708)

This is all very interesting. There are many opinions on why an orthotic works or fails. My opinion is that many devices that are rigid with a high arch also lack proper rear foot control. If you have tight heel cords/gastroc and over pronate the eversion of the hind foot will create more mid stance to late stage pronation, which puts a very strong traction pull on the fascia.

Simply putting a 'lump' or a medial arch under the midfoot, w/o dealing with the hind foot can put more tension on the fascia as well as making the device uncomfortable. Most pf pt that pronate will say that upon rising they walk on the outside of the foot to reduce pain, this is a compensation that reduces the pull on the fascia.

This may be over simplified but in a case of ptti or pf some Dr will put the pt in a hard cast for several weeks. They dont cast them in pronation or wt bearing since that does not reduce the pull on the fascia. Many times the pain is reduced very soon but if the causative factors are not dealt with the pf can return after cast is removed.

With the heel cords and hind foot controled meaning wedging and heel elevation via insert and footwear I feel that symptoms will reduce much sooner than a lump in the arch that functions as a damper in a shock absorber.

Regards to the study that claimed the pre fabs over custom? If that was the one done near San Fran that studay was flawed imho. First the lab for the customs used was very good. The casts were taken by several different people, this is like doing a study on the best pizza and haviong it made by 5 different people, that methodolgy creates too many variables.

the other flaw was that the study was funded by a heel cup company. Once the results were released the wire services just printed 'study done heel cups better than custom orthotics'

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 07:38 (091719)

I don't believe I use the word 'cure' on my web site. It's taken me close to 5 years to put my site together, so if the word 'cure' is there, please point it out. I say this because I am aware 'cure' is a nebulous word in medicine. We are always vulnerable to problems exacerbating, because the underlying condition is always present. I repeat that our problems are a result of wear and tear over time. An orthotic does not 'arrest', it merely minimizes and slows down the condition. If the problem is not felt, and you want to say 'cured', I guess that's OK, I'm not sure.
As for the total success of relief from PF I do say that it takes up to 6-10 years to reverse the health of the tissues (microscopically) the way they were 10-30 years ago. This is because everyday that we are getting better, we continue to antagonize the very problem we are trying to get better, so it's always two steps forward and one back.
Chronic, complex cases do present a more difficult situation. The most complex cases have had repeated injections (cortizone) and/or surgical intervention. What I do say here is that an orthotic may not be totally effective by itself, but regardless, should be wearing an orthotic to address the underlying condition of repetitive excess motion (overpronation). In fact my philosophy is that everyone should be wearing a foot orthotic because prevention is the issue, not just pain. After all most of us brush our teeth not because we have a cavity, but we're trying to prevent them. I'm sure that all or most of my colleagues (as well as others in allied fields concerned with orthoses), would disagree. That's because it's so hard to find an orthotic that fits everyone. This is what is so unique to the silicone orthotic, it can fit anyone. It's just a matter of finding the correct volume of fluid that supports, maintains balance/alignment and is comfortable that is necessary without controlling the subtalar joint. This does not mean you can never get a problem in your life, it simply means that wearing an orthotic can slow down and minimize your vulnerability to injury (same comparison to brushing ones teeth).
Your cases of a PF about to rip, if it's going to rip, it's going to rip.
Obesity? Compounds the problem, not necessarily cause the problem, after all there are many thin people who get the same problem, right? It's a matter of wear and tear of that person's normal mechanics over time.
Entrapment of the lateral plantar nerve, well if that's the case, the patient should still be wearing an orthotic. The variations in complexities are just that and an orthotic alone is not always the only answer, I never said it was.
As for OTC versions of the SDO, they are available through 'Sharper Image' catalog. The major difference is that the volume of fluid in those are generic. Besides the template size of a foot, the key to a prescription is the precise volume of fluid that fits the individual. It feels and works differently than the OTC ones.
Semi-rigid orthotics as you discuss do give a little, but they do not 'flow' in their motion akin to the human foot. They still hold the foot (albeit with some flex) to a pre-set position and terminate the end of the range of motion (pronation/overpronation) abruptly . As I've said before, if it feels comfortable and it works, then that's the bottom line. You have an effective orthotic.
I know that my writings are controversial. I'm not here to argue about it. I let my results speak for themselves, I offer the 'risk free trial'. With nothing to lose, what else is there? My failures are due primarily to patients who are frustrated and diasappointed that they did not have results within the trial period and they did not want to take a chance that they would lose more money than they already have with several others.
But the sdo fit them according to my criteria, which means that they were working, just not quickly enough for the years of accumulated damage as far as the patient was concerned.

Re: relationship of faulty biomechanics to PF

Carole C in NOLA on 8/06/02 at 08:24 (091723)

Thank you for a fascinating post. I always learn a lot from your posts, and this is one I can really relate to due to your discussion of the need for rear foot control rather than a lump under the arch. My feet agree with you 100% at present, although my PF is essentially gone.

You mention hind foot wedging and heel elevation via insert and footwear.

What shoes (if any) come to mind that provide some heel wedging? Are there OTC inserts that provide a heel wedge?

Or were you referring strictly to custom orthotics?

Carole C

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/06/02 at 10:12 (091731)

A 'lump under the arch shows a lack of understanding. There are two arches:
1-medial arch
2-longitudinal (which should include the 'lateral arch' or be a seperate entity.
A lump under just the medial arch would be an undercorrection of a precise alignment fit.

Re: Dr. Kiper

elliott on 8/06/02 at 11:19 (091738)

Appreciate your response; interesting. The word 'cure' does appear on your site, but not in a context which detracts from what you're saying. I used it to save words, clarifying it myself later in the same sentence.

The problem with 6-10 years (or even 2-3) is that in order to judge the value added from the SDO, we'd have to compare it to other orthotics, as well as other conservative means (which supposedly 'cure' 90% of PF anyway), difficult if not impossible to do, although that's not your fault.

Not sure I accept the toothbrush analogy: we weren't meant to be eating all the junk we do, but since we do, brushing is good. Also, after a minute, you put the brush away, as opposed to using orthotics the entire time you walk. Increased risk without them? Don't ride in a car or fly in a plane either. Orthotics aren't risk-free either, e.g., they've been known to cause medial plantar nerve entrapment in runners, although it makes sense yours might not give such problems.

I must say, though, that your money-back guarantee six months forward is very fair, and if for no other reason I hope some of the longer-term PF sufferers here give it a try so we can observe how much they improve. The only problem is, then they'll be flooding this site with 'just call Dr. Kiper!!!' :-)

Thanks.

Re: since you asked, here's the difference

mary on 8/06/02 at 13:14 (091746)

you have too much time on your hands

Re: since you asked, here's the difference

Dr. Zuckerman on 8/06/02 at 13:31 (091748)

Lets see I run a practice which sees forty patients a day. What I have is a computer sitting at my desk that is a DSL. Speed is what I have !!!

Re: relationship of faulty biomechanics to PF

BGCPed on 8/06/02 at 14:43 (091755)

I am not sure if you are reffering to my term lump under the arch. It was used to illustrate the type of devices I see every day that are 3/4 shell, shallow heel cups and lacking proper hind foot control. I think it is safe to assume in laypersons terms that the 'medial' or inside arch is the most obvious arch I am talking about. If we really want to be correct there are actually 3 not 2 archs. The transverse metatarsal arch is also a factor.

Re: re: eliot

paula on 8/06/02 at 15:56 (091761)

where do i get over the counter sdo s from? i'd like to try them

Re: Since you asked...

Mahatmelissama on 8/06/02 at 17:20 (091770)

http://drkiper.com/ for custom ones...

I myself am trying these, only been wearing them since 07/31/02.

Dr. Kiper says 'As for OTC versions of the SDO, they are available through 'Sharper Image' catalog'

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/06/02 at 17:25 (091771)

Now you got me. I'm not sure what you are referring to. 'term lump'?
I understood you to refer to the efficacy of the orthotic by putting a 'lump' under the arch.
As you notice I did mention the lateral arch as a possible seperate entity(your reference 'transverse metatarsal')

Re: re: eliot

Dr Dennis Kiper on 8/06/02 at 17:53 (091772)

The OTC type are from 'Sharper Image' catalog. Actually, they are not a fluid like the SDO, but rather a gel. I've had patients try them before they stepped up to the SDO and the response was favorable.

Re: since you asked, here's the difference

Dr Dennis Kiper on 8/06/02 at 17:55 (091773)

I'm just efficient.

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 18:21 (091777)

Let me clarify the time parameters of the healing process. I expect that in plain old PF (usually less than 1 year's onset), a positive response is noted within 60-90 days (anything from 20%-100%). Presuming the orthotics fit properly and are comfortable, this would indicate we are on the healing track. On average (in my experience), most patients feel 60-90% better by the end of the first year (sometimes two). Many feel 100% better, BUT there is still a level of microscopic inflammation that I am talking about that still takes years to reverse (even though the patient might feel pain free). Generally any remaining pain by the end of the first Rx change is usually resolved within another 6 mos-a year (in most cases). Some chronic patients who are lucky can go through this healing even quicker, just the luck of the draw.
My analogy to the damage accumulated over a lifetime is 1 mile in a car for every foot step, so if you count from the time you started walking on the planet to the time you first experience the problem (not counting the cases who are chronic, through neglect, unsuccessful treatment and worst, injections and surgery)), your feet are like cars with 300,000-500,00 miles.
How quickly do you think it should take to reverse this kind of damage?
Now consider that even with your pains you have to perform your daily life activities, hundreds to thousands of footsteps/day, for runners it's worse.
It's easy to become frustrated and disappointed when you are not getting relief. It's worse when your orthotics are uncomfortable. BUT, when an orthotic meets 3 criteria
1-feel support/fullness
2-comfort
3-stability on the floor
then those orthotics fit correctly and are working. It then is no longer a matter of 'if' it works, but 'when'.
My time frame of 6-10 years for total reversal of tissue health is really
not one substantiated, I only use that to help the patient understand that there is a very timely process involved here. Sometimes flare ups can occur, sometimes one seems to stagnate in their healing process. I always remind them of the time frames of the healing process, to be patient (as long as the criteria of the orthotic fit is met) and to be patient.

Re: Dr. Kiper

paula on 8/06/02 at 18:36 (091779)

i went to sharper image online and could not find the sdo s

Re: Dr. Kiper

Dr Dennis Kiper on 8/06/02 at 19:36 (091783)

I checked it out (gel insoles), you're right I didn't see it either. You might try e-mailing their customer service dep't. It's possible that they don't carry it anymore. I heard good things about it, but it still was not any better than a generic OTC support (precision of fit is key).
Do stay away from the magnets and magnet orthotics, if you want a OTC referral I would recommend 'Spenco' 3/4 length or 'Superfeet'.

Re: Lets put the Kiper orthosis to the test

Dr. Zuckerman on 8/06/02 at 19:39 (091784)

All of this sounds very professional so lets do a study. Would you be willing to have a study of say ten to fifteen heelspurs.com heel pain patients . We could track the results/ This has been done before by Scott Roberts. How does this sound to you . How does this sound to the board

Re: Lets put the Kiper orthosis to the test

Dr Dennis Kiper on 8/06/02 at 20:25 (091786)

What you're asking is a lot of work. I don't personally feel I need to do this study, because a study of 90-100 patients has already been done by a physical therapy group in San Jose (not me). If you want those stats I can get them for you and the group.
The 'real' study would be to have those people who have been suffering with lower extremity injuries take the 'risk free offer' and at the end of the 6 months those who wanted their money back could post their results and be none the worse for it. Those that were helped and wanted to keep their orthotics would be getting their money's worth and the opportunity to be pain free and they could post their results.

Re: Dr. Kiper

paula on 8/06/02 at 21:17 (091789)

thanks, i'll look into the superfeet.

Re: Lets put the Kiper orthosis to the test

Dr. Zuckerman on 8/06/02 at 22:28 (091798)

That sounds pretty fair to DR. Z.

Re: innacuracies

Ed Davis, DPM on 8/06/02 at 22:59 (091802)

Dr. Kiper:

Studies at Univ. of Pennsylvania showed more of a deceleration of the rate of pronation as opposed to a direct effect on the amount of overpronation. The foot moves aginst the orthotic thus no hard stop to pronation applies.

I don't want to nit pick semantics but biomechanics that lead to actions creating pathology is basically a definition of pathomechanics or 'abnormal' biomechanics. I would consider biomechanics to be abnormal if the end results are stresses or strains on tissues of significant magnitude to cause pain or dysfunction.
Ed

Re: relationship of faulty biomechanics to PF

Ed Davis, DPM on 8/06/02 at 23:18 (091805)

BG:

I too am a bit dissapointed that Dr. Kiper refers to a study that is badly flawed and had a political agenda.

That aside, I welcome his input here. New ideas are refreshing but I feel an obligation to respond when controversial ideas are introduced. The obligation based on what I percieve is a need to give readers a broad but critical perspective.

Their is motion between the foot and a (non-fluid) orthotic so the type of rigid 'stops' and control that some suggest really is not there. Even the best made orthotics will not work for all so I am cautious when basic concepts of orthotic design are criticized --- failures will exist due to limitations of any modality.

Plantar fasciitis treatment involves our ability to control biomechanics, inflammation and tissue quality. I referred to three 'legs' but I failed to mention that those three legs or factors are rarely equal and can vary drastically from patient to patient. It is easy to fall into a 'trap' as a provider, by focusing on the 'leg' that we have the most control over -- biomechanics is the leg we work on the most, physical therapists -- inflammation and tissue quality is being addressed now by ESWT. Failure to cure PF is too often viewed from the perspective of one 'leg', ie. orthotics can never be a assured 'cure' for PF, they can only be a treatment for the abnormal biomechanics that can start and exaccerbate PF.
Many times biomechanics alone can effect a cure, but often it cannot even when expertly and perfectly applied.
Ed

Re: guys, I thinks she means me

elliott on 8/07/02 at 00:08 (091810)

Mary, how fortunate you are I have time on my hands so you can be the beneficiary of my eternal wisdom. :-)

---

Re: Dr. Kiper

Julie on 8/07/02 at 01:57 (091812)

Dr Kiper, your thoughts on the generous 6-10 year time frame for the healing of PF ('total reversal of tissue health') make great sense to me. I've suspected from the beginning that those who interpret cessation of symptoms as 'cure' are in for trouble in the form of future recurrences if they stop doing whatever 'worked', i.e. caused the pain to disappear.

If something, or a group of somethings, helped to bring one to an asymptomatic state, whether orthoses of any type, or Birks, or not going barefoot, or stretching, it would seem to make sense to continue doing/wearing whatever it was that helped, and not abandon self-treatment when the pain goes.

Anyway, that's my take on this business of 'cure', so although I was virtually pain free almost two years ago, and have been totally pain free for about a year, I stick to what helped: my feet are never (well, almost never) out of my trainers with orthotics (not yours, but they've worked for me) or my Birks.

Whatever the 'cause' of someone's PF, the result is damaged tissue, so it has to be a good idea to be vigilant long after symptoms disappear. 6-10 years sounds like a reasonable time frame to me.

Re: relationship of faulty biomechanics to PF

BGCPed on 8/07/02 at 09:28 (091820)

My reference to a 'lump' was not intended to support that theory. I was talking about the many non functioning devices that put too much focus on just medial arch support and not dealing with the foot as a whole. Again the 'lump' term was not used in a positive context

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/07/02 at 09:49 (091824)

When you refer to 'non-functioning' devices, are you referring to generic supports?
It is my contention that anything, even wads of cotton or toilet paper placed under the foot is 'functional'. The reason being that anything that minimizes the action of overpronation is helpful. In my opinion the foot functions around an 'optimal' position rather than to a 'neutral' position.
Anything that can put the foot closest to that architecturally aligned position to the ground is going to make the foot and lower extremity more efficient. If you accomplish that, then you have balance and 'control' (I really hate that term).
The more precise you get the foot to its optimal position the better everything is going to work and be more comfortable . I feel that 'rigid' and 'semi-rigid' control has gotten too complex. Furthermore I don't think the foot likes to be 'controlled', it's a dynamic organ that moves across a plane to locomote. The infrastructure of the foot is twisting and turning to accomplish this. Simply support that infrastructure so that it can feel and behave as natural as possible and you've got it.

Re: innacuracies

Dr Dennis Kiper on 8/07/02 at 09:54 (091825)

I am aware that the muscles designation to decelerate the pronation motion, but once it hits the end of the range of allowable motion (constrained by the position of the rigid-semi-rigid) it is abruptly stopped.)
As for only abnormal biomechanics being painful, what do you refer to that patient's biomechanics 1-5 years prior to his/her ever having the first symptoms?

Re: innacuracies

BGCPed on 8/07/02 at 21:08 (091898)

If I may contribute my .02 The patients biomechanics 1 to 5 years prior to ever having symptoms would still be considered abnormal (assuming they are)just asymptomatic. A good anaology would be high bp, cholesterol and tryclicerides when you are 35 and one day at age 39 you are shoveling snow and boom you suffer cardiac arrest and die. You had improper vascular function but didnt get symptoms till later. They are both a result of a pathology that may take 40 years or 10 years to emerge. I would say we can all agree that the majority of pf patients we see they all have some biomechanical and or footwear/adl issue that drives it.

How oten do you get a pf pt that is normal wt, has normal foot function ,proper footwear and gets bad case of pf? I would say only hi milage runners would present like that. Again just another view

Re: relationship of faulty biomechanics to PF

BGCPed on 8/07/02 at 21:12 (091899)

Many devices that rely on too much or just a lump in the arch fail. Yes a cotton ball and a rock or a golf ball could be also called functional. They wouldnt be very comfortable but I assume you mean anything that will alter the foots path.

If you get a pt with grade 2 or 3 ptti do you use this device and get same results? I would assume since it seems to be the answer to most problems compared to most other devices it would work great for those applications. Please if you will explain your theory for higher degree pronation or supinated foot and how your device works so well for both
thanks

Re: innacuracies

Dr Dennis Kiper on 8/08/02 at 09:03 (091934)

So how do you determine 'normal' biomechanics?

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 09:32 (091941)

The fact of the matter is that anyone with poor alignment characteristics, requires the use of an orthotic, even if it doesn't help their symptoms. You have to address the underlying condition of excessive repetitive motion (overpronation) as well as any other therapeutic modalities to get the injury resolved. Then it's a matter of time. Keeping in mind that every footstep that individual takes in their daily life activities is antagonistic to the problem itself, not to mention athletic activities which most athletes try to play or run through. Then they wonder 'why is it taking so long to get better?'

As for the pronator vs the supinator, both overpronate. The available range of motion intrinsic to that foot is normal. Whatever amount of motion is necessary to absorb the incoming shock is maximum, and that maximum amount is the excessive repetitive motion (that every foot has available to it) that produces the injury over time. Certainly there are other variables. But whatever it is, supporting the foot in its optimal position allows the most efficient use throughout the lower extremity.

The difference with the SDO is that as soon as you change the fluid volume, the architectural position of the alignment changes due to the principle of 'fluid mechanics'. The problem with a traditional support is that you can't effectively change the architectural position once it's cast.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 10:27 (091948)

i found it interesting that both pronators and supinators over pronate. i am a supinator with severe flat foot. can you or the other medical professionals here explain the mechanics of this. how does pronating create supination?

Re: relationship of faulty biomechanics to PF

elliott on 8/08/02 at 10:43 (091951)

A supinator does not overpronate; he just pronates, less than most.

In reading your posts, there is one question I just can't get out of my mind: why didn't God make us all with silicone orthotics attached to our feet? I don't mean to sound cynical, but you seem to be saying that ideally everyone should be wearing orthotics, and I find that hard to accept; God made us with walking in mind. Also, it is not lost that your argument is conveniently self-serving in a financial sense. People may want to believe, but they're suspicious of yet another product claiming to solve a large chunk of the world's foot problems.

---

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 10:52 (091954)

If you have 'severe' flat feet you are a pronator, you cannot be a supinator.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 10:55 (091956)

Why weren't we born with contact lenses, hearing aids, dentures, prothetic limbs?
All prosthetics and orthotics are designed to compensate for our human frailty.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 11:04 (091960)

You have every right to be skeptical and cautious. That's why my offer is risk free. You have nothing to lose. If you don't win, I don't win.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 11:09 (091961)

then why do i have more pain on outside of feet than inside and why do i keep twisting outside of ankles? it is very confusing cause i also tilt inward at the arch. and yet my shoes all get worn down at the outside heel.

Re: Why? Because...

elliott on 8/08/02 at 11:50 (091967)

most people don't need it, certainly not right away, and many will never need it. And you never know, but if they wore from day one something they never needed, they might get into trouble.

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Re: I agree about the risk-free offer

elliott on 8/08/02 at 11:52 (091969)

It seems very fair. I wish you'd talk sometimes about foot issues not connected to the SDOs.

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 12:31 (091971)

Because your orthotics are 'overcorrecting' you (supinating). They are pushing you up and over to the outside. This also makes you more injury prone to the ankle.

Re: I agree about the risk-free offer

Dr Dennis Kiper on 8/08/02 at 12:37 (091975)

I'm sorry, but there are no issues not connected to a proper fitting orthotic. Your additional post of some and many not needing an orthotic is also incorrect. Everyone needs a proper fitting orthotic. The issue is prevention first. The problem is that so many orthotics fail, that my profession would be a laughingstock if we promoted that.
If you wear a proper fitting orthotic (silicone, rigid or semi-rigid),
you cannot get into trouble. You will be less vulnerable to trouble and may even be fortunate enough to stay out of trouble.

Re: LOL! (nm)

elliott on 8/08/02 at 13:51 (091983)

.

Re: relationship of faulty biomechanics to PF

pala on 8/08/02 at 16:24 (092002)

i have no orthotics , i'm talking about just walking without orthotics

Re: relationship of faulty biomechanics to PF

Dr Dennis Kiper on 8/08/02 at 16:43 (092007)

You have a high arch. You are a supinator, so there is some slight pronation.

Re: pala

elliott on 8/08/02 at 23:11 (092037)

With very flat and unstable feet and associated problems, it is not uncommon to see arch collapsing inward, compensating leg putting undue pressure on outside of ankle/foot is common. A good doc should not find this mysterious and should be able to help you.

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Re: relationship of faulty biomechanics to PF

Andrue on 8/09/02 at 06:24 (092044)

I don't think Dr. Kiper is saying that everyone should wear orthotics because we all have bad feet.

Our feet have evolved to do their job without shoes, on softish surfaces and probably for only three or four decades. If you don't like the word 'evolved' then substitute 'God made our feet to do their job...' instead. Whatever - it's the same thing. Neither results in feet that are particularly well suited to their current usage.

We are now using them for longer (in years) but with less exercise and on less forgiving surfaces and wearing shoes. It's not too surprising if some people's repair mechanisms are unable to keep up. In fact you could say it was surprising that relatively few people do have serious problems with their feet.

In lieu of as all going back to walking on grass and soil and dying when we reach middle age it might be that orthosis are a reasonable alternative.

Re: pala

pala on 8/09/02 at 09:34 (092052)

i've had lots of doctors. would love to find a good doc. how do i do that?

Re: innacuracies

Ed Davis, DPM on 8/11/02 at 12:09 (092199)

'Normal' biomechanics would refer to a range of values which results in function that does not lead to pathology under normal circumstances. Coming up with numbers requires research -- something most would agree is needed. One available database is the one that Langer Biomechanics used when programming their electrodynagram.
Ed