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A BAG OF BONES

Posted by Dr Dennis Kiper on 8/08/02 at 10:44 (091952)

The foot to me is like a 'loose bag of bones'. Tied together by the soft tissues, each bone moves on one or more of the planes of motion and moves as much as necessary in order to reduce incoming shock
An orthosis to my way of thinking is designed to 'assist' the foot and minimize this motion. It does this by aligning the foot to the ground and tightening up the laxity of the foot motion making it more efficient in its course of action(s).
What the SDO does so well, is allow each bone to move through its natural planes of motion in a fluid manner (NO PUN INTENDED). It does not alter these motions and does not restrict them abruptly. It simply guides the structure through its course of action, yet limits the laxity. This is what makes the SDO so easy, accurate and comfortable to wear.
A traditional support (rigid or semi-rigid) on the other hand (in my opinion) holds the foot to a casted position which is rigid to the planes of motion. Granted, if the foot structure feels comfortable to this position and way of walking, and it works in its concept of healing, then that is the bottom line. To me, just because the foot is custom casted to a biomechanical position, does not mean it fits the way that foot works (that's why I hear so many patients say it is very uncomfortable even if it helps). Especially during an injury where the muscles are under tension and spasm and therefore tight and resticted to the correct biomechanical position. This is why in my experience working with traditional orthotics for 15 years, I found so many failures. And I could do very little to adjust that device to make it that much more acceptable to the patient.
The SDO can be adjusted to anyone (as long as that individual is willing to work with you and understands that just because the orthotic fits does not mean that resolution is going to be quick), because the intrinsic muscles of the foot determine that the fit in that position is acceptable to them. We also know that if an orthotic does work, we will need to adjust the alignment position in 1-2 years to compensate for that shift in fit vs biomechanical position.
Quite frankly I could go on and on, but truthfully, regretfully I'm finding less and less time to discuss this.
Good luck to you all.

Re: A BAG OF BONES

BGCPed on 8/08/02 at 15:00 (091989)

Why did you find that there was little you could do to adjust customs but you feel the sdo CAN be adjusted if the pt is patient and works with you. I also wondered what your theory is that the device needs to be adjusted in 1-2 years to compensate for the shift in fit v biomechanical position?. Are you saying that the foot will improve structurally or that it degrades? Will the change that takes place free up a tight heel cord and tighten up a post tib tendon that is lax? Just a few questions and thanks for the interesting dialog

Re: A BAG OF BONES

Dr Dennis Kiper on 8/08/02 at 15:39 (091997)

I feel I explained the adjustments of traditional vs fluid well, but I'll try again.
In a traditional support (in my opinion) you cannot effect a change in the architectural position of the arch, once casted.
With the SDO, the fluid automatically adjusts under the various high and low pressures of the foot. This automatically changes the architecture of the arch.
As an orthotic renders its beneficial effects, pain, tension, spasm resovles. This creates a more flexible musculo-skeletal structure. But if you remove the orthotic, the structure collapses, and eventually reverts back to its unhealthy state. Remember the orthotic renders its effects through alignment efficiency.
A tight heel cord (have to stretch also) becomes more flexible, a lax PTT tightens up (in a healthy way), although I can't honestly say I've ever seen a lax tendon.

Re: A BAG OF BONES

BGCPed on 8/09/02 at 12:49 (092061)

Well I was using the term 'lax' as kind of an easy for the layperson to understand term. So in a situation of a high grade of ptti with collapse midfoot and tight heel cord be controlled if the areas of greatest pressure and need to be supported the fluid would flow away from the area. I am not trying to split hairs but I dont see in a more severe case that it would control it. It would be better than a stock shoe. As for it creating a more flexible skeletal structure, new flexibility in heel cord and tightening og the post tib tendon are you saying that you have seen meausurable values after say a years use meaning that barefoot the pt would present with a marked increse in arch ht and reduced eversion of the hind foot? Just wondering and thanks for the stimulating exchange

Re: A BAG OF BONES

Dr Dennis Kiper on 8/09/02 at 20:47 (092096)

You have hit the nail on the head as far as not understanding the fluid mechanics (I'm not judging you here, this is exactly the same mistake my colleagues make).
Everyone thinks that pronation at the arch is very forcefull and high pressure and should force the fluid 'away'. It is the reverse. The arch falls (pronates) because it is highly flexible and weak. It pronates as far as it can to absorb incoming shock or weight (as in standing still).
If you go to my www and look at the computer scans that measure the 'ground reactive force' of the foot (the barefoot is seen on the left side of the frame), you will see that the highest forces are the outside (lateral) side of the foot, the forefoot and the rear foot. You'll see that in cases of the supinator, the arch does not reach the ground (is white-no pressure visible) and therefore does not flare the sensors.
If you then look at the severe flat foot example, you'll see that the arch does reach the ground, flares the sensors, but the force is low pressure (blue). The areas of high pressure above, forces the fluid to the arch area and supports it (both standing and in motion), because the arch force is the least force in 'ground reactive force'. In doing this you need to realize that the fluid is re-distributing all the high and low forces in that foot. It starts at the medial arch, BUT remember the fluid seeks its level at all 3 arches, therefore supporting all of the infrastructure. This is why even a generic support can be helpful, minimizing the medial arch motion brings greater (not necessarily accurate) stability and greater distribution of forces.
Even in a state of PTTi the arch force is less than the forefoot, rearfoot and lateral. The fluid puts the foot back into an aligned and stable position and therefore greater efficiency so that the PTT can perform back to a healthy state.
Regarding flexibility, flexibility is a state of health. Stretching does not increase the length of a muscle (or other tissue); it makes it more 'supple'. It's healthy tissue. Not under 'tension' and low grade spasm (as your mentioned heel cord).
I can not say that restoring the foot to health would cause a 'marked' increase in arch height, in fact it may not even be measurable. I have not done any studies in that regard, but my feeling is that it would not be measurable or perhaps in some cases it may be slight.
This would best be studied at an institutional level by some resident(s) who has access to patients and x-ray studies. In my office I did not take x-rays in order to avoid unnecessary additional costs, and I certainly can't take x-rays over the internet which is my present major source of business.
Years ago at a seminar I suggested a new measurement of the height of the medial arch (a transection of the talo-navicular joint and a plumb line to the floor), this could be seen and measured on a lateral x-ray view and a study of the foot in its maximally pronated position and optimal (neutral)
position could be recorded. I was essentially laughed at because it seemed unnessary to them.
Recently in one of my journals I saw that it is being looked at now. We'll just have to wait and see.
The paradigms of scientists are very hard to change. I've worked at it for years, and frankly am tired of trying. I figure I'll just continue at what I do and let them do what they do.

Re: A BAG OF BONES

BGCPed on 8/08/02 at 15:00 (091989)

Why did you find that there was little you could do to adjust customs but you feel the sdo CAN be adjusted if the pt is patient and works with you. I also wondered what your theory is that the device needs to be adjusted in 1-2 years to compensate for the shift in fit v biomechanical position?. Are you saying that the foot will improve structurally or that it degrades? Will the change that takes place free up a tight heel cord and tighten up a post tib tendon that is lax? Just a few questions and thanks for the interesting dialog

Re: A BAG OF BONES

Dr Dennis Kiper on 8/08/02 at 15:39 (091997)

I feel I explained the adjustments of traditional vs fluid well, but I'll try again.
In a traditional support (in my opinion) you cannot effect a change in the architectural position of the arch, once casted.
With the SDO, the fluid automatically adjusts under the various high and low pressures of the foot. This automatically changes the architecture of the arch.
As an orthotic renders its beneficial effects, pain, tension, spasm resovles. This creates a more flexible musculo-skeletal structure. But if you remove the orthotic, the structure collapses, and eventually reverts back to its unhealthy state. Remember the orthotic renders its effects through alignment efficiency.
A tight heel cord (have to stretch also) becomes more flexible, a lax PTT tightens up (in a healthy way), although I can't honestly say I've ever seen a lax tendon.

Re: A BAG OF BONES

BGCPed on 8/09/02 at 12:49 (092061)

Well I was using the term 'lax' as kind of an easy for the layperson to understand term. So in a situation of a high grade of ptti with collapse midfoot and tight heel cord be controlled if the areas of greatest pressure and need to be supported the fluid would flow away from the area. I am not trying to split hairs but I dont see in a more severe case that it would control it. It would be better than a stock shoe. As for it creating a more flexible skeletal structure, new flexibility in heel cord and tightening og the post tib tendon are you saying that you have seen meausurable values after say a years use meaning that barefoot the pt would present with a marked increse in arch ht and reduced eversion of the hind foot? Just wondering and thanks for the stimulating exchange

Re: A BAG OF BONES

Dr Dennis Kiper on 8/09/02 at 20:47 (092096)

You have hit the nail on the head as far as not understanding the fluid mechanics (I'm not judging you here, this is exactly the same mistake my colleagues make).
Everyone thinks that pronation at the arch is very forcefull and high pressure and should force the fluid 'away'. It is the reverse. The arch falls (pronates) because it is highly flexible and weak. It pronates as far as it can to absorb incoming shock or weight (as in standing still).
If you go to my www and look at the computer scans that measure the 'ground reactive force' of the foot (the barefoot is seen on the left side of the frame), you will see that the highest forces are the outside (lateral) side of the foot, the forefoot and the rear foot. You'll see that in cases of the supinator, the arch does not reach the ground (is white-no pressure visible) and therefore does not flare the sensors.
If you then look at the severe flat foot example, you'll see that the arch does reach the ground, flares the sensors, but the force is low pressure (blue). The areas of high pressure above, forces the fluid to the arch area and supports it (both standing and in motion), because the arch force is the least force in 'ground reactive force'. In doing this you need to realize that the fluid is re-distributing all the high and low forces in that foot. It starts at the medial arch, BUT remember the fluid seeks its level at all 3 arches, therefore supporting all of the infrastructure. This is why even a generic support can be helpful, minimizing the medial arch motion brings greater (not necessarily accurate) stability and greater distribution of forces.
Even in a state of PTTi the arch force is less than the forefoot, rearfoot and lateral. The fluid puts the foot back into an aligned and stable position and therefore greater efficiency so that the PTT can perform back to a healthy state.
Regarding flexibility, flexibility is a state of health. Stretching does not increase the length of a muscle (or other tissue); it makes it more 'supple'. It's healthy tissue. Not under 'tension' and low grade spasm (as your mentioned heel cord).
I can not say that restoring the foot to health would cause a 'marked' increase in arch height, in fact it may not even be measurable. I have not done any studies in that regard, but my feeling is that it would not be measurable or perhaps in some cases it may be slight.
This would best be studied at an institutional level by some resident(s) who has access to patients and x-ray studies. In my office I did not take x-rays in order to avoid unnecessary additional costs, and I certainly can't take x-rays over the internet which is my present major source of business.
Years ago at a seminar I suggested a new measurement of the height of the medial arch (a transection of the talo-navicular joint and a plumb line to the floor), this could be seen and measured on a lateral x-ray view and a study of the foot in its maximally pronated position and optimal (neutral)
position could be recorded. I was essentially laughed at because it seemed unnessary to them.
Recently in one of my journals I saw that it is being looked at now. We'll just have to wait and see.
The paradigms of scientists are very hard to change. I've worked at it for years, and frankly am tired of trying. I figure I'll just continue at what I do and let them do what they do.