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Views & Reviews From the Frontline

Bad medicine: sports medicine

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2025 (Published 30 March 2011) Cite this as: BMJ 2011;342:d2025

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Foot loose

Foot loose

As medical professionals perhaps we should be mindful that it is only
too easy to cast doubt on another's profession. Dr Des Spence may like to
take note. It is offensive to those professionals to say the least for
them to read what can only be described as a rant. In the last issue Dr
Spence has, in effect, cast aside a large part of the podiatry profession
describing biomechanics as a 'new musculoskeletal cure all'. It is true
that biomechanics is in its infancy, however that does not suggest that it
is somehow worthless. To state that there is no statistical evidence is
simply untrue. Plantar heel pain is one of the most commonly presenting
foot complaints, many of which appear to be poorly understood by many
others. It is widely known that excessive pronation of the sub talar joint
is contributory in foot pain and in particular plantar fasciitis. The
connection between lower limb alignment and foot problems was described in
the 19th century by Durlacher as a weak foot. Treatments for these
conditions included shoe inserts of metal and wood. The paradigm was first
brought to light by Root in 1959. In 1977 together with Orien and Weed, he
specified at the time that it was just that, a theory and that they
welcomed further research.1 To date this is the basis of treatment,
remains largely unchanged and has not been bettered. It is the mainstay of
corrective orthotic production. It is equally well understood that the
best long term solution is controlling any excessive pronation at the
subtalar joint with use of corrective orthotics. I should mention that
these devices are available and widely prescribed with good effect through
the NHS and that it is not always about private companies profiteering
from pain and suffering.

Corrective orthosis benefit more than one condition. They are
effective in runners suffering from achilles mid portion tendinopathy
demonstrating over pronation.2 Over pronation is a considerable intrinsic
risk factor for injury during running.3 Arch supports wether bespoke or
mass produced have benefit. Medial arch/heel support is effective in
reducing ankle eversion during walking and running.4

Dr Spence makes reference to mans evolutionary changes and I am
inclined to agree although I see these changes as part of the problem. One
school of thought is that, if we go back as far as Dr Spence refers to,
man would have walked on soft earth, clay, sand or mud. Over history this
has been replaced with the much less forgiving concrete, tarmac and stone.
Because these materials do not give way under foot as once would have been
he case. The joint closest to the the ground on initial contact is that of
the sub-talar. It is observed in many cases that this joint will give way
under the subjects weight combined with the ground reaction forces acting
upon it. This is all very well if it were not for the compensation of the
foot to remain in the optimal position with the 1st mtpj in ground contact
in readiness to propel the subject into the next step. This combined with
man's other evolutionary flaws such as weight gain, and the general lack
of hunting/gathering have predisposed us to lower limb fatigues and
injury. It is inflammatory at best to discredit the work that many
consider a speciality, one many of whom have developed careers from. If
the same had been said about much of the research in other fields that
have gone before it then we would make no scientific progress whatsoever.

This is far more than emotion and mere speculation. This has its
roots firmly based in science and many good studies are currently
underway. The shoots of progress may be small at this stage but it is
important to bear in mind that for all 'new' areas of knowledge that this
will have been the case at some point. As we better understand the needs
and requirements of the human body, perhaps it is fair that we let those
who know best deal with each case in point. It is felt that general
practitioners have fumbled, supposed and at best, guessed their way around
foot problems for years. Podiatrists have the benefit of expert knowledge
of the lower limb, how it functions and reacts to the forces placed upon
it. A large part of biomechanics revolves around sport and the performance
of the elite athlete, however, what we should all remember that it is
those same practitioners who work with those with spastic and neuropathic
deformity of lower limbs, rheumatoid arthritis, amputees, and a generally
aging population and will successfully in many cases allow them to
continue to ambulate for as long as possible. With the inevitable links
with quality of life for those, this can only be a good thing. This is
something which should be nourished and encouraged to grow. Descriptions
such as 'pseudo-science and quackery' are simply misleading by any
measure.

1 Root ML, Orien WP, Weed JH (1977) Normal and abnormal function of
the foot. Clinical biomechanics, Vol.11, Chp. 1, 5, 9. Clinical
biomechanics corporation: Los Angeles.

2 Ryan M, Grau S, Krauss I, Maiwald C. Taunton J, Hosrtmann T.
(2009)Kinematic analysis of runners with achilles mid-portion tendinopath,
Foot ankle Int; 30(12);1190-5

3 Hartgens F. (2008) Athletes with exercise-related pain at the
medial side of the lower leg, Ned Tijdschr Geneeskd. 2008 Aug
16;152(33):1839-43

4 Fong D T, (2008) Effect of medial arch-heel support in inserts on
reducing ankle eversion: a biomechanics study, Journal of Orthopedic
Surgery Res. Feb 20;3:7

Competing interests: No competing interests

04 April 2011
Ciaran J Canney
Podiatry undergraduate
Glasgow Caledonian University