Lifetime Lessons

Learned

The Legacy of Richard O Schuster

Stephen M. Pribut, D.P.M., FAAPSM, FACFAS

Past President, AAPSMClinical Assistant Professor of Surgery

George Washington University Medical School

Financial and Conflict Disclosure

I have no relevant financial relationships or

conflicts to disclose.

I have no conflicts of interest.

Thanks

• NYCPM for education, Fellowship,

Residency

• special thanks to the Department of

Orthopedics and Dr. D’Amico

Where Are We

Headed

• Introduction

• Schuster

• Lessons

• Case Studies

• Models, What’s real, what’s not

Thoughts

• “If in the last few years you haven’t discarded a

major opinion or acquired a new one, your

critical thinking capacity may be broken.”

• “All models are wrong, but some are useful.”

(George Box)

• Master the art of “what works”

Fellows in Jimbo’s Getting

Coffee

Wisdom of the Ages

• Over 600 years of experience

• Average over 35 years of experience

per practitioner

• Wisdom of the ages or wisdom of the

aged

• Eyes to the future

Searching For The

Truth

Richard O. Schuster,

DPM:

A Biomechanics IconAn up-close look at a man who helped shape this discipline

by Joseph C. D’Amico, DPM

Mandatory background reading

Biomechanics

Podopediatrics

Sports Medicine

Fellowship Lessons

• Learning and Leading By Example

• Case Studies

• Learn what works

• Be curious

Learn from treatment successes and failures

Looking Back

Podiatric Sports

Medicine was

Starting To Take

Off

Telstar I 1962

Springsteen 1974-75

1960’s-1970’s

Billy Martin with Catfish Hunter 19793 HRs in World Series Game

Shot heard round the world (1951)

Whitey Ford Rookie 1950

562 Foot Homer, No steroids.

Mostly 1950’s

Into The 70’s and Forward

When you want to give your feet

a rest, the NY Subway is the

very best.

Knowledge

Gathering: Sports

Medicine 1977• Journal articles - few on specific sport related topics

• Conferences

• Biomechanics Fellowships

• Preceptorships

• Orthopedic/Biomechanics Residency

• Reading Runner/Runners World

• Reading Physician & Sports Medicine

• AAPSM / ACSM

NYCPM & AAPSM

1977“Post Graduate Course in Sports Medicine”

Early Articles

• Runner’s Knee - Sheehan

• Survey of running injuries -

Stanley James

• Immunity to heart disease

for marathoners - Tom

Bassler

–Jim Fixx ultimately

disproved an incorrect

theory.

What does legacy mean?

Definition of LEGACY

1

: a gift by will especially of money or other personal property :bequest

2

: something transmitted by or received from an ancestor or predecessor or from the

past <the legacy of the ancient philosophers>

3

:

anything contributed or created by someone who is no longer living or active and which continues to be

of influence or impact.

Examples: This esteemed university is the great legacy of its enlightened founder.The introduction of the term "rock 'n' roll" is part of the legacy of famous disc jockey Alan Freed.

Synonyms

bequest, birthright, heritage, inheritance, patrimony

Related Words

heirloom; bestowal, gift, offering, present

Origin:

Wisdom: the ability to identify truth and

make correct judgments on the bases of

previous knowledge, experience and

insight.

The Wisdom Pyramid

Podiatric Sports Medicine

Podiatric sports medicine was an important force in

putting modern podiatric medicine on the map.

Richard Schuster receives the Robert Barnes Service Award

Dr. Schuster’s Special Role In Sports Medicine

Great Moments In Running History

“Dr. Schuster gives George

Sheehan his first pair of

orthotics.” (1971)

“Never trust a thought that comes to you while

sitting.”

Lore of Running: Tim Noakes

“Only when I attended the 1976

New York Academy of Science

Conference on the Marathon

and heard the presentations by

George Sheehan, Richard

Schuster, and Steven

Subotnick did I begin to

appreciate that attention to my

running shoes and the use of

an orthotic might cure my injury.

These measures worked.”

New York Academy of Science:

1976 Symposium on the Marathon

Schuster

Subotnick

Sheehan

Bassler

Noakes

Over 30 Years Later: Still Legendary

Runner’s Handbook: Bob Glover

...George Sheehan’s writings

about podiatrist Dr. Richard

Schuster’s pioneer work with

orthotics for runners led me to

Schuster’s office.

“Then came the great

discovery: My knee pain didn’t

need surgery, just exercises

and orthotics.

It Worked!”

Many go too far too fast too soon. Then, explains

Schuster, 62, "the body begins to break down. It's

like an old jalopy: good enough to get you to the

supermarket, but if you try to run it in the Grand

Prix, it'll fall apart."

Schuster also has worked extensively with brain-damaged children

whose balance system is not functioning properly. His shoe

modifications and inserts allow many afflicted children to walk with

increased stability. "That's the exciting work," he says.

Working out of a small office in Queens,

Schuster uses a tape measure, a

carpenter's level and a mirror, among

other tools, to amass 80 pieces of

information about the ailing foot.

The Runner Magazine 1978-1987

The Runner Magazine 1978-1987

Dr. Schuster was the “Podiatric Editor” and Dr. Sheehan

was the “Medical Editor”.

Also featured: George Hirsch, David Costill, Hal Higdon,

Tom Fleming, Edwin Moses, Bill Rodgers, Frank Shorter,

Craig Virgin, Nina Kusick, and Marty Liquouri.

Sold by Ziff-Davis to CBS to Rodale which merged it with

Runner’s World.

Many hoped the April, 1987

issue was an April Fool’s Issue.

The Runner Magazine: Foot Works

Case studies, tips on injuries, analysis of new

features in shoes, insoles, socks, running trends.

If you did everything as Schuster did 30 years ago,

you’d be a great clinical practitioner.

If you made clinical observations as he did, you’d

do far better than you do now.

The Runner Magazine: Foot Work

Bad habits of running

Morton’s neuralgia

Tarsal tunnel syndrome

Ankle sprains

Blisters

Stress fractures

Forefoot running

Shoe changes

Shoe cushioning

Shoe insoles

Women’s injuries

Children’s injuries

Recurrent stress

fractures

Stretching

Topics:

The Runner Magazine: Foot Work (April 1984)

Bad Habits of

Running:

Too much, too soon.

Changing running

style.

Not stretching.

Faulty stretching.

Compared pre-1978 and post 1978

• Second metatarsal most often

• Moments of force (bending

forces)

• Practical means of treatment

• Early diagnosis - bone scan

Still used term

“pre-stress

fracture”.

Stress Fractures 1972-1982

"Runners with low-arched feet generally don't

have to worry," says Schuster. "The runner

with high-arched feet is usually the one with

more problems.”

Authored many “Body Works” columns

Overtraining

Limb length discrepancy

Practical & educational

Biomechanical Forces of Good and Bad

Did pop culture have an impact in1977?

What did long experience imply in this mysterious field?

The Force:

Newton v. Lucas

• Forces may be good or

evil

• Injunction to measure

and determine abnormal

forces

• Train sense of intuition

• An eternal battle

Forces of Good and Evil

Moving On: The Clinician

Full Definition of CLINICIAN

1 : a person qualified in the clinical practice of medicine, psychiatry, or psychology as distinguished from one specializing in laboratory or research techniques or in theory

2 : a person who conducts a clinic

Origin: 1870-1875; from “clinic” + ian

Word Origin & History

clinician1875, from Fr. clinicien, from L. clinicus (see clinic).

Schuster: Respected For

His

Clinical Expertise• Patients and Athletes

• Print media

• Running Books

• Running Magazines and Columns

–Runner Magazine

–Runner’s World

• Inspired athletes to become podiatrists

Ideal Clinician

• Dr. Schuster exhibited many of the

characteristics of an ideal clinician

• His example stood as a life lesson to

many

Character

• Humble

• Attentive

• Focused

• Clear thinking

• Honest

• Sincere

• Goal directed

• Results oriented

Confident: “The doctor’s confidence gives me confidence

Empathetic: “The doctor tries to understand what I am feeling and experiencing.”

Humane: “The doctor is caring compassionate and kind.”

Personal: “The doctor interacts with me and remembers me as an individual.”

Forthright: “The doctor tells me what I need to know in plain language and forthrightly”

Respectful: “The doctor takes my input seriously and works with me.”

Thorough: “The doctor is conscientious and persistent.”

Standards in Clinical

SkillsProject Professionalism of the American Board of Internal Medicine

has outlined:

specific values, including humanistic and communication

behaviors expected of their membership

The Outcome Project of the Accreditation Council for Graduate

Medical Education requires all accredited residency programs:

to address the training of physicians in 6 core competency

domains:

patient care

medical knowledge

practice-based learning and improvement

interpersonal and communication skills, professionalism

systems-based practice

Seven Habits of Highly Effective Clinicians

Demonstrate aspects of ideal

physician behaviors.

The traits described are from

the interview transcripts and

patient focus groups.

Personal observations of the

research team are included.

Confident

• Makes use of state-of-the-art medical practices

• Applies experience in treating specific medical

conditions or performing procedures

• Is not disturbed by patient's queries about

medical information acquired from other

sources (regardless of accuracy or inaccuracy)

Is at ease in the presence of patient, family

members, and medical colleagues

Empathetic• Makes eye contact with the patient as

well as family members

• Correctly interprets patient's verbal and

nonverbal concerns

• Repeats patient's concerns

• Shares personal stories that are

relevant

Speaks in a sympathetic and calm tone of

voice

• Makes eye contact with the patient as

well as family members

Humane

• Uses appropriate physical contact

• Is attentive, present to the patient and

the situation

• Indicates willingness to spend adequate

time with patient through unhurried

movements

Personal

• Asks patients about their lives

• Discusses own personal interests

• Uses appropriate humor

• Acknowledges patient's family

• Remembers details about the patient's

life from previous visits

Forthright

• Doesn't sugarcoat or

withhold information

• Doesn't use medical

jargon

• Explains pros and cons of

treatment

• Asks patient to recap the

conversation to ensure

understanding

Respectful• Offers explanation or apology if patient is kept

waiting

• Listens carefully and does not interrupt when the

patient is describing the medical concern

• Provides choices to the patient as appropriate but is

also willing to recommend a specific course of

treatment

• Solicits patient's input in treatment options and

scheduling

• Takes care to maintain patient's modesty during the

physical examination

Thorough

(most often mentioned)

• Provides detailed explanations

• Gives instructions in writing

• Follows up in a timely manner

• Expresses to patient desire to consult

other clinicians or research literature on

a difficult case

Handwrite

highlights and

directions and use

handouts as

needed.

Patients as Detectives:

Clues About The

Office• Functional clues

–Lab reports - accurate, not “missing”

–Check on allergies before Rx

• Mechanical clues

–Comfort, sights, sounds, smells, textures

• Humanistic

–Behavior and appearance of physician

• Word choice, tone, enthusiasm, body language,

appearance

These Clues

create the

service

experience.

Practical Suggestions

1. Eye contact—is a basic sign of connecting, listening and caring.

2. Partnership—in a healthcare relationship is not a one-way proposition.

3. Communication—also works in two directions. Understanding needs. Understanding solutions.

4. Time—is what physicians have little of, and what patients want from physicians. They do not want to feel rushed.

Rapport begins before you say hello…

Shake hands

Apologize if you are late

Introduce yourself by first and last name “Good

morning Mr. Smith, I’m Billy Ray Cyrus.”

On To The Next

One? Jay-Z

One Toolkit Is Always

Available

• Brain

• Eyes

• Ears

• Hands

Devices

• Goniometer

• Kurzweil device

• Postage scale

Old School

Computers (pre

1980’s)

Supercomputer

Equivalent

Other Tools:

Old & New• EDG - Father of EDG - M. Polchaninoff/Langer Labs (1977 -

NYCPM Fellow)

–F Scan

–Dartfish

• Internet forums

–PM Magazine, Podiatry Online, Podiatry-Arena, Bartold

–Social media: bane or blessing?

• iPhone

–Data & programs in your hand

• Online forums

• Traditional Journals

Schuster:

Used Careful and Methodical

Evaluation

• Skepticism of unsubstantiated research

–Bayes theorem

• First to note problems of over-stretching

Clinical Observations

& Problem Solving

• Listen

• Observe

• Think

• Solve

• Fix

“If I had an hour to solve a problem, I’d spend 55 minutes

thinking about the problem and 5 minutes thinking about the

solutions” – Einstein

If WD-40 doesn’t fix it, duct tape is the answer.

Gait Analysis: Out Of The Box Thinking

Gait As Revealer of

Aging & Alzheimer's• Mayo Clinic: N= 1341, followed over 15 months

– Lower cadence, velocity and length of stride

correlated with significantly larger declines

in global cognition, memory and executive

function.

• Basel, Switzerland: N= 1153, mean age of 78

– gait became "slower and more variable as

cognition decline progressed."

– Cognitively healthy, mild cognitive

impairment or Alzheimer's dementia.

– Those with Alzheimer's walked slower than

those with MCI, who walked slower than

those who were cognitively healthy.

Simplicity &

Simplexity• Scale Test

– Shoe flexibilty

• Scaled down

– Finger Test

• Diagnostics Use Occam’s Razor. Select the

simplest of all competing hypotheses. The one

with the fewest assumptions.

Measurements

• Navicular drop

• Total varus (Dr. Skliar

discussed earlier)

• Shoe flexibility

–Peter Cavanaugh

–Richard Schuster

Orthotics:

What are they? How do they work?

“An in-shoe medical device which is

designed to alter the magnitude and

temporal patterns of the reaction

forces acting on the plantar aspect of

the foot”

Kevin Kirby

Kirby on Schuster

• Kirby mentioned R O Schuster as a

major influence on his choosing

podiatric biomechanics as a field of

interest.

• Kirby calls Schuster one of the important

historians of the profession. (Schuster

1974. JAPA History of Orthopedics in

Podiatry)

Orthotics:

What are they? How do they work?

How do they work? By altering force application, direction,

magnitude.

Thoughts: Kinematics (motion) or Kinetics (forces)

Conformity of orthotic to foot (foot orthotic conformity and

orthotic topography)

Frictional characteristics

Deformation of device under load

Are these Orthotics?

They changed the thinking of many in one journal article...

But, I look to Magritte for the answer!

Old Orthotic Rx

• Material

• Top-cover

• RF Posting

• FF Posting

• Accommodations and modifications

Old School Root

Orthotic:

Rohadur• The cast is altered significantly during

manufacturing process

• Too narrow to be truly effective

• Very often there was too much arch fill

• Forefoot balancing

–With bad casting technique

Modern Orthotic: Features

(What Dr. Schuster Used In His Orthotics)

• Deep heel cup

• Minimal cast correction

• Good contour to foot

• Wide enough to do the job

• Functions also at talo-navicular and C-C joint and midfoot

• Anatomically correct accommodations

–Sesamoid/1st Met

–Sweet spots - navicular/heel

• Bevel rear foot post when needed

The Clash of the

Cast(ing) Technique

Text

Old: Semi weight bearing or non-weight bearing

New: Wipe out or enhance a plantar flexed first ray

Negative

Impression

Capture

Earlier: Tracings, Trays of Plaster or

Grease.

Plaster Bandage

Casting

Reed E.N.: A simple method for making

plaster casts of feet. JBJS (1933).

17:1007

New Orthotic Rx

• Kirby Skive

• Inversion of cast (Blake or less than Blake)

• RF posting material

• RF post

• Thickness of shell, material choice

• Additions/Modifications

• Plantar fascial groove

Schuster: Impact

On Orthotic

Modifications

Modifications below polypropylene shell. Adding felt or other

material to increase “arch support” and firmness. (Kirby:

Newsletter (Aug 2013))

Thinning shell by grinding in area of arch to make it more

flexible.

(Medial or lateral) Decrease bevel of heel.

Orthotic design has ultimately swung around to many of what

Schuster proposed and practiced

3 Things That Don’t

Exist

(as described)

• Unicorns

• Metatarsalgia as a Condition (It is a

symptom not a diagnosis.)

• Cuboid Syndrome

Or are less commonly seen than diagnosed

Unicorns

Metatarsalgia

3 Things Not To Miss

• Plantar plate injury - symptomatic, low

grade

• Peroneal tendinopathy brevis behind fibula

& longus tendinopathy (below foot)

• Lisfrank injury - symptomatic, low grade

• Today: Skipping Lisfrank and looking at

Sever’s

Internet Research:

MetatarsalgiaDefinition

Metatarsalgia is a condition marked by pain and inflammation in the

ball of your foot.

Metatarsalgia is caused by the compression of a small toe nerve

between two displaced metatarsal bones. Inflammation occurs when

the head of one displaced metatarsal bone presses against another

and they catch the nerve between them. With every step, the nerve is

pushed together by the bones and then rubbed, pressed again, and

irritated without relief. Consequently, the surrounding nerve tissue

becomes enlarged, with a sheath of scar tissue that forms to protect

the nerve fibers.

We can do better than this.

Reality

• Morton’s Neuroma

• Flexor tendinopathy

• Lumbricale tendinopathy

• Plantar plate injury

–Under-diagnosed entity

–Steroid injection or not?

Cuboid Syndrome

Don’t forget

everything else that

is right nearby!

Speed Cases: Better Than Speed

Dating

Case Study: Forefoot

Pain

• 57 year old master triathlete, 5k and

martial arts competitor. 9 months of

forefoot pain interfering with sports and

ADL.

Clinical History &

Evaluation• Chief complaint: 9 months of

undiagnosed and unresolved pain

below his second metatarsal.

• HPI: 2nd MTP & 2nd digit pain,

weakness at toe off. Trail running and

martial arts are difficult and painful for

this long time high level athlete.

Physical Examination

• Thorough examination - check planes

of deformity and MTPJ instability.

• Look for predisposing factors

• Provocative tests: push-up, book-curl

test, Lachman, max-toe

flexion/extension & toe-off.

suggested readings: Gerard Yu (2002), Rich

Bouche lecture on MTPJ instability

Take Aways

• It isn’t always “just a hammertoe”

• Pay attention to signs, symptoms, exam

• Metatarsalgia is a symptom (like angina)

not a diagnosis

MTPJ Instability

• Related MTPJ instability:

–overlapping toes, crossover toes, pre-

dislocation syndrome, splay toes

• Planes affected

–Sagittal

–Transverse

–Combined

Pre-dislocation

Syndrome

Gerard Yu et. al., JAPMA 2002

“idea of idiopathic pain and instability of the

metatarsophalangeal joint is relatively new”

“can develop following jogging, tennis and

basketball or minor trauma.”

Can be viewed as intermediate level plantar plate

injury

Presentation

Yu et. al. 2002Late antalgic gait

Mistaken diagnoses are common

Feel “lump” or bruise at met head

Plantar plate involved (rather than “bursa”)

Pathomechanics

Review• Anatomy: Second Digit - 2 dorsal interossei, no

plantar interossei, medial first lumbricale

• Primary (chronic) deforming force: EDL

• Primary digital flexor: Interossei

• Dynamic digital stabilizers: Interossei and

lumbricales

• Static digital stabilizers: PLANTAR PLATE,

collateral ligaments (also capsule and plantar

fascia)

Key: Role of Plantar

Plate

• Plantar plate is the primary static

stabilizer

• Dynamic stabilization is by intrinsic and

extrinsic muscles

–But is dependent upon intact plantar

plate

Must Read: Yu JAPMA April 2002 182-199

Function of Digits

• Assist balance, proprioception

• Aid in force transfer forward

Plantar

plate/Predislocation

Syndrome

• Pain localized to plantar MTPJ

• Negative tuning fork test

• X-rays - no change in early stage

• Bone scan can show uptake at MTPJ

• Minor trauma may be recalled

• Onset acute or subacute (occ. chronic)

• Digital contracture - late stage

• Positive vertical drawer test

• Absent Moulder sign

• Subtle malalignment of toe

Evaluative Process

Yu (2002)

Kincaid & Barrett (2005)

Normal Disruption of plantar plate following

sclerosing injections

Stance Swing

Intermediate Stage

Plantar Plate Injury: Tx

• Immobilization

–6 to 12 weeks

• Plantar flexion exercises

• Splinting

• Orthotic

–Control abnormal biomechanics

–No anterior bevel

–Poron added from mets to sulcus

• Surgery

Resolved with conservative

therapy. Resumed 5Ks and

martial arts.

Case 2: Mild Plantar Plate

Injury57 year old female runner with a 30 year running

streak.

Pain below right 2, 3 metatarsals

Began after sprint training. Worsened by toe pull

ups and toe press against wall stretch.

Negotiated Treatment

(Case 2)Relative rest. Decrease running from 6 to 4

miles.

Toe curls - strengthen flexors, intrinsics

No sprints, speed work

Avoid awful stretches

Midfoot/heel contact - not forefoot

400’s in future: at sustainable speed with

rest between 400’s not sprint straightaways,

walk curves.

Summary:

Metatarsalgia

• Less than optimal diagnosis

• “Like saying ‘headache’ - S. Bartold

• Under-diagnosed: Plantar Plate Injury

• Lumbricale tendinopathy

Enthesopathy

• Spondyloarthropathies

• Achilles

• Plantar fascia

–Plantar fasciopathy

Case Study: Juvenile

Heel Pain

• Presentation: 8 year old child, student,

and basketball player presents with 6

months of pain in both heels, with the

right foot more symptomatic than the

left.

• He is hoping for an NBA career.

Is Sever’s Disease

Properly Named?

Clinical History &

Evaluation• Chief complaint: 6 months of undiagnosed

and unresolved pain both posterior and

plantar heels.

• HPI: Reports pain during jumping and

running. It has minimally improved with

short term rest, but returns.

• Mom will not let him run cross country due

to pain and fear of he may need orthotics.

Dad thinks it may be Achilles tendinopathy.

Physical Examination

• Thorough examination - examine area

of chief complaint and nearby

structures.

• Look for biomechanical risk factors

• Evaluate for equinus, Achilles and

hamstring tightness and pronatory

forces. suggested readings: JAPMA September

2013

Left foot

Right foot

“Sclerosis is

often seen but

not

diagnostic.

Likewise

fragmentation

.”

Sever’s “Injury”, Disease, or Phenomena?

Inadequate Classical treatment:

Wait until growth plate fuses

Rest

Heel Lift

Growth center abnormality

is not always present

may be present in normals

associated with athletic activity

recent articles call it a “clinically diagnosed disorder”

Seaver the phenomena

Juvenile Osteochondroses, Stammel,

CA Radiology Oct 1940

Lifespan of Misinformation: Endless

The opportunity for education, is always present.

Is Sever’s likely another -opathy not an -itis?

Calcaneal Apophysopathy

No biopsy material

No evidence of “inflammation”

Clearly traction related

After tendinopathy, fasciopathy, why not?

Calcaneal Apophysopathy

Heel pain on one or both sides with 60% having bilateral symptoms

Heel pain with running, jumping

Antalgic gait

Pain elicited when the heel is compressed medially and laterally at

the apophysis

Often classical radiographic signs are present

Growth center appears in boys aged 7-8 and fuses at 15-17

Growth center appears in girls aged 4-6 and fuses at 12-14

Calcaneal Apophysopathy

Acute Care:

Rest, Ice, Elevation.

Relative rest - allow pain free activity

Limit motion using: Heel lift or Pneumatic Walker

In The Long Run:

Evaluate biomechanics carefully

Heel lift

Gentle calf stretching

Intrinsic muscle group strengthening (toe crunch)

Tibialis anterior strengthening

Custom orthotics may be needed

Gradual return to activity

Case Comparison: The Runner

March 1984

cc: 25 yo♀Lateral ankle and leg pain while running

•Ankle sprain - untreated 10 days

•Brief use of soft cast

•5-6 week rest

•Pain

Schuster (Footwork Column):

•Warned of the danger of waiting for

treatment of ankle injury.

•Used lateral wedge below insole.

•Lateral buttress on counter and lateral

aspect of shoe.

•Recommended exercises for the ankle.

•Felt further evaluation and surgery might

be needed if this did not work.

Case Comparison: The Runner

March 1984

Case Comparison: The Runner

March 1984

30 years later..

The lateral wedge holds up and the buttress also.

Case Comparison: The Runner

March 1984

Areas for improvement:

• Improved assessment of ankle injury via better

physical examination, anterior drawer test,

imaging.

• Pneumatic cast boot = better immobilization

• Longer immobilization

•Wobble board training - muscle strength,

balance, proprioception

Case Comparison: The Runner

March 1984

Orthotic Improvements

No lateral bevel

Forefoot - Valgus wedge 3°

Orthotic for contour to foot not insole

(Reverse Kirby skive and -Inversion casting)

Exercise Improvements

Wobble board not just rubber bands and ROM

Bracing or taping

Shoes - avoid mushy, over-cushioned shoes

Case Study:

Lateral Ankle Pain in Olympic Triple

Jumper

• 26 year old elite Triple Jumper

• Lateral foot and ankle pain for nearly a

year

Case Study:

Lateral Ankle

• Symptoms present in training shoes,

running on grass

• Shoe role in pain causation - Mizuno -

soft & squishy

• Previous treatment: Injection at PB

tendon behind ankle: FAIL

Case Study:

Lateral Ankle

• Physician suggestion via phone: Sinus

tarsi injection

• My suggestion before examination:

“Let’s check it out and see if it is

something else and we can do

something mechanically.”

Case Study:

Lateral Ankle• Somewhat tender at peroneus brevis below

ankle

• My suspicion: Training Shoes

• Symptoms present in training shoes, running

on grass

• Symptoms not present in competition flats and

track work.

• Shoe role in pain causation - soft & squishy

(miz)

Treatment

• Change to more solid shoe, different brand

• Add 1/8 to 1/4” heel lift to decrease forces

on PB tendon

• Wobble board therapy + Calf/Posterior

muscle group stretching

• Consider orthotic as discussed above:

–No lateral bevel, 2 degree valgus post to

sulcus for training shoe only

Belief Systems

“Beliefs held by patients about their health and

illness are central to how they present, (and)

respond to treatment”...

Peter Halligan, (2007) The Psychologist, 20:6 358

Beliefs are pre-existing notions and typically

involve strong personal endorsement for a

proposition considered true and beyond

further inquiry.e.g. Mom of 8 year old whose “feet are still growing”

Competing Belief Systems

Models & Principles

• Schuster - clinically oriented

• Root - neutral position

• Kirby - STJ Axis

• Dananberg - Sagittal plane

• Nigg - muscle tuning

Schuster on Root– “...research by Inman, Strauss, Elftman,

Manter, Hicks, Hibbs, and many others

was put together in a meaningful

biomechanical concept by Dr. Merton L.

Root”

– “Root...emphasized the relationship of the

forefoot to the rearfoot and provided

..validity for the comparatively hazy

balance concepts of earlier years.

Misunderstanding

Root

• There is a difference between the

Aristotelian average and the Platonic

ideal.

• Ideal normal is different from average

findings.

• The ideal was lost to the mundane.

Kirby• Foot orthoses have effects

on Midtarsal/Midfoot Joints

• Plantar Ligaments and

muscles cause a

longitudinal arch raising

moment

• Longitudinal arch stops

lowering at position of

rotational equilibrium

• Foot orthosis acts to

reduce tensile stress on

plantar soft tissue

structuresillustration: Kevin Kirby

Endless Debates on

MTJ Axis

And More

Simon Spooner trying to make

Kevin Kirby think hard

cop: position 1; mtj: position a; STJ axis i =?cop position 2; mtj: position a; STJ axis i =?cop position 3; mtj: position a; STJ axis i =?cop position 1; mtj: position b; STJ axis i =?cop position 1; mtj: position c; STJ axis i =?

New paradigms in shoe design lead to new injuries.

Don’t wear more shoe than you need or less

shoe than works.

What would Dr. Schuster say today?

Schuster on The Future of Running

Shoes

“running injuries vary year to

year in response to the latest

“advances” in running shoes. “

Changes in flexibility of the

shoe and the rigidity of the

heel counter may help some

runners but cause problems

for others.

Schuster on The Future of Running

Shoes

“As shoes get lighter with the use

of new materials, injuries may

result from less support and

cushioning.”

“Shoes must offer flexibility,

cushioning, support and they must

fit your feet.” (feel comfortable)

Schuster on Running

InjuriesOver cushioned shoes can create

problems.

Shorter strides can help hip and

gluteal problems.

Calcium balance and hormonal

issues contribute to women’s

stress fractures.

Heel lifts are not evil.

Stretch wisely.

Meme of “Shoes Bad, Barefoot Good”

Soil Classification

If we are going to use minimalist shoes, we need

maximal analysis of what we are running on.

Concrete is not the answer.

RESPECT &

RESULTS

Do your own casting and don’t use foam!

THE END IS HERE