I’ve been mulling over this one for a while and two things pushed it to the front of my mind. Firstly, a discussion on one of the Podiatry Facebook groups recently which, as is often the case, turned into a Root Vs Tissue Stress debate (which I’ve started thinking is actually quite unhelpful). Secondly, a great blog from Prof. Nester entitled “Foot Biomechanics is Dead. Discuss” which was actually a far less provocative blog than the title suggests and was more a call for people to appreciate that the human foot is far more complex than just being a triangle stuck on the end of the leg which is a slave to only mechanical laws.
So there are potential problems for the future of the sub-specialism of biomechanics within our profession. Those of my age, and older, were solely taught the Root Theory of foot function. Many are now taught Root Theory alongside numerous other theories and are left confused due to some of the obvious conflicts between theories. Furthermore, over the decades a sort of Chinese whispers effect means most are not even exactly sure what it was Root Theory originally stated. It’s now rather well agreed upon that Root Theory doesn’t stand up to scientific scrutiny. Yet many still subscribe to it (or to an interpretation of it). How can this be, given it is 2018 and we are allegedly an evidence informed profession? The quest for greater knowledge in this field is a lifelong journey full of ups, downs (and of course infinite reading), and from comments I’ve read it is clear many are not willing to take on that kind of commitment. They just “want to be told what the right thing to do is” (paraphrased from actual quote read online recently) or at the very least pointed towards the correct thing to read to get up to speed (like there is one bit of reading which would cover it all); or else they may just keep doing what they’ve always been doing or pick the one with the simplest explanation (guess which one that is!)
This is probably the reason many fear or avoid podiatric biomechanics and almost certainly the reason for such diversity in the thinking and clinical approaches taken across the UK (and indeed the world). The biggest problem here is clasping on to the belief that one day any one of these paradigms will prove itself to be superior to all the others, or that a new one will come along which holds all the answers. It is highly unlikely that is going to happen, and we almost certainly need to let go of this notion. We (as a profession) need to be striving to improve and progress our understanding of foot function and also the mechanisms/effects of our interventions, and subscribing to Root Theory “because it works” and “because nothing better has come along” is really not good enough and will actually be detrimental to our evolution.
There may be a strong argument here for the point that the whole concept of ‘paradigms’ is unhelpful. Why are we obsessed with labelling stuff? We are treating the human body, which by its very nature is an incredibly individual and complex ecosystem. Do we really believe we will ever find a theory of foot function that will account for all of this? If not, then why not just disregard all of them? It got me thinking – can anything be done about the current climate of confusion? Do we even need a paradigm of foot function to assess, diagnose and successfully treat our athletes/patients?
The comfort of a paradigm
As humans we like laws, rules and guidelines. We like the concept of right and wrong, or of normal and abnormal. Suspicion is high that this may be another reason Root Theory has been, and continues to be, so seductive. Yet these concepts when applied to human architecture, posture/alignment and movement are actually close to impossible to define, they woefully lack an evidence base and in most cases they actually correlate very poorly with pain or injury. Many won’t move away from this, even in the face of such strong evidence, as they simply would not know ‘where to go’ if they did. The safety net of having a ‘theory’ as a sort of framework to work from is too great, even when this theory is scientifically unsupportable. Perhaps this could be in part a result of the way we are trained?
Change the training?
The are some people quite vocal about it being the responsibility of undergraduate training to fix this. I do not believe it is fair to lay the blame solely on the doorstep of the undergrad training, nor suggest that the solution is entirely in their hands,
That said, experienced clinicians all have ‘baggage’ but undergrads are a blank canvas. Imagine if we completely removed Root Theory from the curriculum… what would this mean for future generations of Podiatrists? Whilst on the one hand it sounds as if it would be a really positive step (and I’ve definitely been a supporter of this in the past) when you stop and think longer there are much bigger issues at play. Firstly, upon graduating this new crop of clinicians would be entering the real world where they will have to communicate with patients/athletes, coaches, Physios, Doctors, other Podiatrists etc. etc. We are foolish to assume this whole issue is a Podiatry issue – because it isn’t. The easiest way to teach, educate and promote more up to date thinking is to be fully cognizant of the other side of the argument. Would we effectively be handicapping our future generations with respect to communicating with everyone around them? Furthermore, the famous quote from Edmund Burke needs to be considered: “Those who don’t know history are doomed to repeat it” – in order to move forwards we really need an historical context. Ironically, the one true bit of gold that Root et al. gave us was a steer regarding some of the things we probably shouldn’t subscribe to.
So what is the answer?
Honestly, who knows. It’s a complex issue, and even if we found a solid solution within Podiatry it would then have to have magical osmotic powers to permeate through the rest of the health professions (and society) to have any significant effect in the long term anyway. Whilst not teaching new students any of the theories of foot function would be an interesting experiment, (and I truly believe it would not hinder them in assessing and treating their athletes/patients) it makes sense that they should be in the historical context – and let us not forget that the history lesson does not start with Root!
Imagine if all Podiatrists had a really strong understanding of the following areas:
- Research Methods & Critical Appraisal
- History taking & Communication
- Anatomy
- Physics
- Basic Engineering
- Materials Science
- Pain Science
Instead of trying to learn/memorise what we believe the foot should be doing, and then how we “fix” or address the “dysfunction” we think we see in front of us, I truly believe that a solid understanding of all the above would equip anyone to deal with life as a musculoskeletal/sports podiatrist. Every single topic there has strong/robust evidence behind it, and all interlink beautifully to influence every clinical decision that has to be made. I’d say our ability to assess, diagnose and manage our patients would not only be no poorer for not applying any paradigms of foot function, I’ll put myself out there and suggest it could be significantly richer for it.
Agree or disagree?
