Tag Archives: japma

How does stuff like this make it into professional journals?

Any publication with the title of A Novel Treatment Approach to Over-Pronation Dysfunction is going to get my attention, mostly because of the nonsensical understanding of “overpronation”. I was not disappointed and it was as bad as I expected.

Even before I got the full paper, just reading bits like this in the preview: “The literature supports a forefoot varus as the most frequent cause of over-pronation compensation. 1,2“. The two cited references did not show that and one was him quoting himself saying that. The alarm bells start going off about a lack of academic rigour and lack of critical thinking skills. A true forefoot varus (based on the textbook definition) is actually quite rare and far from being a common casue of “overpronation”.

On reviewing the full paper, the author proposes a new treatment for forefoot varus (which he has a patent on), when they don’t even know what forefoot varus really is! The author is confusing the theoretical constructs of ‘forefoot varus’ and ‘forefoot supinatus’ and really has no clue how foot orthotics even work in those two different constructs. There is certainly a lack of critical thinking skills and academic rigour in what is being written by the author (not to mentioned the editorial and peer review processes that allowed it to be published). I have written many times before (eg) about this confusion between the two and the chicken and egg situation with research that is done on one or the other or both.

I went onto great detail on the difference between the theoretical constructs of forefoot varus and forefoot supinatus here. Both present as an inverted forefoot when the lateral column is loaded and the rearfoot about neutral. Basically, the construct of forefoot varus is that it is osseous, rare, not correctable and is a cause of “overpronation”; whereas the construct of forefoot supinatus is that it is a soft tissue contracture, common, is correctable, but is the result of “overpronation”.

A simple cursory read of the paper shows that the author had no idea about forefoot supinatus (and does not even mention it) and ascribes some of the characteristics of forefoot supinatus to confuse it with what he thinks is a forefoot varus (its not). As a forefoot supinatus is a soft tissue contracture, then what he proposes can be helpful, is not new and is not novel and has been like a number of strategies that have been used for a forefoot supinatus over the years. The nature of what he is proposing will facilitate the stretching out of the soft tissue contracture as have mobilisation techniques been doing that for years. So too has the nature of the short foot exercise been restoring the “arch height” of those with a forefoot supinatus. However, all those techniques, including the one proposed by the author, will fail in a forefoot varus as it is a bony or osseous issue.

The problem with a forefoot supinatus is something is causing it. This is not acknowledged by the author, let alone understood by him. The approach advocated by the author is destined to fail in the long term unless that cause is removed. Short terms gains in arch height could be expected with what he is proposing.

The author then justifies his approach by applying the “it worked for me” logical fallacy. Seriously? In a professional journal?

At least the journal did include a response by Robert D. Phillips, DPM to what was published. My only criticism of what Daryl wrote is that he was too polite and should have ridiculed the concept.

I do acknowledge that there can be a difference of professional opinions, but in this case, this is not a case of professional opinion, but a confused superfical misunderstanding of the literature and a misunderstanding and misuse of concepts and terminology. It certainly lacks the academic rigour to be published in a professional journal.

On one hand, I am perplexed how something as confused as this can make it through the editorial and peer review process of a professional journal. On the other hand, we are talking about JAPMA who regularly publishes papers that are below an acceptable standard (see my posts here and here) and for some reason, republished the paper that was previously published in another journal (Journal of Orthopaedic Physical Therapy Practice) that from what I can tell does not even exist as a journal. There is a magazine by that name, but not a journal!

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Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+

The APMA are taking some heat for this advice on childrens shoes and its hard to defend

On the website of the American Podiatric Medical Association, is this advice regarding children’s footwear with this graphic provided by the children’s shoe manufacturer, StrideRite.
children's shoes
It is not too dissimilar to the advice that I have seen being widely given for the use of children’s shoes. Where a problem arises is that I periodically come across comments in social media calling out the APMA on what they are advising, asking how robust the advice is and what is the evidence supporting the advice that they are given. I have yet to ever see the APMA respond. Here the most recent couple that I have seen:


The onus on any professional body giving advice or guideline is to ensure that that advice and guidelines are consistent with the latest preponderance of evidence and not underpinned by any commercial bias. What evidence is underpinning the above recommendations? There is none. There is no evidence that a children’s shoe should have a stiff heel. There is no evidence that a children’s shoe should only bend at the toes. There is no evidence that the midsole should be rigid. It is on that basis that the APMA is being called out in social media for this advice.

The cynic could simply respond superficially by saying, do those who are criticizing the APMA have any evidence that the claims are wrong? They don’t. However, the ‘burden of proof’ fallacy is that the burden is on those making claims to support and defend them. So you can’t just twist it around to get the critics to provide evidence of the opposite by deflecting the burden of proof to the negative.

What sort of issues does this raise?

  • What are the responsibility of professional representative organizations to issue advice and guidelines that are evidence-based? (surely the answer to that is obvious!)
  • If you follow some comments in social media, the commercial bias and imperative is often raised. In this case, the graphic on that APMA page that is posted above is provided by a commercial manufacturer. I do not have a problem with commercial sponsorship and support for professional organizations as the money is typically used to fund the goals of the organization, but they should not dictate or influence any policies or guidelines of the organization. In this case, StrideRite has a ‘seal of approval‘ from the APMA which they would have had to pay for. This certainly opens the APMA to criticism in giving non-evidence-based advice on a product that is giving them money. As money is involved, this increases the scrutiny as to the quality and robustness of the advice being given
  • Why is the APMA not responding to the call outs in social media to defend what they are advising?

So what advice should be given for children’s shoes?
I would have thought that the most appropriate logical and intuitive advice on shoes for kids, in the absence of any evidence to intervene, would be to use shoes that have design features that do not interfere with the developing foot. That contradicts with some of the advice being given by the APMA.

This is, of course, assuming that there are no problems present that need intervention. We can have a debate on the evidence for that another day.

Postscript:

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Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+