An Approach to Foot Orthopedics

Merton L. Root’s vision for the podiatry profession was precision. Precise definitions. Precise quantification of deformity. Precise individualized treatment designed to nullify the forces that cause pathology. In this brief article, Root for the first time addresses his entire profession with his vision. Although the concepts in this essay may seem commonplace now, his ideas were revolutionary at the time.

Before Root, the fields of orthopedics, physical therapy, and podiatry used jargon that was ill-defined at best. Subsequently, communication among podiatrists and among professions around the world improved as his definitions were accepted. Precise definitions may have been Root’s greatest contribution.

Root envisioned creating a unique treatment plan, including surgical and mechanical modalities, specific to each individual patient’s morphology and associated abnormal forces. A parallel can be drawn with the ophthalmologist’s quantification of nearsighted-ness or farsightedness and then prescribing a lens or surgery to correct the deviation from ideal vision. It is very difficult to have the discipline to evaluate and treat patients with the precision necessary to execute Root’s vision. Thus detractors were born.

On the other hand, many researchers have embellished Root’s concept of precise quantification and individualized treatment. Kevin Kirby quantified ground reactive moment arm length to the subtalar joint, and he also developed the medial heel skive to treat variations from ideal.[1] Howard Dananberg[2] developed the kinetic wedge to address the abnormal forces created by functional hallux limitus. E. Dalton McGlamry advocated addressing the cause of plantarflexed metatarsals by straightening the respective toe rather than directly altering the metatarsal. Mc-Glamry’s concept was later quantified by Scot Malay and Howard Hillstrom.

With regard to quantifying foot deformity, a study published by Jinsup Song and colleagues[3] has been frequently cited by members of a variety of professional disciplines as a breakthrough for quantifying foot morphology and for predicting gait and associated forces in a consistent fashion.

Root developed foot orthoses that move. The amount of motion prescribed for the patient depended on the foot’s ability to influence leg rotation as determined by the deviation of the subtalar axis from the horizontal plane. The actual motion was determined by the flexibility of the plastic and the rearfoot post. Gilbert Hice[4] described a technique for treating feet with above-average deviation of the midtarsal axis from the transverse plane.

When reading this article, it should be remembered that most of the concepts were new, and that the established concepts were presented as part of a new vision. Root did not accept that one treatment fit all patients and their pathology. His vision was that through precise communication, precise quantification of deformity, and precise individualized treatment and evaluation of that treatment, treatment results would improve. If the podiatry profession had executed the vision described by Root, perhaps retail foot-care products would be no more prevalent than over-the-counter corrective lenses.

William H. Sanner, DPM Ochsner Clinic Foundation of Baton Rouge, Baton Rouge, Louisiana