In the 1970s, a disagreement between two of the foremost authorities in podiatric biomechanics led to a split that became known as East Coast versus West Coast biomechanics. Such disagreements are not uncommon in scientific circles. One of the most famous was that between Albert Einstein and Neils Bohr on the reality of quantum mechanics. Dr. Richard Schuster was chief of orthopedics at the New York College of Podiatric Medicine and Dr. Merton Root was chief of biomechanics at the California College of Podiatric Medicine. Unfortunately, the result of their disagreement was very different methodologies being utilized in making functional foot orthotics, which continues even today and confuses many in and outside the orthotic industry.
I was a good acquaintance of Dr. Root until his death in 2002 and had many discussions with him about biomechanics and some ideas that I have had through the years. Though I never personally met Dr. Schuster, I have met on many occasions with his nephew, Dr. Paul Coffin as well as his very close friend, Dr. David Skliar. Both I respect greatly for their clinical and academic ideas. It has taken me many hours of discussion to try to understand why there should be a disagreement between podiatrists, who should have a united theory of foot function yet have adopted very different clinical practices. To you, the reader, I will boil all my discussions with these great people down to a simple "fork in the road" where two great thinkers parted and never came to an agreement. That fork is the examination of the forefoot to rearfoot relationship. Dr. Root believed that the examination should be done with the subtalar joint in the neutral position and the midtarsal joint pronated to its end range of motion. Dr. Schuster believed that the examination should be done with the subtalar joint in the neutral position but with the forefoot relaxed neither pushed into full pronation nor full supination.
The difference in the examination technique led to a difference in describing normal position of the foot in a relaxed standing position. Dr. Root believed that when a normal patient stands up, the subtalar joint should be in its neutral position and the midtarsal joint should be fully pronated. I have come to call this idea "The Root Postulate" because I can find no instance in the literature before Dr. Root that expresses such an idea. Dr. Schuster believed that when a normal patient stands up, the subtalar joint should be in its neutral position and the midtarsal joint should be in the middle of its range of motion, neither fully pronated nor fully supinated. As a result of this difference in the theory of normal foot position when standing, the two great physicians pursued different techniques in making molds of the foot for functional foot orthoses. Dr. Root developed his nonweightbearing technique, in which he put the subtalar joint in its neutral position and fully pronated the midtarsal joint. On the other hand, Dr. Schuster pursued his technique of doing a semi-weightbearing mold of the foot, also placing the subtalar joint in its neutral position but allowing the midtarsal joint to be neither pronated nor supinated. Dr. Root then pursued the use of acrylic materials to fabricate orthotics from whereas Dr. Schuster pursued the use of semirigid materials. Interestingly, both physicians can point to great successes with the devices they made, to the point that many have come to doubt that casting position makes any real difference in the outcome of the orthotics.
So the problem we have today is whether the Root postulate is correct or not. It makes sense to me as it incorporates the ideas of Steindler (1929), Hicks (1955) and Sarrafian (1987) in describing the foot as a twisted plate. The idea that forefoot varus was a major reason for flattening of the foot was not new with either Schuster or Root. Steindler had noted that a shoe correction for flat foot required both a varus wedge under the heel and a valgus wedge under the forefoot. Cotton (1936) and Perkins (1948) had proposed surgery to correct forefoot varus. Many authors over the last 150 years have concentrated on the correction of flat feet by either producing a varus torque on the heel or a valgus torque on the forefoot. It seems that both the Schuster and the Root orthotic were able to prevent the heel from abnormally everting, but in my analysis, there is a different mechanism on which each works. The Schuster methodology seems to refine the ideas of Whitman (1898) whereas the Root methodology seems to refine the ideas of Steindler (1929). High school physics will teach that light can be considered to be a wave to describe some phenomena and it can be considered to be a stream of particles to describe other phenomena. Physicists have still not totally agreed on whether light is a wave or a particle. One of the problems with all of the research that has been published so far on orthotic function is that one specific foot type is not isolated in any study. Are there foot types that the Root device works better for? Are there foot types that the Schuster device works best? Most podiatrists isolate themselves to either one theory or the other based on who their preceptors were.
A human trait, which also is seen in almost all scientific arenas, is that one stakes out their domain of thinking, and then builds walls to defend their domain and throws weapons at all those who would seem to attack those walls. True scientists, though, always keep an open mind as to possibility that one's ideas may be wrong and that the ideas of others need to be investigated. So it is with our profession. Instead of one staking out their own territory with words such as, "In my hands ..." one needs to consider why a person doing things differently may also be having success. We need to be reaching across the aisle of disagreement to find out more about the ideas of those we consider to be doing things wrong, we can start to devise experiments to find, possibly, theories that would find why both sides may be considered right. This takes courage for anyone. A saying that I heard when I was young, which I cannot find the source of, which hopefully can guide us all is, "Only unafraid of truth will you find it." I note that the Richard O. Schuster Memorial Seminar has invited speakers who can represent the ideas from the East Coast and from the West Coast. Such a seminar may produce some disagreements, but it also should stimulate discussions on why disagreements may exist and more importantly stimulate all attendees to consider why others' ideas may be valuable to consider. Most importantly I'm sure it will stimulate more research that will explain when one idea may correct and when another idea may be correct and lead us to a real unified theory.
