Cluffy Wedge

[rothbart]

Has anyone used the Cluffy wedge? (http://www.cluffy.com) And, if so, what has been your experience(s) with it?

Prof B

[robertisaacs]

No.

But the website (duff link btw try www.cluffy.com/pro_index.html)
Does not inspire confidence. A series of arrows, a couple of before / after pictures and some unsupported claims do not a breakthrough make!!

Welcome to the next phase of foot biomechanics!

If i have a pound for every time i'd heard that i'd have...well at least £6.50 (one of them only claimed to be a leap forward, not a new paradigm altogether.)

The principle seems simple enough. Stick something under the hallux to dorsiflex it and the windlass will kick in more / quicker therefore less late stance pronation. Based on the amount of dorsiflexion involved it occurs to me a similar effect could be acheived by raising the heel...

It also claims to "unlock" a functional Hallux limitus although for the life of me i cannot figure out how!




Anyone else see it? Its a bit like those magic eye things. I stare for hours but just don't get it. Cure HL by dorsiflexing the joint which hurts to dorsiflex.

Regards
Robert

[rothbart]

Dear Robert,

Thank you for your observation. The same thought came to me, curing HL by dorsiflexing a joint that supposedly already has limited range of dorsiflexion. Makes no sense to me, yet our esteemed Pod community across the pond are extolling the virtues of this approach - see www.podiatry-arena.com/podiatry-forum/showthread.php?t=3651

Just to give you an interesting historical fact about the cluffy wedge, or what Dr Paul Liley called the Demi pointe equalizier that he patented before the Cluffy Wedge (6,182,380 Initially filed June 1998 - Cluffy Wedge was initially filed in 2001 I believe).

Dr Liley (a dentist practicing in Anchorage Alaska) worked with me from approximately 1990-1994. We wrote a paper together describing the link between the feet and the bite. At that time I was using a very severe type of supportive orthoses. That prompted Dr Liley to patent his own idea, an extrapolation of mine. I do not believe Dr Clough is aware of Dr Liley's patent and I do not believe that Dr Liley is aware that Dr Clough has infringed on his patent.

Prof B

[robertisaacs]

Have had a look at that thread and sought some clarification from the great and the good.

It would appear that whilst the tranch of patients for whom the CW is not appropriate is quite broad there is some rationality to its use for functional hallux limitus.

Its a good thread. Recommended for others.

Robert

[robertisaacs]

Dave's reply regarding the cluffy wedge, reproduced from pod arena

In my MSc research I attempted to do an in vivo study of the hallux windlass and its effect on the MLA integrity and plantar fascia tension, stress and strain and how this related to FncHL.

This is my expanded conclusion to the above.


For optimal progression of the foot through the saggital plane and to avoid Functional hallux limitus is appears that after heel lift and as the hallux dorsiflexes there should be decreasing dorsiflexing moments, applied by hallux and 1st MPJ GRF, about the NCJ.

Functional Hallux Limitus exists when the MLA excessively extends and lowers after toe contact at 33% stance and before heel lift at 57% stance. The relative increase in PF tension, due to the windlass action, increases the stiffness of the Hallux Plantarflexion reaction to dorsiflexing GRF. This in turn results in a longer moment arm for the 1st ray and a shorter moment arm for the plantar fascia to act on the NCJ. This culminates as increasing dorsiflexion moments about NCJ after heel off.

It appears that the correct progression of plantar pressure sub 1st MPJ and sub Hallux is inhibited when this situation occurs and early and high-pressure sub Hallux is seen. It appears then, that FncHL follows lowering of the MLA, then dysfunctional plantar pressure progression develops with FncHL. As proposed by Dananberg et al (2,12) this sequence of events results in slowing of the sagittal plane progression of the CoM due to increased GRF dorsiflexion moments about the TCJ and a corresponding increase in Achilles Tendon tension (46-48), which retards the forward motion of the tibia.

As stated it is thought FncHL exists when GRF acting on the hallux and 1st MPJ result in increasing dorsiflexion moments about the NCJ of the lowered MLA. However it may be that it is progressive in nature in that the Hallux RoM is increasingly limited by its increasing stiffness to GRF due to increased PF tension. However because the PF becomes much thinner at the insertion most of the PF extension occurs here and therefore Hallux dorsiflexion and forward progression can be maintained within certain limits of PF tension. Further research is required to establish the exact point that could be identified as FncHL if indeed an exact point exists

Data collected and analysed from RS Scan pressure mat and Kistler force plate may show an indicator for normal HW action without significant FncHL. It indicates that total peak forefoot GRF should occur after Heel off (HO) and before peak sub Hallux force. If Peak f/f GRF coincides with or succeeds peak sub Hallux force then significant FncHL will occur. This theory will require further research to confirm but has been similarly proposed by Gheluwe and Dananberg et al 2006 (2)

When the Cuffy wedge is applied it will then encourage early dorsiflexion of the hallux and pre tensioning of the plantar fascia. Therefore the lowering of the MLA will be stopped slightly earlier in the stance phase and optimally, well before heel lift. Without the wedge the toe windlass can unwind a little more and so allow more lowering of the MLA which perhaps will continue well after toe contact and before or even after heel off and become low enough to allow FncHL as explained earlier.

The material characteristics of the plantar fascia may be the reason why the CW may not work on some subjects. Even with the pre tensioned plantar fascia the material properties of the plantar fascia particularly at its thin insertion, which has a lower strain / coefficient (N/mm) i.e. it stretches more easily, may allow the MLA to lower to the point where FncHL occurs.

This really makes a great deal of sense.

In KISS language for them as don't got an MSc : -

FnHL happens when the PF is stretched cos the foot goes long and flat. Init.

Puttin' a Cluffy wedge to dorsiflex the hallux will kick the windlass in earlier so the foot does'nt get as long and flat.

Foot not as long and flat = less pf tension.

Less PF tension = less force trying to planterflex the first mpj whilst its trying to bend cos the person has lifted their heel. = less Fn HL.

Of course there are exceptions and people for whom this won't work. Best you do a full biometric assessment to find out if the conditions are favourable...

Anyway. Back to the thread on how simple biomx is.

Regards
Robert

[rothbart]

Dear Robert,

I respectfully disagree with you regarding the logic behind the Cluffy Wedge. Allow me to digress somewhat, and provide you with a historical account, citing what Craig Payne published published in the Journal of Bodyworks and Movement Therapy. Dr Payne wrote – “the use of the medial column support …. would restrict first metatarsophalangeal joint dorsiflexion. This will prevent the windlass mechanism of the plantar fascia from working, resulting in a very unstable foot during propulsion.” (JBMT, October 2002, pp 260-261).

The Cluffy Wedge elevates the hallux relative to the 1st metatarsal and will create a problem in a Hallux Limitus foot, regardless of the Windlass mechanism (by further limiting the range of dorsiflexion in the 1st MPJ which is already severely compromised). Yet this device is highly spoken of by the Podiatry Forum in the US. While the same Pods highly criticize a device that places a wedge underneath the entire medial column (including the 1st metatarsal and hallux).

This makes no sense to me, at all. Either both inventions are useful, or not.

Prof B

[robertisaacs]

Ah i see! I thought this was going to be the first thread you had been on where you DON'T mention postural correction insoles.

Disagree with me all you like! I enjoy it. To quote you, its stimulating.

I respectfully disagree with you regarding the logic behind the Cluffy Wedge. Allow me to digress somewhat, and provide you with a historical account, citing what Craig Payne published published in the Journal of Bodyworks and Movement Therapy. Dr Payne wrote – “the use of the medial column support …. would restrict first metatarsophalangeal joint dorsiflexion. This will prevent the windlass mechanism of the plantar fascia from working, resulting in a very unstable foot during propulsion.” (JBMT, October 2002, pp 260-261).

I cannot find the full text of that quote. However i suspect the medial column support in question is one which comes under the first MPJ. Not so?

If so then the key is in Davids rather splendid thesis where he says

As stated it is thought FncHL exists when GRF acting on the hallux and 1st MPJ result in increasing dorsiflexion moments about the NCJ of the lowered MLA.

In other words incresed grf under the 1st met head will increase dorsiflexion moments at the NCJ and subsequently increase internal hallux Planterflexion moments => FnHL

The Cluffy Wedge elevates the hallux relative to the 1st metatarsal and will create a problem in a Hallux Limitus foot, regardless of the Windlass mechanism (by further limiting the range of dorsiflexion in the 1st MPJ which is already severely compromised). Yet this device is highly spoken of by the Podiatry Forum in the US. While the same Pods highly criticize a device that places a wedge underneath the entire medial column (including the 1st metatarsal and hallux).

Wheras the Cluffy wedge (theoretically) engages the windlass early which increases the planterflexion moments at the NCJ. => less arch flattening => less pf tension at heel lift => less fnHL.

Basically, (for those jogging along side) push up under the 1st mpj in mid / static stance it will flatten the arch. Puch up under the hallux itself and dorsiflex it and you will see the arch rise.

This makes no sense to me, at all. Either both inventions are useful, or not.

Not so. One elevates the whole medial column (dorsiflexes the 1st ray) , the other merely dorsiflexes the hallux causing a PLANTERFLEXION of the 1st ray.


So there is a difference.

The ROM of the FUNCTIONAL HL joint is limited by the increased PF tension at heel lift caused by elongation of the PF. Therefore if the PF is pre tensioned during mid stance when the MLA flattening peaks there is LESS tension when the heel lifts => less limitation in ROM range.

Regards
Robert

[rothbart]

Dear Robert,

I still do not follow the logic. If the 1st MPJ has a limited ROD (e.g., Hallux Limitus), the last thing I would do clinically is raise the Hallux which, in essence, is dorsiflexing the 1st MPJ. The logic of DF a joint that is already comprised, with a limited range of DF, makes no sense to me.

Now, one can talk about GRF, windlass action, plantar pressure progression etc etc, it still does explain the logic to DF a joint that already has a limited ROD.

However, when you read the Pod forum, they are having good success with the Cluffy Wedge. The question is, why? I would answer that question, in the same way I answered the question of why we use a MCS. If you have a PMs foot structure, using either a MCS or Cluffy Wedge will improve the functioning of the foot.

Prof B

[robertisaacs]

Whats a ROD?

If we were talking Structural HL i would agree.

Now, one can talk about GRF, windlass action, plantar pressure progression etc etc, it still does explain the logic to DF a joint that already has a limited ROD.

Absolutly it does. We are talking about a FUNCTIONAL Hallux limitus. Change the function, there is no longer a hallux limitus, no longer a limited ROM (or indeed ROD) and you can dorsiflex away to your hearts content!

Lets face it, conventional wisdom for FnHL is to planterflex the 1st met. That will have the effect of effectively dorsiflexing the hallux and we KNOW that works!

A cluffy wedge will have the exact opposite effect of a MCS. It planterflexes the 1st ray instead of dorsiflexing it.

They are two very different animals.

Regards
Robert

[rothbart]

ROD = Range of Dorsiflexion

A functional Hallux Limitus is a very different animal than a structural Hallux Limitus. I see very few structural HL and most of them are due to trauma. A functional HL is fairly common (in my practice).

A medial column system is only (and read that as absolutely only) used when you have a Primus Metatarsus Supinatus foot. In such a foot, when the STJ is placed in joint congruity (e.g., its nP), the first metatarsal and hallux are off the ground. (This is a structural relationship, not a functional relationship) During late stance phase, that foot must twist inward and downward to place the 1st metatarsal and hallux on the ground. This late stance phase twisting (e.g., abnormal pronation) distorts the pattern of stimulation which results in a distorted posture. By placing a MCS underneath that foot, the pattern of stimulation is normalized, which in turn, reverses the postural distortion. (You can read all about this on my research site and I feel a more in depth discussion is inappropriate on this thread).

The important point here is that in a PMs foot type, the 1st metatarsal and hallux are structurally raised off the ground when the SJT is placed in its nP. In these feet, the MCS is NOT raising the metatarsal or hallux. However, if you use a MCS in a non PMs foot, you will definitely be raising the 1st Met and Hallux, which can lead to pathomechanical changes.

So where am I leading to? The point I am making, is that in my opinion, in the PMs foot type the Cluffy Wedge should not be used. In the non PMs foot type, the MCS should not be used.

Prof B

[birdman]

Dr Rothbart

1. You obviously started this thread becasue you eventually wanted to promote your product.

2. You misrepresented what the Cluffy Wedge is and then claimed how could it treat a structural hallux limitus. There is nothing on the Cluffy Wedge website, nor in the publications by Dr Clough that has ever claimed it was for structural hallux limitus. Its designed for functional hallux limitus. What are you trying to achieve by this misrepresentation?

3. You made the claim that Dr Clough's patent infinges on Dr Liley's patent. That is not even close to being true. Dr Clough's patent is about dorsiflexing the hallux. Dr Liley's patent is about dorsiflexing the medial column. Why would you misrepresent the claims in the patents? That is offensive and you owe Dr Clough an apology for the claim.

4. Even when Robert clarifies things, you continue to ignore them.

5. There is a big difference between dorsiflexing the hallux and dorsiflexing the medial column. Why do you not get that?

Birdman

[rothbart]

Dear Birdman,

Let's clarify some of the points you raised.

(1) I have no product to promote. True, I invented a type of proprioceptive insole specifically indicated for the PMs foot type, however the company that sells that insole is owned by Bjorn Svae, not me. (e.g., it is not my product - I wish it was, he's making a fortune)

(2) You misunderstood me regarding using the Cluffy Wedge in treating a structural Hallux Limitus. I would use neither a Cluffy Wedge or a MSC to treat a SHL.

(3) Dr Clough's patent infringes on Liley patent. Factual and easy to confirm by doing a search in the US Patent Office:

Liley's patent issued February 2001 #6182380
Clough's patent issued Sept 2005 #6938363

Both devices elevate only the Hallux.

(4) I do not ignore Robert's statements, we just disagree on certain points.

(5) I am very well aware of what the MCS does (I invented it) and the biomechanics of the Cluffy Wedge.

(6) There is a huge difference between placing a proprioceptive insole underneath the medial column and elevating the big toe. On that point we agree.

I do have one request, however. Your next post please provide us with your name so we know who you are. In my opinion, one loses credibility by signing their posts with pseudo names or anonymously.

regards,
Prof B

[robertisaacs]

And once again TIME OUT!

This is NOT going to turn into a slanging match. Won't have it. We stick to the biomechanics and we discuss the ISSUE in a civil way or not at all.

Birdman i don't know if your post was edited by you or david but the post i read last night was rude and personal. This morning it is somewhat better, but Brians motivations are not under scrutiny here, only the subject of what he says. If you think what he is saying is wrong then explain why. If you critisise his motivations for saying it the debate becomes about HIM not what he says.

Brian, Birdman has a perfect right to post anonymously. Whilst i agree that people have more credibility if they are willing to stand by what they say it is not a requirement and people should not be critisised if they don't want to.

Regards
Dad

[birdman]

rothbart said:

(3) Dr Clough's patent infringes on Liley patent. Factual and easy to confirm by doing a search in the US Patent Office:

Liley's patent issued February 2001 #6182380
Clough's patent issued Sept 2005 #6938363

Both devices elevate only the Hallux.

You have dug a really big hole for yourself. Anyone can do a patent search and see that you are wrong.

Here is a link to Liley's patent:
www.google.com/patents?id=frsEAAAAEBAJ&dq=6182380
The claim is: "The equalizer pad extends from the tip of the big toe to a point behind the metatarsal parabola" ie its under the metatarsal head!

Here is the link to Clough's patent:
www.google.com/patents?id=DB8UAAAAEBAJ&dq=6938363
The claim is: "wedge adapted to be placed under the phalanges of a toe" ie it NOT under the metatarsal head.

As I said, you owe Dr Clough an apology for your lie.

[ronm]

rothbart said:

Dear Robert,

I respectfully disagree with you regarding the logic behind the Cluffy Wedge. Allow me to digress somewhat, and provide you with a historical account, citing what Craig Payne published published in the Journal of Bodyworks and Movement Therapy. Dr Payne wrote – “the use of the medial column support …. would restrict first metatarsophalangeal joint dorsiflexion. This will prevent the windlass mechanism of the plantar fascia from working, resulting in a very unstable foot during propulsion.” (JBMT, October 2002, pp 260-261).

The Cluffy Wedge elevates the hallux relative to the 1st metatarsal and will create a problem in a Hallux Limitus foot, regardless of the Windlass mechanism (by further limiting the range of dorsiflexion in the 1st MPJ which is already severely compromised). Yet this device is highly spoken of by the Podiatry Forum in the US. While the same Pods highly criticize a device that places a wedge underneath the entire medial column (including the 1st metatarsal and hallux).

This makes no sense to me, at all. Either both inventions are useful, or not.

Prof B

prof B

the main bone of contention expressed by the good fellows on podA is not your device per se, it's more what is claimed can be achieved by said device.