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10.18.11 FOII notes

I just want to finish up on the different modifications that we can incorporate into the

appliances and then we are going to move into how to try and put some of this togetherinto a coherent prescription which, of course as you will see has to be based on some

knowledge of what it is that we are trying to treat. Just keep that in the back of your

minds. You dont treat forefoot varus. What you are going to treat is a consequence of

the forefoot varus. You treat the plantar fasciitis that the pt came in with. Which, by theway pts do not come in and say I have plantar fasciitis. They may well have been told

this by other doctors and it may turn out to be a true case. But they will come in and saymy heel hurts, my arch hurts on and on and on which we will then discover to be as aresult of a plantar fasciitis, heel spur, nerve entrapment and so on. So as we are

developing this, keep it all in the context. You have to discover the reason why they are

there complaining of pain in the foot, narrow it down to a specific diagnosis based on inour world of biomechanics if it is a biomechanical etiology, what factors are causing this

foot to break down to lead to this diagnosis causing that pain. And then we will go ahead

and be able to neutralize as many of these influences as we can keeping in mind thatsome are controllable or capable of being neutralized and some are not. The end result of

which hopefully will be a pt that maybe we cant eliminate ALL of their pain but pts, if

you give them 5% relieve god bless you and you are their best friend. So this has to be a

stages approach.

Dispersion padding traditionally those of you that are in medicine if you have a lesion

sub 2 usually you construct a little wing pad or a U-pad and often times,. If you are goingto disperse say 2 or 3 you are going to disperse weight off of 3, traditionally the U pad

will extend over. If you are looking to disperse 3, the wing pad will go over 2 and 4. If

you have your apt/home and your responsible for painting it any holes you have tospackle. In a sense that is what you are trying to do with balance or dispersion padding.

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You are trying to disperse as much of those GRFs across as broad a cross sectional area

as possible. If I have you hold up your hands and if you take you opposite hand with one

finger and you press into the palm of your hand as hard as you can, very quickly it startsto become uncomfortable as opposed to if you were be able to register how much

pressure it took to become uncomfortable, back off, open up the hand and then go palm to

palm with the same amount of pressure, you will barely be aware of it.

Schuster used to call this expansion of forces snowshoeing the expansion or the post. It

is basically strapping a tennis area to your shoe. The point is you have dispersed thepressure under your food 3-5 fold, which, if everything works out well, you will only sink

a few inches into the snow as opposed to without the snow shoe, if its powder, all the way

down to your waste or deeper.

When you disperse, if you look at the lower R hand side of the slide, when you have an

area that you want to disperse by the lab we get this all of the time. The doc will send

in the prescription and say they would like to offload 2 or 3 or 1 and 5. It is certainly not

that the technicians are incapable. They are certainly really good at looking at models ofthe feet and surprisingly better than the docs sending the prescription in and pointing

things out about the anatomy of the foot based on that positive model. BUT to make theirlife easier and ultimately the success of your orthotic better, a nice trick is, if you are

working in plaster take a cast marking pencil and any of the labs you work with will give

them to you. When you dip this into water you can outline the area to be dispersed on the

plantar aspect of the foot when you apply the plaster it transfers over as a negative. Ifyou are working with the STS stocking material, the fiberglass socks, as you know you

need to put a plastic bag over the foot before the fiber glass goes on. Also, do not ever

activate the cast with warm to hot water. It is a very exothermic reaction. When you putthe plastic on the foot you cannot use this technique to demarcate an area to disperse. So

what you do is take a piece of inch felt and cut it into the shape of the lesion you want

to disperse, peel and stick it directly to the foot. When you apply the fiber glass sock, asit is setting take your hand and for a moment of 2 take your hand away from stabilizing

the TN joint and from loading the foot plantarly and just kind of massage the fiberglass

while it is curing around that inch dispersion and you will create a little dimple in thatarea and if you want you can even enhance it on the inside with a regular sharpie or felt-

tipped marker. But now when they pour the positive they will know where it needs to go.

With dispersion padding as well as with the crest pads and met pads, keep in mind that inparticularly feet that have hyper mobility what is the definition of hyper mobility? It is

mobility when it aught to be stable. The term defines what often is the reason why; again

we sometimes get calls from mad customers asking if the technicians were drinking thenight before. Again, pull the positive, take the orthotic, line it right off and balance the

pad to disperse the area that is marked. BUT a hyper mobile foot implies an unstable

foot, a foot which tends to change appearance from off to on weight and in particular thelength of the foot and more in particular the relative length of the forefoot relative to the

stable heel there is only one heel bone. So it cant really elongate itself, but distal to it

you have lots of joints that can unlock and open. If this is the off weight foot that I have

taken the cast of and marked and dispersed, the pt hits the ground, here is where I edged

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off my dispersion and sometimes the pts will say (just like with met pads) it feels as if it

aught to be (and you can insert 9/10) more distal.

In Europe they do a lot of semi-weight bearing casting. So I usually get asked the

question, why dont we use semi-weight bearing casting for this because you would

anticipate the full or partially weight bearing part of the foot or anatomy or location inthis semi weight bearing position. The answer is YES but what is the purpose of an

orthotic? Remember the definition. Orthos from the Greek means to change or to

alter. You are looking to change the functionality of that foot. The way you are going todo that is by repositioning certain key bones of the foot in particular the calcaneus and

the met heads in an effort to effect STJ mobility and MTJ alignment. The problem is

you have to do that through the interface of the plantar fat pad. Yes, semi weight casting

will capsure a more anatomically accurate position of those abnormally located met headsbut what you will sacrifice is critical contouring and an ability to realign the STJ and

MTJs. So one balances off the other and if you again.

This is the art of medicine. There is a certain amount of science to this but they still refertot his as the art of medicine. You will get a sense of which pts have these extreme

ranges of motion and with that being the case there is nothing that says you cannot stagethe therapusis. The pts love this. It sounds great. You are staging the therapusis. What

do I mean by this? What it means is that I am going to create a basic design on the

orthotic. You will then wear it from 2-3 weeks at which time you are going to come

back. Based on that wear pattern I will then send it to the lab for completion where it willcome back with the cover and everything. So there are 2 ways which you can approach

this and both of which will work.

Heel spur pads it is interesting. When pts have pain in the heel, all heel pain becomes

heel spurs. my friend Shlomey had a heel spur. If you have a bunion, I have a bunion.

All things are not created equal. All heel pain does not necessarily mean heel spur. Oneof the most difficult things that you will have to be able to explain to your pts is that

many times some of the most acute heel pain when you see in your office, when you

shoot that lateral projection you cannot find the spur. As we know, the presence of a spursimply means that this process has been going on, in some cases a heck of a lot longer

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than the pt has even been aware.

What is a spur? A spur is very simply one attempt by the body to resolve this problem.What is the problem? The problem is that the arch is changing too much from the off to

the on weight bearing position. We are only born with a plantar fascial band of x amount

of mms or cms in length. Once you stop growing and once the foot stops elongatingthat is it. I can not get any bigger. The problem is, from my off to my on weight bearing

position and you do not have to go from a CMT type foot to a flat as the table foot it

is just that IF the off to on weight bearing arch contour is exceeding the ability of thefascia to comfortably elongate, it wills tart to tear away from both its insertion as well as

its origin. If you look at the insertion and origin of the fascia, which is more defined?

The origin. It comes off the tubercles of the calcaneus. Where as distally it fans out and

encompasses the MPTJs.

So the point is that even if a spur is present, which tubercle generally produces the spur?

Medial or lateral? Medial. Why? Due to the rotation of the calcaneus. It calls all the

way back to FUI. That horrible course. And then FUII is not much better. Origins,insertions, axes of motion, varus, valgus, up, down, L, R it is awful to go through but

now, put it together. By the way, when you have pts that have lateral tubercle calcanealpain, push off on the fasciitis for a moment but classically it is medial tubercle. Why?

When the STJ pronates where does the calcaneus move? Everts. It all comes back to the

basics. So everything on the medial side of that foot, including the fascial band is going

to get tighter. It is going to pull primarily away from its medial tubercle. You divideheel pain into tractional and impact. Under tractional is facial type pain.

So in this instance though, when we look at pts even that have a plantar enphysiophyte(spur) the location of this opening is WRONG. What good does the U-pad do? That is

where the spur is residing, why are you opening the center.

Some swear that these help. Schuster had a theory that said the presence of a heel spur

pad just acts like a very odd looking heel lift and by elevating the heel it relieves the

equinus which is causing he foot to break in the 1st place. If you do go with a heel spurpad, you aught to combine it with a deeper heel seat. The other name for a heal seat is a

heel cup. The reason being is that you want to encompass the calcaneus. The more stuff,

as you will see in a second that you put into the heel cup the more obliterated or

superficial the heel cup becomes until finally the pts are standing ON the devise ratherthan IN it and they start to then complain of pain around the medial and lateral rim of the

devise.

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There is a modification of that that became very popular and is probably more popular

now than it was. It is a heel cushion, which is just a solid piece of material. Generally

we use poron or some of the docs with pts with fibromyalgia you can use pink plastazoteand they seem to respond better to that. It is a solid, solid application of poron into the

heal seat area. If the pts have a tendency toward excessive inferior heel shock, if its a

higher arched foot for example with a restriction of STJ pronation this modificationseems to work very well.

Again, you should compensate for that by deepening the heel seat BUT the deeper theseat the wider the orthotic is going to become. Docs want a devise that fits loafers and on

and on and on and they want it all. BUT you cant do that. There are certain restrictions

to these design restraints.

Heel raises when you put a lift on an orthotic they are very potent modifications that areuseful for not only the most obvious, which if Im short on one size I can try to equalize

that leg length but they are also very effective if you want to alter the phasic activity of

gait meaning if I want to get them out of the contact phase quicker. If I have a pt whohas STJ arthritis and it is painful when you move it and for whatever reason either they

are not ready for surgery or they are not surgical candidates, one possible way that I can

effect them in a very positive, meaningful manor is, if I reduce the amount of time that

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the STJ participates with the ground there will be less STJ movement and therefore less

pain in that joint. So, just take it to its very ridiculous extreme, does the STJ work longer

or shorter as I elevate the heel? Take it to the ridiculous extreme I am right now almostin full extension or PF at the ankle SO the higher you bring the heel off of the ground the

less time the calcaneus spends in contact with the supporting surface which means the

STJ will NOT have to move the calcaneus against the talus. And if there are arthrititieswithin it or if there is a suspected coalition you can use this. This is one modification that

often comes into the package for designing an orthotic for kids that have suspected

coalitions. Bring their heels up a little bit. It reduces the amount of time that the STJ hasto interact with the ground.

One thing you should be aware of and it is harder for me to show you but visualize for a

second, if I have 1 limb that is substantially shorter than the other or it doesnt necessarilyhave to be get rid of that substantially. If one limb is shorter than the other, one way to

compensate for a short leg is what? If I am shorter on this side and I need to get this foot

down to the ground, if I PF the ankle I will bring the forepart of that foot to the ground.

If I simply fill in that gap under with a HEEL LIFT, Yeah I have contact of that foot backdown on the ground BUT the problem is that I have that foot maintained in a PFed

position. And then you have to ask yourself, is it really normal to walk around with afoot PFed, even though the bottom of the foot is contacting the ground by virtue of this

heel lift, is this a normal way to walk? The answer is NO. So sometimes, in the past we

were taught if the LLD was > of an inch that the lift needs to be extended from the heel

out to the met heads. You dont want to go distal because they you are interfering withMTPJ rotation. But if you bring that heel lift out to the met heads now you have

maintained the foot in a more parallel arrangement in relation to the floor rather than

maintaining them in equinus. Do you see the diff?

There are people in Michigan at the college of osteopathy where they have linked a lot of

our understanding of the foot to low back dysfunction. Pts with as little as 2 and 3 mmLLD, they are suggesting to modify that or neutralize that limb length.

Obvi, if you have a contracted heel cord. Remember, if I have a pt who presents with an

arch that is obliterated through the MTJ, until proven otherwise, if they ask you on your

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externships what is the most likely etiology for that mechanism or for the appearance of

that foot, think EQUINUS until proven otherwise. Equinus is the most commonly

occurring deformity that is going to directly attack the MTJ. So heel raises, if we aregoing to try to produce an orthotic devise that in theory the pt is going to be able to

tolerate depends on, again, if you use a somewhat controllable material, it doesnt

necessarily have to be acrylic, BUT if the reason for the collapse of the MTJ isntneutralized remember all this devise is doing is contouring the corrected position of the

foot. If I take my eye glass frames and pop the lenses and put the glasses back on the

frames, I wouldnt be able to see beyond the 2nd or 3rd row. I need the lenss to correctmy vision. If it is a sagittal plane problem, this devise MUST have some heel platform,

the amount of which will depend on the severity of the equnius in order to neutralize

enough of that so when the pt stands on this doesnt have a scenario whereby they have a

MTJ that is broken. The irresistible force is the immobile object. It should start to click.

It stars in the 80s. Lots of the stuff that you see: orthotic combos of materials of things

are discovered by accident. Usually what ends up happening, the use of poron as a heel

lift, was just one of those instances where the doc had specked out a heel lift andsomeone mis-read what was said, PPT was interpreted and added and they found out it

doesnt work as bad as you think. You would think it would be a little on thecompressible side. Well, there are times where that may be desirable. You would want

the ability to add a little bit more of dampening of shock or dissipation of shock at strike.

SO you can be creative. You are only as limited as your mind when you design orthotic

devises.

The worst thing you do when you get into practice is doing 03Rs. Everyone gets a spot

devise with a 0 forefoot post and a 3 varus rear foot to the met heads. BOOM. And itdoesnt matter. L foot, R foot doesnt matter. Diagnosis doesnt matter. Age, sex,

shoe doesnt matter 03R. There are lots of other people out there who are buying for

the attention of the podiatrically/biomechanically challenged public.

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We will finish with a couple of things on covers. By way of definition, extensions and

top covers sound alike but they are still different. There are consequences if you ask for

the wrong thing. The diff is that a cover covers the entire shell. The length of which youcan vary. But it begins back here at the heel cup and extends distally. So with a cover

you cover the entire devise. You can end it at the met heads. You can bring it out at

the sulcus or you can go full length. Thickness is standard 1/16th to 1/8th but I have ptswho comes up even thicker. The more stuff you add to the dorsal aspect of the appliance,

the more likely you are obliterate its contours and render the devise not as effective as it

could be.

Shoe gear. Lets look at a loafer. Unfortunately it has a removable foot bed. BUT think

for a minute, if the pt wants to wear a loafer, just a standard loafer, if you send me Nowlook at the toe box. Some shoe anatomy: The counter of the shoe is what holds the heel.

The area right under here, this is called the tongue of the shoe. It is easily to see it whenyou have a toe shoe. It is right under the laces that flaps around. It is to protect thedorsum of the foot from being bound up by the laces.

If you have a pt that complains that the tongue of the shoe is always shifting off to theside, think for a second what is going on in that pts foot is there is a significant amount of

MTJ movement going on and what is happening is the foot is going this inside the shoe

and literally shifting the tongue off to the side. The pt barely is in the chair and you have

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3 things in the back of your head. That is impressive when you are on externships. This

equinus or a complensated forefoot varus. One of those 2. Everytime. Pt has just taken

their shoes off and you have 3 things ready to throw in an attendings face. It wouldimpress me. But the point is, with extensions the toe box, which is up here covers the

forepart of the foot. You look at the shape. In order for a shoe to be a loafer it needs to

be shallow and narrow in an area where unfortunately where you design orthotic devisesit needs to be a little bit wider and deeper.

The toe box, many times in these shoes I cant for the most part extend this devise muchpast the mets heads. Which means if I have a problem where I was going to try to add a

crest pad for whatever reason it is NOT happening UNLESS they alter their shoes.

Certain requests for orthotic modifications, it is not going to fly. I hate having to say this

over again, play Doctor. I tell you this because there are situations where if you dontstand up and say look it has to be this way and even this way may not give us what we

are looking for when you start to compromise, your orthotic design, because of their

wants will haunt you later on. You have to be willing to say Im sorry. At some point

you have to be able to say Sorry, you are not following what we are telling you and wehave to move you on.

You can laminate materials. Most commonly you will see us downstairs laminate

plastizote over poron. It never goes the other way. If it comes back from the lab wherethe poron is on top of the plastazote they were deff on a bender last weekend. The poron

is used BENEATH the plastazote. Some doctors love plastazote sandwiches for wound

pts. It is designed for implosion of that material. They are designed to keep compressing

and compressing and compressing. If you take even a thin layer of poron and put it underthe plastizote, the plastizoe implodes as you want it to but as a much slower rate which

translates to a devise which you can extend out as long as its life span. You see even in

pts that do not walk that much how quickly the plastazote (especially pink) compresses.This is a good thing but you dont have longevity.

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Certain things, it is much better if the location of the modification is done dynamically.This is one. I can only tell you that if you order a toe crest pad directly at the time you

send the cast to the lab you are going to be disappointed.

You can use these crest pads both mechanically (in medicine we see the contracted claw

and mallet toe deformities) where you put a crest pad in there and you can lift that part of

the anatomy off of the foot bed. You can also use these pads very effectively

neurologically. There were some neurophysiologist in the 50s that started some work andcontinues through the 70s, Dunkin and Manfreidy using these types of crest pads (they

did not call them crest pads but this is what they are) to inhibit excessive clawing of the

lesser toes in spastic pts and how it reduces the tone of some of the proximal musculatureas evidence by EMG analysis, specifically in spastic pts where the over activity of the

gastroc muscles, the adducturs and the hip flexors can be dramatically reduced by just

sticking a stupid little crest pad under the lesser digits. We will show you in ortho how in

the right pt this can be achieved. In pts with movement disorders you can spec a deviceout with this modification and you will be amazed as to how well this positively effects

gait.

You need to put these modifications in ACCURATLY. If you follow my pointer (37:07)

this is how often they orientate if you ask them to do this at the lab. Dont ask me why. I

have tried to explain this over and over and over and they end up sticking them on so theyare perpendicular to the long axis of the foot. We have one downstairs to show you. This

is very typical of all of the labs and we cant figure it out. SO spec it out without a top

cover and locate it later.

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Just to make a comment: an extension begins at the distal end of the shell so there will be

nothing over the shell other than the vinyl or leather covering system, the padding when

you ask for an extension only begins here. So are there cases where you would ask for anextension vs. a top cover? Sure. Where maximum contouring of the shell may be

critical, bulk. Many times we will put a very thin extension of 1/16th PPT beginning at

the shell and ending at the sulcus with the intent of, on a low profile design if I want to

install either a dispersion system, a met pad or something of that nature OR if I want tojust provide minimum shock absorption to the met heads. So I want to keep the profile

down.

So just so you understand the difference, a cover starts at the heel seat and moves distally

to the length you spec. An extension begins at the edge of the shell.

This is the same devise and what I did was I covered the top 1st with 1/16th PPT and I amtrying to get you to look at the diff between the heel seat. You see here there is more of a

heel cup in this. Up here you see how it becomes obliterated? It is just simple logic. Ihave a standard heel seat from the labs and it is 3/8ths of an inch deep. Deep heel seat isspecked out at 5/8ths of an inch. If I have 3/8th and I apply 1/8th, it is not that you subtract

the 1/8th from the 3/8th and you are left with 2/8ths or because remember it is a

circumference so it is an additive effect. It closes the heel cup down very quickly. So ifyou put a lot of stuff in the heel and again, I just think of this 1 customer every orthotic

he orders he specks it out with 3/8th of an inch of stuff and when the devises go out you

barely see a heel cup. He has so much stuff built in. We quietly many years ago

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Orthotic prescription Writing, Problem Solving:

Putting it all together

What we are going to try and do is explain this process. When you try to design an

appliance for a pt there is an overwhelming feeling. You have the pt, you have arrived at

a diagnoses, Randy hands you a prescription and he says fill this out and even on the 1st

choice line which is a reduced portion of the full Langer where the heck do I start?

No, this is not going to be on the test but this is for your own edification. I put 2 slides in

order for you to understand. This is where its at. The nature of medicine is changing.

This was an excerpt from an article in last months current podiatrists managementmagazine. We have kind of just let go of biomechanics. There are some very imp

thoughts here. This was from a seminar that was held here March of this eyar. It was a

3-day, dawn to dusk residency hash it out. Many of the directors from programs got

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together and discussed ways that they could improve the programs form the teaching

aspect and what concerns do you have as attendings. There were reps from the various

schools of podiatric medicine. One of the things that was voiced was that in many cases,but I will tell you, which wasnt in the article, thanks to the fact that you are suffering

through this and apparently retaining it, because one of the things that did come out

which they did not mention in the article is that the people coming out of NYCPM for themost part have absolutely blown away the competition from many of the other schools in

their ability to articulate at least some of the basic foot mechanics and an understanding

of how a foot works. But as a whole, most of the residency directors said that the skill setof most of these students BM skills set has deff eased down the line in a negative

direction. It is trending downward. At that seminar there were only two 20-minute

lectures on BM. A need was expressed for additional training in BM of the LE. But as I

said, what wasnt expressed in that article was the fact that many of the directors wasexpressing an interest in the fact and a curiosity as to why the people coming out of here

seem to be ahead of their colleagues.

When we have these lectures at continuing education seminars look at what is offered atmost of these major programs. It is generally sx and wound care, sx and wound care, sx

and wound care. However, when they are offered, you cannot get in. Usually when it is

a separate workshop, BAM they are closed. If you limit the number to 30 because itshands on, it closes within days.

One thing, if that doesnt get you excited then take a look. He reads second bullet.Thats a big chunk of change folks. If you think you are going to get wealthy just doing

sx, think twice. In order to be successful in doing this, you have to have yourunderstanding.

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I just want you to understand something here. Who else is doing this stuff? He reads

down the list.

The point I am trying to make here is WHY YOU? You have all of this competition.Why should they come to you? Why you is because once you set yourself up in yourarea you will be able to very quickly demonstrate both to your own pt population and if

you go into a group you will introduce yourself to all of the diff types of docs in your

area and what it is you can provide those pts. Very quickly you will see that your end ofthe practice will grow.

Some talk about revenue in working in a group..

What are you trying to accomplish? So how do you successfully write a prescription that

leads to a successful outcome. Well, what are your goals? Remember, I told you at thevery beginning of this program 2 types of appliances: those that alter the function of thefoot and those that just wave the white flag and just accommodate the deformity where

you are not looking to change anything. Are you looking to alter, whether you are trying

to enhance or restrict movement? Remember, of the 2 it is easier to restrict excessive

mobility than to enhance motion that isnt there. It is very difficult to artificially providewhat the STJ does anatomically. This is a real tough nut to crack.

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Are you looking to work posturally, specifically the pt that the local orthopedist that took

a liking to you sent you a pt with patello-femoral syndrome medially? Because of the

fact that the orthopod recognized that the pt has a pronating type of a foot and perhapsthat is the etiology. He did his job and evaluated the pt and found no intrinsic damage of

the knee. Remember, you are in practice and a 1st time pt walks in with knee pain and

you look at that foot and you see that the foot is pronating, technically you cant directlytreat that knee pain. That is out of your scope. In my practice, what I often will do is say

look, Mr. and Mrs. Pt I suspect that the etiology is down here but lets be sure, I want you

to see a colleague of mine and depending on where they live I send them to a referralsource. You have to be certain that it is not something else. I am the podiatrist. If their

sole complaint is knee pain and they have no foot pain whatsoever, keep in mind, there is

no foot complaints you are on thin ice if you jump in and you do something podiatrically,

biomechanically and it also happens to turn out that the pt also had a partially torn ACLmanifesting as medial knee pain. Because the pt didnt seek orthopedic care for 3 months

because they were wearing your CFOs and it wasnt getting any better now the grade I

ACL tear is a grade III, you better believe there will be a letter in the mail or a knock at

the door.

The idea is to take a look at all of these factors that are contributing to the abnormalfunction of the foot and within the context of what we are capable of effecting, try to

negate or neutralize. We try to neutralize the effect of these abnormalities. What we use

for that, as you will see later, is we will take all sorts of different treatment modalities;

certainly orthotics will be in the mix.

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The brand new current podiatric management magazine has this article in it. Blake wroteit and there is a cast technique called the Blake inverted technique. He and Kirby were

classmates. Rich has an article called the top 15 orthotics/shoe modifications that are

useful in your office. This is a really nifty magazine to read. Rich had an interesting

article once. This is interesting because over the last couple of years the basis of yourtraining has been based on the things put forth by Root. Root and Reed and ORyan

combination normal and abnormal function of the foot. One of the things that I spoke

about at the conference was the fact that you should understand over the past severalyears, Root and his tenets of foot function and approach to treating the foot have been

scrutinized and in some cases morphed. You can see that the way that Root visualized

how the foot worked was maybe not necessarily occurring in every case. HOWEVER,one of the things that no one denies is the fact that Roots basis of understanding how this

foot works is without fail the best entry level approach to understanding foot function.

The one thing with Root is that most of the stuff is based on an understanding of the STJmovement on the frontal plane: STJ pronation and STJ supination.

As I spoke to the people at the conference, along comes Dannonburg, who really is the

one who is credited with articulating the concept of this hypermobile first with a resultant

momentary or functional locking of the 1

st

MTPJ functional hallux limitus. Grosslyspeaking, as much as Root got us to look at the foot from the frontal perspective,

specifically the posterior frontal perspective in calcaneal movement, Dannonburg got usto turn the foot around and look at it from the side and get a better appreciation of the

sagittal plane mechanics. The one thing you should understand is that you are going to

be assailed with all kinds of theories moving forward after finishing FUII and NYCPMand your residency and you are in [practice. That is ok because some of the stuff that you

will be hit with, as far as a new way of controlling the foot, some of it might have merit

and some of it might be complete Whooey. But as Rich was saying you have to test out

the waters a little bit and see what works. There may be elements of a particular theorythat work well and there may be some of those elements where you want to run like hell

and stay away from. But dont think for a minute that everything I am telling you isGospel.

Here is a classic case: the strappings. Doc has a really cool way on that LowDye where

those 1st 2 straps you encompass the heel and you get it to PF under the 1st. To this day, Istill cannot do it. I cannot get those straps to cross plantarly. In theory it would work

really well if I could do it because it helps to drop the 1st and the 5th ray. So it is not that

when I stay medial or doc goes plantar, one is wrong. It is just if you can get it, if it

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works in your hands, go with it. But the underlying theory is the same.

So when you take a look at these feet and these are 4 case scenarios that we will examine,

the whole purpose of approaching therapy programs or protocol or designing anappropriate therapusis is to get at the basis for it and in order to that that we have to

perform an examination.

I cant tell you how many times pts come to me with sometimes 1 pair and sometimes a

bag full and as I am performing the exam, doing the most rudimentary measurements as I

am drawing a couple of the lines to set it up I often play a game with the pts. It keeps me

entertained. I tell them, as I am drawing the lines, I have them prone so I can draw mycalcaneal bisections and so on and I will apologize to the pt: I am really sorry, I am

SURE this has all been done already but when you take measurements we all measure a

little differently and I need to get my own measurements

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This is what you hear. If anyone ever bothered to take even a rudimentary ROM what soever then the pts get all riled up. They say he came in and he did this to my foot and

he said you have a heel spur, you need orthotics, he walked out and the net thing you

know the secretary that was collecting my co-pay comes in and starts molding my feet.Then when they get the orthotics, of course, they didnt work. What you find is as you

get better at this, your office will become the dumping ground. They come to you with a

bag. They have spend hundreds and sometimes thousands already and nothing isworking.

I told you about a pt that came to me with equinus with a bag full of orthotics and not oneof them had a 1/16th heel lift on it. What does that tell you? No one bothered to look at

the foot to recognize that something as grossly apparent as an ankle equinus was present

and therefore should have been neutralized in those orthotic devises. So if you are going

to take on that responsibility, provide the service. This is a secret to be successful. YOU,

the doctor provides the service, NOT your chair aid. You get in the pts face and you putyour hands on and do the work and you will be more compensated.

Bringing Doc back, he talked

a little bit about this dominant

plane theory that has been putforth many times. It becomes

so simple sometimes it is

madness. If you just keep an

open mind you will see howvery simple it is sometimes to

arrive at a properprescription.

You only have 3 choices.

There are only 3 body planesand the influence that is

destroying the foot resulting

in the abnormal strain not

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we will use PTTD, has to come from 1 of 3 body planes, or like a Chinese menu: a little

from column a, b and c. It could be all 3. But also, there could be a dominant plane,

which is imp because if the dominant plane is sagittal then the dominant approach tooffset that had better be on the sagittal plane. If you do it this way you will be very

successful.

This is very simple. If I look at this foot. This is out of Scarlados (spelling?) bookwhich is in the lib. He was out at the Cali College during the days of Root. It is called

the California compendium of podiatric biomechanics. It is long out of print. It is an

awful book because it was never indexed. It was a series of articles and this is an

illustration from one of them. It is very interesting and very apparent.

Remember, if you see a calcaneus that is everted, not only relative to the leg bisection by

relative to the floor, most likely that is a result of a compensation for a forefoot varus.

SO if I need to offset a varus deformity I need to apply something that will neutralize.

You want to inhibit, if you will or certainly reduce the need for the foot to have to

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collapse so much. So when we look on the frontal plane we have issues in the forefoot,

in the rearfoot in a varus or valgus direction.

In this instance, on the lower left, I have the foot in a neutral position. Here is the 1st

because of the sesamoids. I placed the foot in a neutral position and we trying to

illustrate a calcaneal varus issue a deformity.

Upper Right again, STJ has been manipulated and stabilized and you can see that

relative to the heel bisection I have dotted it, put an arrow, tried to make it as apparent asI could notice the inverted attitude of the forefoot a forefoot varus.

Lower right this is the one that sometimes get confusing. When we were students we

would sometimes call this a California valgus. Remember, a true forefoot valgus, is itclinically possible its like when I ask you the Q, is the STJ possibly able to compensate

for an equinus. If they say COULD it be used? You say yes, but it is not a good joint as

we have discussed many times. Could you have a true forefoot valgus? The answer is

sure, but a true forefoot valgus where the entire forefoot is everted is not all the common.You often see it in conjunction with a spasticity of the peroneus brevis muscle. You see

it many times in equinovalgus feet, UMN. More commonly what you see is a rigidlyPFed 1st ray that normal foot type doc eluted to. When in your eye, when you bisect the

1st and the 5th ray you see, relative to that heel bisection you see the foot gives you an

appearance of a forefoot valgus. When we were students we used to call this California

valgus. So a rigidly PFed 1st.

You have other frontal plane issues that you have to keep in mind as well when you have

genu varum or genu valgum. Both of these can be pronating influences on the foot if theSTJ ROM is available. Particularly genu valgum because, as I have shown some of you,

with genu valgum grossly speaking it places the foot everted to the entire floor. Genu

valgum is a wicked extrinsic pronating influence on the foot, particularly extrinsic.

Here you go: I have an obese 54 year old peri-menopausal F with unilateral medial ankle

pain which you suspect is a partial tear of the post tib tendon. She has sever genu valgum

and a unilaterally, asymmetrically, much greater pronated foot. The MM area is warm to

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touch. There is pain along the course of the post tib tendon. Well, we get our MRI and

YES it is confirmed. It is a stage 2 tear. We CAM boot her for a while, whatever. We

calm it down. BUT we cant CAM boot for the rest of our lives. We have to get it backinto a shoe. For a moment, think. She says, here is the shoes that I like to wear this in

and again, she produces a very non-descript but orthotic un-friendly slip on loafer. It has

to be able to fit these. These are the shoes she wears. The answer to that is, NO thoseare the shoes you used to wear. Why? Because I cannot tell you how many doc call in

in tears because they went ahead and they made a devise to fit that shoe, which is

generally what they did was they took a piece of 3/5 carbon fiber with an intrinsic post.Remember the intrinsic post is just a shell and we angle the correction to the thickness of

the shell but 3 mm, how much correction on the frontal plane can you get? The answer is

just about 0. The other thing I told you about an intrinsic vs. an extrinsically posted

orthotic as far as stability is that it is LESS stable on the frontal plane if its intrinsicallyposted. Why? Because extrinsic posting spreads out the frontal plane width of the

devise.

SO lets say she is 54, 240 lbs with severe genu valgum. Are you getting the picture?She puts the orthotic in the shoe and WOW it fit the shoe. Great. She puts her foot in,

she steps up on it, stands up and what? SAME THING. The foot goes right over theshoe. Should you have been surprised? NOPE. And nor should you be surprised when

she starts screaming at you because she just dropped 6 bills on your because it is not a

covered idem in her insurance plan. So BETTER to recognize that here are these

extrinsic factors that you MUST take into account in your orthosis design.

this is a fully compensated foot in the R side. Notice the diff between the 2. The right

foot is in the RCSP (relaxed calcaneal stance position). Notice, relative to the floor the

heel has now been brought perpendicular. The foot has no reason to go any reason,which tells us there is almost likely NO forefoot imbalance causing that STJ to have to

pronate any further than that. L foot is also in its neutral position.

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What I did is I had this foot relax as well to neutralize the effect of, in this case that lowertibial varum. You have to look at the ROM of the various joints of the foot. Doc showed

you the week he did the calcaneovarus and then he had fully, partially and un-compensated. If you have a lot of frontal plane issues: calcaneal varus, tibial varum andso on. And the STJ anatomically doesnt move all that well in a pronating direction what

you may end up with is when the foot is maximally pronating it still may look like this.

So the symptoms may be much different. So this is why we have to get into looking atwhat is going on with the foot.

By large, what we would like to do, as DAmico said is you like to try and neutralize

some of the effects of those frontal plane imbalances. In this case, since this forefoot hadno imbalance, most of the pathology resided in the rear foot I will apply a buildup to the

rear part of the orthoses, specifically a rear foot varus post. How much will be

determined by the deformity we will measure.

When doc kept saying that the measurements arent all that critical, this is probably one

area where I disagree a little bit because I like to take measurements. One thing you will

find though is that measurements are an art. Measurements take years to fine tune.

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However, when you get good at measuring these deformities and at this stage I think the

key would be to discern if there is an asymmetry in the total amount of a varus deformity

of one extremity vs. another and perhaps offset that a little bit asymmetrically in thecorrection. BUT it is a good idea to fine tune a prescription if you can take the

measurements because you are now telling the lab, much like the diopter on these lenses

where my R eye is much weaker than my L, to balance out the vision or to balance outthe function of those feet. Basically what we are going is we are going to offset. We are

holding this foot closer to that neutral position.

There is what I often refer to as a paradox of the foot. Very simply speaking here is a

foot in its neutral position and you can see and I have hopefully made it easier for you to

visualize, look at the angle that the fore part of the foot makes when you place the hindfoot back into a stable or neutral position. This is the paradox, meaning the consequence

(think of it that way) of as a fetal creature we are occupying a studio apartment that has

all rounded walls. You are living in a pear for 9 months. What it tends to do is it tends tobow all of the extremities of the upper and certainly the lower extremity. The problem is

now, when you are born, if those frontal plane twists and torques have not fully de-rotated you essentially have a problem relating all of those twists and turns and torques toa flat surface. At all costs, the body will attempt to bring as much as itself to the

supporting surface as possible. So in this instance, if there is a significant frontal plane

imbalance, well you can walk around with your foot in this position.

However, if you look carefully, see right here see the bulging? Which muscles is this?

Tib ant and EHL are firing like mad to hold the fore part of that foot up, which is one

possibility. You are off sometimes. Pts with fasciitis or shin splints syndromes runnerswill say this a lot they say they find that if they are running on the outside of their feet it

doesnt hurt as badly. What they are doing is they are way overcorrecting themselves.

They are trying to hold themselves in a corrected position. This is what is going tohappen.

When I say to this pt, ok, let your feet go and relax. BOOM the muscles stop

contracting and BOOM what happens? Gravity kicks in and by virtue of the mechanicsof the STJ, where in the calcaneus everts, the talus adducts and PFs, the leg internally

rotates and BOOM the medial side of the foot hits the ground. That is the paradox of the

foot.

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So in that instance where there is an obvious forefoot imbalance I have to find a way tosupport, if you will or neutralize that effect so the foot doesnt have to bring itself all the

way to the ground and we are going to use a forefoot post in this case. If it is a varusimbalance I will fill it in thicker on the medial side then the lateral side.

Same thing before, if it is a relatively valgus relationship that you have, whether its theCalifornia valgus where the 1st is rigidly PFed OR in fact a TRUE forefoot valgus, SAME

thing, diff direction.

Back 1 slide, moving from here to here, how does the STJ move to get from L to R?

Does it supinate or pronate? It pronates. Now take it the opposite way. A rigid PFed 1st

how do I bring the lateral side of that foot to the ground? You have to supinate. If theonly part of that forefoot is on the ground (think of it that way) is my 1st met head, it isthe same thing. Remember, I told you the paradox is that in that instance the only part of

that forefoot is the 1st. That body is going to try and put the rest of that foot in the

ground, which on this case is the lateral. If I pronate that foot it is going to get worse. Soit has to supinate. So to prevent that, we will fill in the lateral side of the forefoot post in

this case.