• LecturehallPadding and Strapping
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Unidentified Male Speaker: Next, we have a program that will – is labeled accommodative padding and strapping, but it's going to be so much more than that. For the residents in the room, I've been a foot and ankle surgeon for 30 years. Probably 100 % of what I do involves biomechanics. There's always going to be padding and strapping component, and that's really what differentiates us from our orthopedic colleagues. We're all sterile carpenters, but what we know about biomechanics, what we can do with padding, and strapping orthotics, and offloading, really separates us from our colleagues.

    Two of my fellow constituents will be up, Dr. Iorio, who you may know from the New York College of Podiatric Medicine. He's completed two residences through the VA, and then years in private practice, and went on to earn his MPH from the Medical College of Valhalla, joined the faculty of NYCPM in 2004, and became the chairman of the Department of Medical Science in 2004, remained the chairman until 2007. He was also named the Assistant Dean of Continuing Education, and was named the Chair of Department of Community Health and Medicine in 2009, the same year he became the chief at Lincoln Medical Center Department of Podiatry.

    Along with Dr. Iorio is my good friend is Dr. Jeff Cusack, who I know very well, and always find to be an excellent resource for anything that I don't remember about biomechanics. He became an Assistant Professor Department of Orthopedic and Pediatrics in New York College of Podiatric Medicine. Received his BS degree in Chemistry from the University of Miami in Florida. Dr. Cusack is passionate about biomechanics, which is an understatement. He exudes biomechanics anytime you're anywhere near him. So, we are very fortunate to have these two expert physicians with us today. Please give them a warm welcome and to the podium and there we go.


    Dr. Jeff Cusack: All right. Thank you. Pointer, here we go. I'm told don't touch the center button. Laser works, excellent. All right, thanks. What we're going to do, the title maybe somewhat misleading. But then again, we didn't have time to jazz it up and make it fanciful. But what we are going to do, we'll get to our house keeping. Dr. Iorio and I both have nothing to disclose. What we were charged with has been an evolution of what you've heard throughout this weekend certainly, and in the last several years in the, I guess house-ordinance type publications in our fields, specifically with regard that to the direction that the field of podiatric medicine has taken.

    Some concern in the fact that there has been an increasing exposure and expectation, particularly among the students as I'll show you in the second and residents, as to the amount and types of surgery that they will ultimately be performing in their office upon completion of their training. And as many here, I'm looking at some faces of folks that I know well, and we know well. Yeah, the surgery is there to be performed. However, it is based upon as many of the iconic figures in our field have always said the decision making as Dr. Bromley just alluded to is and should be based on a thorough biomechanical assessment of the patient. [Dr. Phillips] [00:03:32] was floating here. I don't know if he still is or not, has had a very strong opinion about doing a very thorough biomechanical exam, his notorious 14-point lecture on pre-flatfoot recon is one to be looked into, as well as the paper that went along with it.


    So, what we would like to do here for the residence that are with us, once again, maybe re-establish is probably a better word to include up there. Strapping, padding, padding and strapping, I'm using the S and P to shorten it up. As clearly a component and appreciate its usefulness as many of us that have been around the block know as both a diagnostic, as well as a therapeutic modality. And yes, we will show for many of the residence here, some of the fabrication, application, tricks. But of course, you can't expect me to stand up here and ignore biomechanics.

    So, there will be some tricks that you can incorporate even if you are taping, and strapping, and padding. Let me show you a couple of tricks that we've been able to do over the years that might make it a more effective for you. I don't know if I really want to explain the saying. Those that are in my age and above certainly know how to complete this statement. Many of the millennials, if you're not quite certain how to complete this statement, but ask us after I get off here. I'm just afraid if I complete this statement, [Pete] [00:05:12] will be out protesting present at their next meeting.

    However, for more the seasoned practitioners out there, understand, we could spend three hours on the Campbell's rest strap, the low-dye trap alone. So clearly, we were charged with trying to present some information in a very, very limited amount of time, which has actually been morphed for this morning as well, try and move the program along. Again, by way of background. He talked to students depending on what rotation they happen to be in at the time or residence, and you start to present scenarios or patients that present to the clinic and/or respective rotation.


    Simple three-month on set, no history trauma, no physiologic concern on set of a heel pain in the morning, the classic post dyskinetic AM pain first arising out of bed. Shoot the film and there's the plantar evidence of excessive traction of the fascia. Okay. The inclination angle is slightly declined, maybe a slight breach in the cyma. Dr. Schoenhaus's functional elevatus with a small dorsal lip of the head. Yes, the student and/or resident, what would your thoughts be? There's been no prior treatment, this is the first hello visit by the patient, and they start right in.

    Well, let's see. We'll resect the spur length and let's do a gastroc recession to improve the inclination. Let's improve the medial column, drop the first ray, and you say, "Whoa, wait a minute, try in again." Patient three or four down the line, I've got a patient that's got a long-standing tyloma sub 2. And it comes in periodically to get it debrided, how might you approach it? Well, let's see. How about wild, we'll do it wild. Yeah. Let's do it wild. Shorten the mat and on and on, hammertoes and so on.

    And the only thought that constantly runs through my head is that one of the great lines from Ghost Busters when Bill Murry's character is trying to have a quite dinner with Dana and in come the colleagues all loaded with slime, and turns to him, and says, "Ray, you're scaring the straights here." And as I say, the students and certainly the residents that are here, what you're going to be doing is developing what we like to call some sort of a plan, a therapeutic plan. Specifically, I remember when [Dr. Langer] [00:07:56] was alive, and I spent a lot of years with him as many of you know. He used to have a saying among many, orthopedics is not just biomechanics and biomechanics is certainly not just orthotics.


    And as we know, those of us who've been out, you set a plan and it's been described either as a ladder or a pyramid, primatal approach or climb the rungs of the ladder. And you start at the bottom of the base or the bottom rung, and the level of, however you want to describe your treatment, whether it's level of sophistication, intensity, invasiveness, whatever. But the patient walks in the door with no prior treatment with a issue with integrity of the foot resulting in a fasciitis, we don't really want to start to talk about it surgery on that first visit. You will scare the straights right out of your office.

    So, you have goals for your patients, and these goals are the same goals, whether you're going to ultimately accomplish this by a simple strapping and padding and/or ultimately, if necessary and believe me, I'm not anti-surgery, far from it. I'd love the types of work that's being done. I sat here and listened to Dr. Vito yesterday and my jaw hit the table, I never knew that we're here for it on his approach to Charcot arthropathy. But by enlarge, since the vast maturity of what we see in the office is a result of a malfunctioning foot, perhaps in our strappings and such, we'll see if we can improve the alignment, which if it is a soft tissue structure that's being abnormally tractioned, we'll reduce that tension.


    And if necessary, with our dispersive isolation padding, redistribute pressure for these patients. And there's always requirements as we know, and the main one being not only a thorough knowledge of the anatomy, which of course is understood for the surgeons and surgeons to be, but the understanding of the function of that particular structure that may or may not be affected by our treatment, whether it is conservative or surgical. Reason being is as you could see here, you can think these things through, and device things on the fly, and most importantly, as all old Hippocrates said, try not to do too much harm along the way.

    So, what we're going to try and cover here in this remaining portion of the didactic and this modified little workshop that we'll conduced here, we're going to look at the low-dye and Campbell's rest strapping, and I have to stop. I just love the beginning of the year in July when the students come down into the clinic, and when they're inserting their notes, and we have to talk about the application of a low-die, D-I-E, low died, he died strapped, and I have to explain to them. I guess we probably should do that a bit more that there was doctor die or Ralph, a family of podiatrists.

    So, that's always fun at the beginning of the year. We're going to talk about metatarsal pads, dispersion or isolation padding, crest pads, buttress pads and of course, the bouton splinting. And again, more for the residents, things that have been learned over and over, and it takes you a bit to figure this one out. And it's important when you're treating your patients, tape does stretch out with time. It is not indestructible. The so-called law, diminish returns is rearing its ugly head.

    You have to tell your patients that when you apply this taping that whatever beneficial effect that you feel today is only a temporary. It depends on the mechanics of the foot, the size of the patient, and on, and on, and on. But as long as some response favorable is experienced, that's somethings that's obviously very, very important.


    It does have as we know, a maturating and that's something that these patients also have to understand that that - and it's a good and a bad thing when in the development of a primatal approach, possibly the next level being design of a foot orthosis to mimic the effect of your taping. That can work in your favor. You say to the patient we have good news. Taping your foot resulted in a resolution of all of your symptoms. The bad news is look at your foot, you left it on longer than I told you to.

    So, what we'll do is take it to the next level. We'll make something that's going to be removable for you that you can put on and take off to allow the skin to breath. Extremely important in the winter months for the residents up here in the northeast where the humidity drops, the skin becomes very psoriatic and inevitably, patients moisturize their feet. Many patients, depending on your clinic, you say moisturize, they may or may not be familiar so you have to use some vernacular. Do you cream your feet? Do you grease your feet?

    If so, if it's a positive answer, you could douse that foot with probably acetone and not remove all of the moisturizer, sufficiently that even if you use a spray-on pre-tape, your strapping probably is going to fail. If you've ever experienced patients that had a tape reaction, those are not fun either. You put a low-dye Campbell's rest combination, an hour later the office is getting a call that the foot is exploding with pruritus. I always found its easy, patients that have that sort of an allergy, they can't even put a band aid on the foot.

    You ask, what do you do when you cut your finger? Do you just put a Band-Aid on it and those that have that sensitivity often will come right back at you and say, "Oh no, doc. I've got it wrap it with cotton or a piece of gauze, then put a Band-Aid around that. I can't let it touch the skin." So again, for the residents, you may want to make certain that you query them about it.


    Tincture benzoin spray, it takes them a bit early in the training to figure out how the hell to put the tincture on the proper way. If you're a motorhead, you are familiar with powder coating. The frame on a car, you blast, you lightly dust the foot, and by the way, again, those that are just been out a while, this stuff is horrible as far as – and I'll show you in a bit, but when you do apply this, you want to have something to preserve your furniture because this stuff sticks to everything.

    And once it's there, it will attract dirt, skin, everything to it. So, you may want just put a simple piece of paper or manila folder that will just act as a barrier as you lightly spray the foot. A couple more thoughts just in general with strapping, although the time constraint is certainly a consideration, to me, it's always better to use more pieces as a lamination. So, as I've indicated, two pieces are better than four pieces of two, or are stronger than two pieces of four. It just makes for a stronger strapping.

    We were always encouraged as far as the appearance of the strap, but beside the optics, that money strap that [Dr. Roberts] [00:15:37], if any of you had to be examined by her to get your license in New York, we dreaded having her come in the room for the plantar fascial strapping. Because if that locked down layer did not adequately conceal the Campbell's rest layer, she failed you. You had to sit around for another – I don't know if it was two months or something to get the exam again. One thing I don't know if you've seen this, any of you that are working with your residents, they don't seem to know how to tear a tape.


    You tell them to setup for strapping and immediately, the scissors come out of the pocket. So, it's something that try to beat down the kids at the college more and more. I want them practicing tearing that tape rather than trying to cut each piece. I said, "You'll go broke trying to do it." All right. Some biomechanics in – oops, I did it. I hit the one button I wasn't supposed to do. There it is, sorry. A couple of things with just strapping, and padding, and the combination of the two that we found over the years.

    This enhancement of the lateral arch, specifically, the calcaneocuboid area. This goes back many, many years in the '80s when we were practicing at the original Langer Institution in Paul Jordan. I was sitting around and trying to decide a better way to control the foot, the flexible flatfoot that you see with Down syndrome children, which as you know is probably the most difficult to control already been employing the so-called [Wiggle LaPorta] [00:17:16], he wasn't calling it that back then, but several years ago, [indecipherable] [00:17:20] LaPorta was talking about [reclinus] [00:17:23] influences on the foot, and he mentioned what he called the nonsurgical Evans modification to a foot orthosis.

    Meaning, a long low lateral flange to block the transverse component of if you go old school, oblique access midtarsal pronation. And it worked, but on a lateral view, we found that the inclination angle of the calcaneus with the flange still wasn't what we were hoping for, and it was funny. I remember Jordan had a positive model of a child's foot in his hand, and he had it upside down, and his palm was in this area, and he said, "You know, if there's just a way of holding this up and one of the technicians who built all the braces for us said give me a minute and he'd grab the cast, ran out of the room, and took a big rat tooth file, and just gently enhanced that curvature, and brought it back, and said, "Here, is this what you had in mind?"


    And it was exactly what he had in mind, and you can actually in many of the laboratory, he's asked for an enhancement of that calcaneocuboid joint, and surprisingly, combining it with a flange works well. So, even in your taping as I'll show you when you set up for plantar fascial strapping. Sometimes the first strap applied as an enhancement of that joint makes a world of difference. And if you've heard me, we speak a lot or I do a lot about third rocker mechanics, the MTPJ and the importance of it.

    You do not want to take your tape and block some of that motion. So, starting that first layer just proximal to the MTPJ makes a world a difference. As I will show you at the very end of this lecture, using some F-scan technology. The ability and the necessity for that joint to bend during the active part of the propulsive phase cannot be over emphasized. It is critical to the and function of the entire lower extremity and for smooth passage of the center mass.

    With respect and praise to Dr. Schoenhaus, he's always been one to talk about the elevatus position of the first as an outcome killer. I always use that quote of his from time to time. And as we know, a first ray that it can be moved comfortably into a bit more of a plantar flex position relative to the second two through fifth metheads, enhances the amount of that so-called good stuff as we say or the arthrodial component of MTPJ rotation. So, the plantar flexion of the medial column can be a very, very nice enhancing modification to your strapping.


    Just one thing with this heel lock. As I tell the students, the proper application is critical to something that Dick Scholl used to talk about with the design of his – specifically, his heel type, heel pain orthosis with a very, very deep heel seats. Dick always talked about the physiologic heel cushion.

    I know Dr. Phillips, about a year and a half or so, maybe about a year and a half ago, had an article published on forefoot, displacement of the forefoot fat pad in older patients and in diabetics, specifically talking about as we age out, and the effect of the tissue change in diabetics that the tissue holding, the septal fibers holding the fat pad and the forefoot, or the pronating influence in the hindfoot distorts and ultimately tears lose the septal fibers of the plantar fat pad, which is why in patients that have pronate, we see a bit more of a bulge laterally. So that strapping in the heel to pull that fat pad and hold it in place and act as the physiologic buttress is critical.

    Some of the residents that train outside of NYCPM are amazed when I ask for the wax when we go over waxing, but as many of us know, the use of a paraffin rubdown does two things. Obviously, it will help waterproof your strapping, but it also makes it easier for the patients to put their socks over the strap, so you don't tear the sims apart. So, the use of the paraffin, I always tell the students that when you are near that tubercle, if that's what you're treating, that medial tubercle rub easily because that can often drive the patient right out of the chair.


    So, for application at least in New York, I mean, I was always taught this way. We like to combine the low-dye with the rest strapping as a unit. I tell the kids ahead of time, whether you're working solo or even your assistant, depending on obviously the size of the foot, but you can just use the base of the chair or a mayo stand. You get all the tape pre-torn and ready to rock. It can be done. I show them how to sprits the foot and then as long as you're applying the tape backward as you're measuring it out, one can be done while the other is drawing.

    Again, looking for that lateral arch and starting that first set of straps, there're two of them that I like to use and just basically, it's a very low J-strap right in that CC joint. Personally, we tend to favor more at New York, staying around the medial lateral boarders of the foot rather than crossing beneath the foot. Again, the disclaimer with the scaredy-cat, there is more than one-way slide. I know many do like to cross laterally, and then bring the strap around the heel, and then drop plantarly as you go across the foot.

    Technically, it is more difficult for students to master that technique early on. They have enough trouble to staying medial and lateral with the foot. What we tend to do in New York is if we start medial and go one-five, the second swing goes lateral five-one. Again, I tell them stay proximal to the MTPJ, and as you are applying this strapping, I like to tell the kids and the residents that as you're bringing up that heel lock, this is important at some point, but this is as good a point as any because you're in the heel.


    As you know, if you've ever had a strap put on or you've seen this on your office, patients do have to be told there is a difference in – and it is a discomfort generally from the strap pulling on the skin, which has to be differentiated from the tubercle pain that brought them into your office in the first place. But for the residents, if it's a well-applied strap, there are patients who will refuse injection therapy. They will opt for the strapping. They're just needle-paranoic, and it's amazing. Patients that limped into the chair, it's the classic definition of what we as podiatrists do, where we enable that patient to walk out with virtually no pain. But they need to told that it's going to feel different and then you can feed into what we talked about earlier, the law of diminish returns.

    If it feels a little snag today, not to worry because in a day or so it's going to keep stretching out. All right. Some words about the padding now. Again, it is a critical branch of what has been called when I was a student certainly, practical podiatry days of [Charlie Perchin] [00:25:17] and so on. Obviously, lots of options. And one thing for the residents, when we have you carve a pad, it's partly for one very good reason. It is absolutely is in a way an exercise if you will to improve your hand-eye coordination development, the hand skills that you will ultimately need to execute some of these magnificent surgeries that you're all learning. All right. So, don't ever downplay the design and the fabrication of these various pads. One definitely fits in with the other.


    Just as there were some practicality with strapping, a couple of thoughts. When you are skiving these pads because you don't want to leave a rough edge, so generally, it's done with scissors. The waxing of the blades, many of us know although a lot of scissors that the kids have nowadays have that nylon or Teflon-type caoing in there, so they're not as likely to stick as they did in the old days when we were doing it. Don't know if anybody still, I hate when I ask audience participation, if anybody feels like shoving their hand up, fine, but anybody still use a skiving knife in the audience, still use a skiving knife? Yeah. A couple of hands.

    As you know, those things or anybody breaks into your office they'll think it's a butter knife. You could probably whack a hand off with it. When we were students, they really didn't emphasize how sharp these things can be and one of our classmates almost sliced a finger off playing around with the darn thing. For residents, I have to put this in. I know I'm not the only one, but I just couldn't believe with my background when I set my own office up, this was model, it was even the color match the office. It was great. I was so proud of it. My brand-new grinder, 450 bucks, and I'm grinding away.

    I always prefer to grind. I like to grind the perimeter of pads. I find I get a better drop off than with any scissor or skiving knife. It's quick. And the bag that comes, it's not shown in this photograph, very anal about it. I was emptying the bag because I go through tons and when I was in practice, tons of felt for adjusting orthotics, and strapping, and padding patients. And I happen to notice, after about a month six weeks maybe that I had this brand-new grinder that I started to see dust gathering on the table top just beneath it, and I dumped the bag, and vacuum all this out all over here, and hang the bag, and same thing.


    And after not quite two and a half months, I went to use my grinder one day, turned it on, the machine froze for a second, started turning backward, which is never a good sign, and the engine component here started getting so hot that you could feel the heat. At which point, the engine seized, I took it down to Langer. I was part timing at my office and working at Langer. One of the techs said, "Holy Christmas, take a look at this," and he had taken the hose off that feeds the impeller, which then dumps to the bag. The whole impeller area was solid with felt, about 10 weeks worth of felt. It didn't matter that I was vacuuming the bag. So, if you do use a grinder to bevel the edges of your padding, please not only empty the bag, but do unhook that hose. It's very simple to do, and pull the felt out of there as well.

    Oddly enough and it's kind of joke become a joke out at Northport VA where I've been an attending for many years as a graduation gift to the kids, just something to remember me by. All the laboratories if you ever visited, this is what they are all using for their top covers, and cutting pads and such. These are called inlaid scissors. If you just Google it, it's a number 20 10-inch inlay scissor. They're about 25, 26 bucks. This is what I've always used in the office, especially if you're using a – if you're trying to cut a quarter inch felt pad. These scissors, the torque on these, if you take the bite down by the hasp down here, the torque on this is phenomenal. Just be very, very careful, you definitely can do some digital amps with these, but if you just Google number 20 10-inch inlaid scissor, these things are wild.


    So, yeah, I always give them, I wrapped them nicely and give them to the kids as a parting gift. Something to always remember Dr. C by. A couple of words on met pads, yeah. Clearly, in our profession, how do they work and Kirby's, one of his newsletters, and I want to say the third one, he has a real nice discussion, a very engineering background discussion on how these met pads work and they basically fall to these ground reaction forces. Dick Scholl used it in his own simple but brilliant way, just very simplistically, met pads eased the white bearing on generally, the middle three metheads.

    Why the middle three? Because the first generally is unstable, podiatric term, hypermobile, Kirby's preferred term the medial column lacks sufficient dorsiflexion stiffness to resist the reaction force of the ground. As those who've been in practice know, met pads probably, one of the most difficult to properly locate, and here's part of the reason right here. Mechanically, as we feet pronate as you know, the medial three columns do tend to drift distal lateral as the foot pronates. So, the position this foot and generally, when we apply met pads, where is the patient sitting?

    They're sitting in the chair is going to differ. And again, here's Dick throwing us to cents and post and again, how this is located can be an issue. I don't know where this came from. It was in one of our padding, strapping books. No one's name was given, but clearly, put those in the wrong place and patient will have a bad day. You can if the patient is somewhat compromised, as far as the ability to place the pad to this skin directly, and it seems that most of the patients that we see are for various reasons, you can use the foot pad of the shoe.


    And what we can do is either visualize the hotspot or ink the hotspot and have them walk in it. Okay. But if it's wrong, they generally, it's wrong, too far proximal, they'll say it one or two ways, okay. One thought, if you have an existing orthosis, and you want to add a met pad to it, try this, this is from his third book. Locate the pad, the distal edge of the met pad 15 millimeters distal to the distal edge of the orthosis as a starting point. Isolation pads, a couple of things. One, as the folks out there well know and it's just simple engineering, the broader you make the pad, you spread that out over a broader cross-sectional area.

    So, if I have a lesion sub 1, and I go one-three, it's not as efficient as if I go one-five and disperse that weight. I have students more so than residents, but it's critical that we encapsulate or get our opening as close to the lesion as possible. So, same lesion, but with a broader cutout, it's going to be virtually ineffective. And of course, all of these can be made into removable by just simply flipping our old term Elastoplast. It's now pretty much Tensoplast, same material, flip it backward and make it a removable pad.

    Just a quick word on buttress or crest pads, the classic indications, this fixed hammertoe deformities, we have those distal erosion or plantar pads. Of course, they will act on the retrograde pressure on the corresponding mets. However, something and again, I had to put a couple of things in here to just have you wet your whistle, there are so called neuro motor, didn't how else to describe it. If you have patients and there are more of them in our office, with movement disorders, not just parkinsonian, but they're classifying them as movement disorder now in the elderly.


    You want to see a patient walk better, I don't know how else to describe it. Make a set of removable crest pads for them and slip it on to each foot, two-four and have them walk, you may see it initially, have them call the office the next morning. Nine times out of ten, they're going to ask what the heck did you do for me because I haven't walked this well in a while. If you're treating patients with upper motor neuron issues, CVA, and so on, and you do see evidence.

    Now, I'm not talking contractures, but if there is still evidence of the unshielded mass flexion extension response, digital crest pads have been shown, primarily the work of [Ductin] [00:34:50] and [Manfridi] [00:34:50], some neuro physiologist, by inhibiting the distal end of the chain, which is the digital flexion, you can break up some of the action of the corresponding gastrocs, a little hamstring hip flexor muscles. So, again, crest pads in a way that you probably may not have contemplated. Fabrication, we'll go over a little bit more in the lab, but the point being again, the length will be determined.

    And one of the things that I think all of you will agree, the two-three-four or certainly a two-three or a three-four, multiple digital buttress pads, a little bit more successful than singular. The singular, no matter what you seem to do, they start to actually rotate on the foot. There's just not enough way to stabilize them, and in which case in, I find the bouton splint or a silicon, these silicon shields, the full toe shields probably do better, particularly if it's a rigged deformity. Bouton splints, really cool. Technically, I just prefer to go with the pre-engineered because just time to build these darn things.


    One thing I do tell the students though is that you've got to be somewhat cautious with patients, especially, you don't want them yanking. These are elasticized of course, and some of the patients, they don't have that same proprioceptive feedback. It's like a diabetic trying to feel the temperature of the tub before they take a bath, and not warm enough, and raising it up to where to parboil themselves. So, patients do have to be somewhat cautioned when they are using this, not to pull too tight on the straps.

    They work obviously better with a reduceable deformity and they really are nifty when you have this early plate disruptions. You can create a pad taping system to extend the effect of the partially disrupted plantar plate, which of course is the way we use the plantar fascia to stabilize it. Two quick case histories and we're done here. And [Dr. Sherman] [00:36:57] had said in the initial stream of e-mails, you have anything that proves this stuff works? I said sure, why not?

    We took a patient that had a very discrete lesion sub 2 and just did a quarter inch full width dispersion pad, ran him through an F-scan and the unit does have an ability to measure focal pressure. And you can see pre-imposed that there's almost a 50% reduction in pressure, which by the way, if you noticed, we didn't enhance the pressure to adjoining mets. The one I love and I use this quite a bit is a patient then had classic fasciitis. Patient did have a documented functional hallux limitus condition, okay? Left foot is what we're concentrating on, and what we did is first, we look at the background of how these two are connected to each other.


    The abnormal pull on the medial band of the fascia as relates to the inability of the first MTPJ to rotate as the heel lifts. That elevation blocks arthrodial rotation, abnormally stretches the fascia. So, when you look at the pre-strap, look at the left foot data, which is up here. First, look at mid stance. Now, remember, the event that terminates mid stance is heel off, all right? If there are issues with in the midfoot that delay the heel from leaving the ground, which generally happen when the midtarsal joint is being called into play abnormally.

    The heel will remain on the ground and you will see that the heel lift phase is delayed, which will stretch the mid stance portion of the cycle from 37 to what it is here. I can't read from here, but it's quite high. Secondly, a delay in reestablishing midtarsal integrity affects the next distal area of concern in light of this diagnosis, which is abnormal strain on the medial band of the fascia, and that is inability for that MTPJ to rotate as the heel lifts, will cause what [Annenberg] [00:39:17] always called the retrograde [phonatory] [00:39:18] force and create the dorsiflexion moment right across the midfoot and block the ability of the first to rotate.

    The best of way to look at that is you go down here to the active part of the propulsive phase, and I tell the residents, the true measure of your surgical prowess in the forefoot will be measured right there because that's when maximum ground reaction force is going to be looking to deflect or distort the forefoot in a dorsiflexion direction. So, look here, I have a high, abnormally high mid stance, absolute lack of MTPJ movement as reflected in the active part of the propulsive phase.


    We did the classic low-dye Campbell's rest combination, enhanced the calcaneocuboid joint. We put a quarter inch, what is often referred to and vernacular at the labs as a reverse Morton's, quarter inch to enable a significant amount of – or drop of the first to encourage maximum arthrodial rotation and of course are [windless] [00:40:21], look what happened. We retest the patient with the strapping, we drop that down to 40, just barely over the accepted norm, and most importantly, I had no active movement at the MTPJ at the time it was required.

    I'm now right up in here in the 23. Normal, no, but a damn sight better than what it was. All with just is taping and padding, that's it. Now, obviously, from this, what do we say to the patient? Again, can't wear tape for the rest of your life, but this is very, very good indication that the next step in the pyramid or the next rung of the ladder will be a creation of a foot orthotics. Specifically, for you, not some garbage you're going to buy off the rack at Modell's. And with that, that will end the didactic part of this set.

    TAPE ENDS [0:41:15]