• LecturehallABPM Pathology - Specific Biomechanics Templates and Surgical Planning
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Matt: Marc Bernard is the assistant director of the American Board of Podiatric Medicine and is formerly the organization's executive director and examination chair. Dr. Bernard is also co-director and president of the Baja Project for Crippled Children/Operation Footprint, an organization which over the past 40 years, has had over 30,000 patient visits, and performed over 3,000 foot and ankle surgeries on children with congenital and acquired neuromuscular conditions. The project has trained several hundred residents in the process. Dr. Bernard is the former chair for the Committee of Disaster Relief of Rotary International, District 5280. He is certified with both the American Board of Podiatric Medicine and the American Board of Foot and Ankle Surgery, and lectures nationally in the areas of pediatric and adult biomechanics and surgery, and he is a Rockstar when it comes to that. I can attest to that. It's an amazing presentation. So, Marc, it's all yours.

    Dr. Marc Bernard: Thanks, Matt [phonetic]. Thank you, Matt. Matt, before you leave, I heard something that you mentioned, and I want to emphasize something to the young people and to realize to everybody in this room. We're talking about the political action committees relative to getting a message out and supporting our position. I'm one of the principals for the political action committee for Southern California. We call that One Voice. We invite residents from the region to come on in. You need to be invested in your profession politically. I don't care whether you like it or not. It may not be your bailiwick. It wasn't mine early on. And as I got older and realized that without it, you are – it is unbelievable, literally, how far we have come when you look at the number of podiatrist relative to the number of allopaths in this country. We are infinitesimally small, but are – no pun intended, our footprint is way bigger than our numbers. Am I right?


    Matt: You're correct.

    Dr. Marc Bernard: I cannot emphasize enough to you the need to stay politically active in your profession, alright? It's not something I paid any attention to as a resident in the early part of my career. I was naïve. Don't be naïve. Okay, let's get into this. Thank you.

    Matt: Thank you.

    Dr. Marc Bernard: Okay. This lecture actually emanated from a lecture I gave in Tenec [phonetic] in the faculty development track, and the intent of the lecture was to show the residency directors and other admin that attended the faculty development track, the value of using a biomechanics template, I don't care what you call it. But a full biomechanical assessment to the surgical patients, because all too often, what's happened in our profession is this partitioning between biomechanics and surgery as though they're mutually exclusive, when in fact they're utterly inextricable. Who was here yesterday? Who attended the most would – I got the lights in my eyes. Did most of you attend yesterday? Yeah? Okay. So, you would've heard Dr. Shaun House [phonetic]. You've heard Dr. Shapiro [phonetic], and it's not be accident that they're lecturing like that.

    So, I'm going to come at this – if anything that I say enhances or embellishes, or duplicates, that's okay, because there's a reason. It was not done with intent, but it just enforces for you the importance of utilizing biomechanical principles. In the bottom line, knowing how feet and ankles work, if you're going to call yourself the specialist of the foot and ankle in the healthcare delivery system, rather than just a well-trained technician. That's what makes a difference. It's knowing how feet and ankles work better than anybody else.


    And being in a position to take a knife to a patient, to enhance that function, and knowing when you do need to take the knife to him, when you don't, when it's time to wait, when you use some combination of surgery and non-surgical bracing, i.e. orthotics. So, that's what makes you special. Otherwise, the world doesn't need you, alright? With that, let's move on. Or not. What did I do? Left or right? I touched the right. Thank you.

    Okay. So, this happens to be a slide from Operation Footprint. We do a lot of major reconstructions, a ton of club feet and so forth. This is just a shout out to any residents that may be interested when you get into your PGY-3 year. If you have a notion to want to learn this kind of thing, which is not what I'm going to be lecturing about today, talk to me. We'll see if we can accommodate you.

    Okay. I am, as you heard, a member of the American Board Podiatric Medicine staff. What we're going to do today is go over the pathology-specific biomechanics templates that ABPM developed for the purpose of facilitating, for no other reason, the residents' ability to understand comprehensively in a more comprehensive way and logical way what's going on biomechanically and pathomechanically for your patients. That's it. It had nothing to do with per se orthosis, physical therapy, or anything else, because once you understand how feet and ankles work, you move on from there, and you use that as a tool in your toolbox for anything that you're going to do. Okay. We have several available. This is not to be an advertisement, but we have several available, easily accessible, both on our website. You can also, there's a hyperlink. If you go to the Council on Podiatric Medical Education's website for residents, you can access it that way.


    I talked to Allan Sherman [phonetic], one of the principals of this conference, and he suggested that I use pes planus as an example for this for sharing with you today. So, we're going to talk about pes planus, but this is equally applicable to the others. Okay. So, I'm going to take this from the template. Here's what you're going to be seeing. I'm going to be taking the text from the template, generating a discussion of that, and showing you how and why you're going – this would be relevant and useful to you when you're planning a surgical intervention for your patient. So, from the template, alright? You would describe – again, this is pes planus, low arch, plus or minus any digital deformities, noted right left bilateral. That would be obvious. And if there was more to say about the digital deformities, there's another piece of the template that you could pull in and add that as needed.

    You're going to talk about – It's asking the resident, and this is voluntary by the way. You're not mandated to use this template or any other, but it's a tool for you, alright? The forefoot to rearfoot, and we're going to talk about why you need to know what the forefoot to rearfoot relationship is. We don't want you to mindlessly record these things without any of it becoming cognitively valuable for you, alright? In the sagittal plane, the forefoot is neutral or dorsiflexed at the level of such and such. In other words, what we're talking about is making an – asking the resident to make an assessment of whether there's a sagittal breach and where that breach is occurring and why that's important.


    Lateral border is, and we're looking at transverse plane. What's a lateral border? I'm going to embellish all of this. This is the pretext to what I want to talk about as we go through this. We're asking a resident to make an assessment of midtarsal motion. I'm not going to read this word for word because you can get it off the template. And we're asking the resident to make an assessment of subtalar joint motion. So, why is it important? Because recording the presence or absence of – so, let's talk about digital deformities right now. So, the presence or absence of associated digital deformities will raise your awareness as a resident of whether the deformities are fixed or phasic. Well, why is that important? In either case, you may need to do adjunctive digital surgery whether they are fixed or not, and not just because you've got a fixed hammer toe and it's irritating the patients in the tops of their shoes.

    There's a reason that patients develop hammer toes. There's a different reason that they – and I'm not going to segue into a whole another lecture, but there's a reason that the patients develop hammer toes with hyperpronatory feet, and it's a completely different reasons for why patients develop hammer toes in cavo-adductovarus feet. And you need to know the reason why so that when you approach these feet surgically, you can do the right procedure, a code or of procedures, to make sure these things are addressed. Fixed deformities may require surgery, osseous surgery, be it arthrodesis, digital arthrodesis, so as to create proximal stability of the toes, understand? Toes that are hammered have lost their proximal stability. So, the distal flexors have overpowered the lumbricals et cetera, et cetera. Again, I don't have time to go into that.

    [00:10: 00]

    But you've got a dynamic imbalance in propulsion which has created a need for the patient to grip. Overtime, they develop hammer toes. Well, you need to restore proximal stability to those toes so that when they propel, you've got the base of the toe flat on the ground, so that when the heel comes off the ground, the metatarsals can plantar flex against the base of that toe. That's basic understanding. So, doing hammer toes just because the toe is bent means nothing. It's doing hammer toe surgery to restore functional – the function of the foot at that phase of gait.

    Patients may have phasic contracture with their toes. In other words, they don't have fixed hammer toes. But as you watch them walk, which demands that you watch them walk, because you're not going to be seeing this in a static images that are taken in bilateral stance which absolutely does not replicate what's going on in the real world. And habitually, we are taught – I was taught the same way, to look at patients with AP and lateral views taken in bilateral static stance. That stopped when people developed pathology. Use your head. That's not when people developed pathology. They developed pathology in gait and in single and support, or bilateral limb support, but one foot is way in front of the other, not bilateral static stance.

    So, that's when you really need to assess your patients. I'm not saying don't look at images. That's fine. But the images are adjunctive. The static images are strictly adjunctive. It's the gait analysis and the weightbearing assessment compared to the non-weight bearing assessment, that's going to – that's where the money is in terms of your understanding of how feet and ankles work. So, if you have phasic digital contractures, why? It tells you again that the patients go propulsive instability or they would not be contracting, A.


    And it's also telling you that they're propulsive. Because if the patient is not propulsive, then the demand for gripping may not be there. And I'll show you what I mean. So, the question becomes if you got a patient with phasic contracture and not fixed contracture, will doing the surgeries proximately, that may need to be done, be sufficient to line the foot up in a way that you have enough functional restoration of the foot that you eliminate the patient's need for gripping in propulsion because you've stabilized the foot at heel contact, at midstance, so it's set up appropriately for propulsion and the toe stopped gripping, alright? That's saying a lot, but I have a lot of material to cover.

    By the way, I'm available here all day. If any of you want me to talk to you more about this during break, I'll be very happy to do it. Alright. So, let's take a look at this foot, hyperpronated foot. You can see where the medial arch is on the left foot. You can see on the right and the left, if you look closely, that there's adaptative malitoes [phonetic]. You've got varus, rotated toes four, five. You've got malitoes two and three. Got it? Alright. So, without even watching this patient walk, which I'm going to be watching the patient walk, before I even get him in the – before I even touch them and evaluate them, 90% of what you need, if you know what you're doing, you're going to get from watching a patient walk. In one minute, in 30 seconds, if you're good at this, I know 90% of what I need to know about a patient, because I understand what I'm looking at during gait.

    And then, you corroborate it with your other findings, alright? So, this patient, I already know he's propulsive. They wouldn't have malitoes if they weren't.


    And obviously, they're hyperpronatory. As opposed to this patient, which is the image I showed you before, this foot is no less flat, but look at the toes. They're nice and straight, alright? So, I would know then a patient like this, this patient is apropulsive. And there are decisions that I don't want to jump the gun here, there are decisions I would be making surgically on this patient to rule in and to rule out, and I'll cover it later, based on what I'm seeing here and what I'm seeing when I'm watching them walk. Alright. Let's go back. So now, I highlighted in black the forefoot to rearfoot relationship, and again, to reemphasize what the sagittal plane is, and what the foot is doing sagittally. Is there a breach? If there's a breach, why is there a breach? Where is it occurring, and what can we do about it surgically? Can we do anything about it surgically? And these are the decisions you need to make, not by looking at static images, but by looking at the dynamics of a human being walking, alright? And then, we'll talk about subtalar joint motion later. And again, we're looking at midtarsal motion.

    So, let's discuss it for a minute. Recording the forefoot to rearfoot relationship will raise your awareness among other things of planal dominance. If you're not familiar with the concept of planal dominance, understand that – and this isn't intended to be a joke. It's a broad statement, and there's a heavy measure of reality to this. When you've seen one flat foot, you've seen one flat foot. That's not precisely true, but basically, what I'm trying to tell you is that, unfortunately, the way you're trained and the way I was trained, except by the sheer luck that I had and the brilliance of the people that were able to train me, and the circumstance that I was in.


    The circumstance that you're in is, for all the surgeries that you're doing, your contact with patients, with a given patient, may be very, very brief. Prior to the time that patient goes on the table and you are doing the procedures where your attending is handing you the knife and you're doing the procedures that the patient's been consented for, with minimal time to really do an assessment to see whether the presenting pathomechanics matches that procedure or whether the procedure that's being done is comprehensive enough to handle the pathomechanics, to handle the deformity of the pathomechanics that's present, and you haven't had the time to assess it. So, you, as the resident, and it was true of me. I don't know if this is not, I'm better than you, smarter than you, or anything else, do not – or circumstantially in a situation, to take advantage of what I'm teaching you unfortunately.

    The best you can do perhaps is get it in the clinic, if you have a clinic attached to your programs. But very often, the very patient that is in clinic is not the patient that you got a chance to see in the OR. So, there's this unfortunate disconnect that's built into the educational process that doesn't validate everything I'm telling you. This is what you need to know to connect the dots, alright?

    So, forefoot to rearfoot relationship will raise your awareness of planal dominance. Planal dominance means that – and I'm going to show this to you, from one hyperpronated foot to another, the reason that this given foot is hyperpronating can be very different than the reason the next foot is hyperpronating. And grossly on static two-dimensional images on the lateral, you may not be able to see any difference. But functionally, they're very different feet, and they need to be treated differently, and I'm going to show you this. So, I'm not going to just throw this out to you and let it disappear.


    Okay. Moreover, if the foot is not rectus, meaning, if the relationship of the forefoot to rearfoot is in varus or valgus, or abducted or adducted, is the condition flexed, flexible or is it rigid? If it's flexible, what can you do about it? And what cohort of procedures or procedure do you need to do to abrogate that angulatory problem so that you can get the foot functioning in a rectus attitude and centralize the weightbearing of the superstructure over the foot? What procedure or procedures do you need to do? Because if it's flexible, you're going to handle it another way than if it's rigid, and we'll go through it.

    So, if it's in fixed varus, as an example, just as an example, is the patient a candidate for a medial column stabilization? And there's a variety of ways to go about it. You could do a cotton with a graft at the cuneiform level to drop the medial column. You can use a Lapidus. Although, I agree with what Dr. Shapiro said yesterday. Lapidus is not a phenomenal procedure to stabilize the medial column. Why? Because, by then, it's too late. By the time you go that far into the gait cycle to where the first ray is hypermobile, you've already got the hyperpronatory forces that bear weight, is it better than not? It is. It's better than doing nothing, but that's not where the pathology is going to be. Pathology is typically is more proximal than that. So, as somebody who really understands how feet work, you're going to want to work more proximally. So, cotton may be appropriate. Maybe a Lapidus. You may want to do some adjunctive FDL transfers, peroneus longus, reefing, other things, but understand the why behind the what.


    You have a hyperpronatory condition. It's pronating at this point in the gait cycle. I need to do this here. What's left, I've got to do this at midstance, surgically, or to affect midstance, and I've got to do this surgically to stabilize in propulsion, or maybe I don't. I've got to know the foot or maybe I need to incorporate something more proximally, and we're going to talk about that too.

    So, again, I alluded at this before, is the lateral column subluxated? And why would the lateral column – not to get into a biomechanical discussion, because this is – I have a tendency to morph into other things and steal my own lecture time, but why would you have a subluxated lateral column? Well, think about it. If somebody's got a fixed varus of the forefoot that does not come around, that's not completely compensated with high-end foot pronation to get the forefoot on the ground adequately, then you're going to be overloading lateral column. And if an overloaded lateral column step after step after step, one of two things is going to happen. You're going to subluxate the fourth and fifth metatarsals on the cuboid, or if they've got the axis to accommodate, then there will be transverse plain accommodation so that the cuboid into your calcaneus will abduct on the cuboid. And in an x-ray, you'll see that as a cuboid abduction angle, alright?

    You know what a cuboid abduction angle – not to insult your intelligence, but cuboid abduction angle, correct? Cuboids aren't abducting. The anterior calcaneus is adducting because the forefoot's captive on the ground. This is closed chain mechanics. But understand, when you see that, that that is the result of a problem.


    That angle is there for a reason. It's there because you've got transverse plain compensation of the foot to accommodate the need for motion. So, if either a frontal plain compensation or a sagittal plain compensation, and if they're unstable there, do you have to address that surgically? By way of – there isn't any number of things in opening with a graft, dorsiflex or osteotomy at the cuboid, et cetera, et cetera. As the foot and ankle expert surgeon, you need to understand – you need to make a decision based on your understanding of foot and ankle mechanics as to whether the lateral column needs to be addressed in addition to the other cohort of procedures that you're choosing for that flat foot correction, okay?

    I talked about that. I tend to get ahead of myself. I'm sorry. Here's another one. This is a little less common, but you will see it. You'll see a flexible forefoot valgus. A lot of hyperpronatory feet have a valgus relationship in a non-weight bearing attitude between the forefoot and the hindfoot. And in the olden days, because I'm old, we called it a flexible forefoot valgus. Terminology aside, what you're looking at is an innate valgus relationship between the forefoot and the hindfoot. And what happens is, heel contact, midfoot loads, and because there's an innate relationship of valgus of forefoot to hindfoot, you don't lock the midtarsal joint. The midtarsal joint is not locked by ground reactive force adequately. So, what happens with these feet is you go into late midstance into heel off, and because the midtarsal joint is not locked, it suddenly pronates, because you have an unstable midtarsal joint.


    So, you need to make an assessment as to whether that patient's got an unlocked midtarsal – a flexible forefoot valgus. It might matter in the cohort of surgical procedures that you're going to employ. Again, you won't see this on an x-ray. And in so doing, if you do the cohort of procedures that you need to do proximally for the patient to correct the flatfoot, what's going to happen with that hypermobile forefoot because of the forefoot valgus? You may need to employ some bracing, an orthosis of some type, to make sure that as they go into propulsion, you keep the lateral column stable so that you haven't wasted your time with all the other surgery that you've done, alright? Again, it's all one thing. Whether you take a knife to this part of it and put an orthotic brace in the other part of it, it's all one thing. It's functional restoration of the foot, okay?

    Another clinical pearl, if you want to see where neutral is, you want to assess the forefoot to rearfoot when the foot is neutral. If you look at the left image, that hindfoot is neutral. One of the giveaways as to whether that hindfoot is neutral is where the tendon Achilles is centralized relative to the posterior leg and ankle. Take a look at the right. The minute you hyperpronate the foot, don't look at valgus varus. Valgus varus is so overstated. Hindfeet don't go in great unless the Charcot or unless you're dealing with ligamentous laxity and other kinds of conditions, true varus and valgus is a rare thing. What is very, very common is Kite's angle. Meaning, the AP talocalcaneal angle opening or closing. That doesn't necessarily relate to varus or valgus of the hindfoot.


    But what it does relate to is with just a little bit of pronation, look at where the tendon Achilles is relative to the posterior aspect of the leg. See it? That hindfoot's not a lot of valgus, but it does take one of the strongest muscle tendon complexes in the body and shifts at lateral to where the – to the superstructure. Big difference. And, when you do that, look at what happened to the forefoot to rearfoot relationship. The minute you pronate, even a little bit, you start unlocking the midtarsals. You see it? And this is just with the pressure of my thumb, let alone what ground reactive force is going to do, alright? So, going back to this foot, is there a transverse plain issue here? Is that a hypermobile? Is that a gorilloid fifth metatarsal base or is there an innate metatarsal adduction there that needs to be considered when you're doing the hindfoot?

    We're going to talk about this, because if you're correcting the hindfoot to neutralize the hindfoot into a better functional position, if there's an innate adducted position of this forefoot to the hindfoot that you're not seeing in the relaxed position when you decompensate the hindfoot to restore functional position to the subtalar joint, are you now going to push the adductus to the forefoot, and does that need to be addressed surgically? We talked about lateral column subluxation. Here's an example. Look at lower right. And you will see in a normal foot when the foot comes off the ground, the lateral column is intact. When the foot is hypermobile at the midtarsus, when the foot comes off the ground, you get the banana peel effect.


    You're peeling the foot off the ground and that's subluxation of lateral column. And by the way, lateral column subluxation can occur with a partially compensated pes planus where you're still overloading the lateral column, or a pes cavus, where, for a completely different reason, the lateral column is constantly overloaded, because the foot remains on the supinated side and never gets to neutral, and it's constant overloading. Two different reasons that the lateral column can subluxate, you as the foot and ankle expert, need to know what those forces are, how to neutralize them, and it may be that you need to do it surgically, and then maybe that you can do it non-surgically. But, if you're going to do it surgically, you better know what to do.

    Alright. I talked about planal dominance of the forefoot to rearfoot. These are both flatfeet. When I say flatfeet, let me say, these are hyperpronatory feet. Both of them are hyperpronatory. The essential difference or one of the major differences between these two feet is, on the left side, the so-called too many toes sign that you're looking at, you're all familiar – don't laugh at me, but are you all familiar with the term, too many toes sign? Do they still teach this? Yes? Thank you. I hate the term too many toes sign, because it makes – because if I ask you what that means, you're going to say that the forefoot is abducted on the hindfoot, right? Now, is the forefoot abducted on the hindfoot? No. The forefoot is captive on the ground at midstance. The reason you can see the toes is because in the transverse plane, there is enough motion at the midtarsal joint that the anterior calcaneus is moving medially with the leg on the planted forefoot. It's just the reverse of what they're teaching you.


    I'm not saying they're teaching you wrong, but the terminology that they're using is misleading. And if you don't think about it, you're going to take that as a gospel. The forefoot's not abducting on the hindfoot. The midfoot is following the leg and adducting on the forefoot. Well, why is this important? Alright, so that's the why. Now, let's get to the what. What is the what of it surgically? If I need to surgically stabilize – and this also tells you that this foot, if you look at the position, the rearfoot to leg and the heel to ground, and the heel to leg position, there's not a whole lot of medial lateral offset there, alright? The tendon Achilles is reasonably centralized. That's not where this foot is pronating. This foot is entering a hyperpronatory scenario in late midstance in propulsion, and that's why – and this patient has this particular patient has an axis, midtarsal joint axis, that's predominantly allowing transverse plain motion.

    Well, you're the surgeon. You need to understand what you need to do. What this patient needs, if they need anything, is an opening Evans with a graft, because what's going on proximally doesn't need to be addressed. But not because an x-ray said so, because of what they're doing. Now, look at the foot on the right image which is the left foot, very different scenario. Look at where the tendon Achilles is relative to the posterior ankle. You've got – where is the laser pointer on this thing? Is there one? Top button? Alright. Here's the talar bulge, right here.


    This is the head of the talus. Here's medial malleolus. Here's head of talus. Kite's angle on this foot, and I don't need an x-ray to tell me this. I know it. I know it because I see it. Kite's angle is way open here. The leg is being pulled medial relative to the planted foot. Is this heel in a lot of valgus? No. That's a very pronated foot though, but this heel is not in valgus. It's the offset between the leg and the planted foot. This patient is compensating at heel contact. And because they're compensated at heel contact, the cascade effect to the rest of their foot puts them in a hyperpronatory state, but look at the lateral border here compared to here, alright? This patient's hyperpronatory at contact in early midstance and they stay that way in propulsion. There's no reason to do a lateral column procedure here. What this patient needs is something more proximally. It may be a calcaneal slide. It may be a combination of arthroereisis calcaneal slide, if there's a tight – and we're going to talk about this later. You may have to do a partial recession, percutaneous TAL, et cetera, et cetera, to abrogate the forces that are impacting this foot. But you have to understand that these are two different hyperpronatory situations and you need to do the assessment so that you know it.

    Alright, let's move on. Here's another foot. This happened to be a kid that I did years ago, and it's great that I was post-op on one side and still pre-op on the other side. So, take a look. This was a kid that had a hyperpronatory hindfoot with an adducted forefoot. The old term of that, it was a stage – not to get technical, but it was a stage three skew foot or a Z foot. You may follow it in the literature.


    Well, why is it important to understand this? Because if you don't do a proper assessment of the pronation of the hindfoot and just straighten out the forefoot because of the obvious adduction, you're going to destabilize this patient. Because you're going to take out the medialization that's keeping the leg over the – keeping the foot under the leg as it passes over during gait. If I then straighten the forefoot without stabilizing the hindfoot, I'm going to make this kid more unstable. So, you have to do a thorough biomechanical assessment to know it. And if you look here, you might be able – darn it. Sorry. Why is that happening? How do I go back? There it is.

    Alright. So, if you look here, there was a medial calcaneal displacement. You see the scar? So, relative – this the pre-op foot. This is post-op here, medial calcaneal displacement osteotomy. And if you see the incisions here, I did a midfoot, several midfoot wedges here to restore the forefoot to rearfoot in the transverse plain, but I had to bring the heel back under the leg. So, if you look at the functional – I swear to you, it's not because this kid is leaning to his left, alright? Which is an easy thing to –you could say he's just leaning to his left. The kid was not leaning to his left, alright? This was bilateral, even weight, in stance, but by restoring subtalar position or tendon Achilles position to leg and forefoot, you now have an alignment of heel to leg relative to this foot where the superstructure is medial to the planted foot, got it?

    And because this superstructure is medial to the planted foot, if I only did a forefoot correction, then I'd take the forefoot and bring it further out and have a more destabilized position.


    You've done worse for the patient than better. You need to understand how feet work. Alright, let me continue. By the way, this was changed. I have an hour. We changed the sequence. So, I've got another 26 minutes here to torture them. Alright. Everybody understand the concept here so far? Alright. Alright. So again, you have to ask yourself, we talked about this a little bit before. This is the radiograph of this kid's foot. So, look at where Kite's – look on the left. Look at AP Kite's angle. You see how far anterior the head and neck of the talus is relative to the anterior calcaneus, alright? So, not only is the talus dropped, but relative to the calcaneus, it's medial. Look at where the navicular is. And look at the amount of adductus that you've got on the forefoot.

    So, obviously – and yet the lateral of this, you don't see very much, because you're looking at two-dimensional static images, and you simply cannot rely on two-dimensional static images to give you an overview of what's happening with the foot, let alone the fact that when you're taking images in stance, the leg is always directly over the planted foot. It's always over the planted foot. It's always directly over the planted foot. That doesn't capture what's happening dynamically. So, you look at this strictly adjunctive as a surgeon to what's going on functionally. And yet, when you go to conferences, and you'll be going – and I'm sure you do it, when you have your grand rounds, when you do this, what's the first thing that people do? They throw up static images, two-dimensional images. When you go to any of the conferences that you're going to be going to, they throw up static two-dimensional images.


    They are at best adjunctive, alright? And as I joke, all I ask that you do is do what – listen to what I say and do it that way the rest of your lives. Okay. No, but seriously, when you do this, you understand that if I neutralize the hindfoot here and close Kite's angle by doing an opening Evans, let's say with a graft and/or a medial display end, probably on a foot like this, a medial displacement calcaneal osteotomy. As I decompensate the hindfoot, I'm going to take the forefoot and make the adductus even worse. So, what you've got to do when you approach this sequentially as the surgeon is you start from the hindfoot. Neutralize the hindfoot. Use your imaging. Feel what the forefoot to rearfoot is doing when you've fixated the hindfoot to wherever you need it to be and restore it to neutral position. And then, do an assessment of – a manual assessment on the table as to what the forefoot to rearfoot is doing. And then, decide how much abduction you need of the forefoot to the neutralized hindfoot – the surgically neutralized hindfoot, to then make your assessment.

    Are you going to the mid basis? Are you going to do it at the midfoot? I don't care where you do it. What I care that you do is understand why you're doing what you're doing and how much of it you need, alright? Here's another thing that's clinically – this is a clinical pearl. We are trained, and it's completely understandable, habitually, if you are given the luxury in your program to do a thorough of enough assessment of a patient to watch them walk and observe them in bilateral – and observe them in stance, the tendency is – and you should do it. The tendency though is to observe from directly posterior.


    In other words, from the midsagittal line, and that's what this is. And if you did that with this case, this hyperpronatory kid, if you did – or an adult, I mean whether it's a child or adult in this for what I want to talk about, it doesn't matter, but if you do this, you would say, "Okay. There's a little more hyperpronatory activity on the left side than there is on the right." So, it's not quite symmetric, a little bit more in the left than the right. Well, let me show you. Now, trust me on this, and you can see that it's legitimate because it's – we're just worked out that way, that the right foot is sitting on the line in the middle of the Orthoposer, you see it? And you see that that line is still under the heel of the right foot.

    I did not reposition the patient. I repositioned myself. So, what you're looking at here is independently lining your perspective up to look directly posterior at the right. And how do I know I'm directly posterior? Because I see where the tendon Achilles is relative to the malleoli. Do you see it? And look at the hyperpronatory position there. Look at the degree of rearfoot pronation there. Then, look on the left. Do you see how asymmetric these feet really are? But if I go back here, you might miss it. You would see that there's some asymmetry. Does it matter? You bet it matters, because on this side, as I move forward again, what surgery did this kid need on the right? None. On the right, the kid needed on orthotic. On the left, I did an arthroereisis and an opening Evans, and I did a peroneal tendon balance, which is something that a lot of you don't do, but the left side needed surgery.


    The right side didn't. That's because you do a biomechanical assessment. Then, of course, you've got to have the technique and all of that. That's a given. You have to know technique, but technique is technique. It's how you apply the technique to a given set of pathologic circumstances and what cohort of procedure you bring to a given patient's foot. Alright. I'm not going to spend a lot of time here. This is obvious. If there is presence or absence of pain or crepitus, is there enough DJD, in other words, in the foot to warrant targeted arthrodesis with an angulatory to effect angulatory change and so forth? That would be a given. And that in fact is corroborated with – that's a good reason to look at a radiograph. But it's still, it's a combination of clinical assessment and the radiograph. Okay.

    From the template again, ankle joint dorsiflexion with the knee extended is such and such, and with the knee flexed is such and such. Why does it matter? Why does it matter that I have to, I, the resident or the clinician, have to asses ankle joint dorsiflexion? What does it mean to me? Well, recording ankle joint dorsiflexion and assessing it during gait, as well as not during gait, will raise your awareness of the possible need for proximal surgery. So, might you need to do in a given hyperpronatory scenario an adjunctive proximal procedure, like a recession, a Bollman [phonetic], a percutaneous TAL if it's a neurologic patient, which we see a ton of, it might be a Murphy procedure, which is anterior advancement to the tendon Achilles, moving it much closer to the posterior subtalar joint to decrease the fulcrum.


    You have a lot of surgical options available, but which option you choose or whether you choose the option at all, is based on an understanding of what that given foot is doing, and none of that will you see on a bilateral static image. None. You got to check that in gait and in stance, and in a non-weight bearing. Another thing is you do an assessment, is this condition longstanding? And, if the condition is longstanding and you're dealing with somebody who's up in years, whose relatively apropulsive and the hyperpronatory situation is long established and it became hyperpronatory and fixed in that position years before, and now the patient is functioning in an apropulsive manner, you may have a patient who's very abducted. You may have a patient who's stride length is much shorter than it was when they were younger, so that the leg coming over the foot is not as dynamic. You may or may not need – you may be able to get away with it just doing the foot hyperpronatory surgery or the – I said it backwards, the surgery for the hyperpronatory foot without having to worry about whether you need go superstructure and do a recession or whatever you're going to do, because the patients' needs are not there.

    You may get away with just doing the foot correction and put the patient in a slight heel elevator, without subjecting them to additional surgery, alright? But it's up to the specialist to know that, the specialist, which should be you, to know what you can and you can't do.


    What if the ankle joint dorsiflexion appears to be present and the hyperpronatory condition is limited to the subtalar joint distally? Well, did you do an assessment? Did you do an assessment for ligamentous laxity? What's the soft tissue status of this patient? Are you dealing with something that's not so much pathomechanical in terms of gait-induced, but they simply have more ligamentous laxity? Is that the foot that you're dealing with that's causing a hyperpronatory condition? And therefore, do the decisions that you need to make have to be based more on that and you're doing more osseous stabilization and tendon transfer work and so forth to get this foot better?

    It matters. It matters that you do a thorough assessment. Can posterior release therefore be ruled out or will that patient by way of the decompensation that you've done in correcting the flat foot create a demand on the leg because remember, these patients – if a patient's hyperpronated and it's not due to ligamentous laxity and so forth, then the reason the foot is pronating is because it needs to make the – meet the demand of sagittal plane competent – sagittal plane motion for the patient to get from here to there.

    And if it's not occurring at the ankle because there's some equinus condition of the ankle that doesn't allow the leg to move adequately over the planted foot, then that motions got to be taken up at the subtalar joint and the tarsal joint and maybe adjustments and stride length and so forth. Well, when you're doing reconstructive surgery on a hyperpronated foot, you are doing what? You are decompensating those compensatory mechanisms to realign the foot.


    Once you decompensate them, there's still that demand for the patient to get from here to here. You may have to go proximal. And if the patient's got enough range of motion innate to their ankle joint, you may need to do a recession or a partial recession, or any of those cohort of procedures that I mentioned. So, it's incumbent upon you, the surgeon, to know number one, that you have to do it. Number two that you have to look for it. Number three to assess it on the table.

    To anticipate it, to consent the patient for it just in case. And then, do what you need to do when you need to do it on the table if that's what the patient needs. And not only that, choose the right procedure. Because if you do a percutaneous TAL, remember, you're weakening both the soleus and the gastroc. Or you may not have to weaken the soleus. You may just want to weaken the gastroc and do a partial recession. You don't want to weaken the gastroc but create a length.

    So, percutaneous TAL, remember, whenever you do that, you're affecting two muscles because you're lengthening both soleus to heel and gastroc to heel. There are reasons – there are times you may have to do that. Other times, you don't want to do that. It's up to you to do the assessment to know which one it is. Am I sounding like a broken record? I apologize. Evaluate for equinus. Now, what you don't know is and I'll point it out. You see where the – on the left image? You see that the stool is pointing to the left rather than straight up? I assess, this isn't – shouldn't be part of this but real quickly, I assess ankle joint dorsiflexion with the knee with the patient prone.

    I start with the knee flexed and the foot then dorsiflexed relative to the leg. And then, in that scenario, I extend the leg. So, I'm going from a knee flexed to a knee extended position which is what you see on the right.


    The only thing I did so you can compare the two is I rotated the image, the clinical photo 90 degrees. Alright? But actually, if you turn that 90 degrees clockwise, you'd understand that the leg is pointing up this way and I'm pushing down on the foot. Everybody understand that? Yeah? Okay. So, in this scenario, why do I do it this way? Just a clinical pearl. If patients don't anticipate that you are going to hyperextend their ankle because subconsciously, they know it's going to create tightness behind their knee. Particularly, in their hamstrings when you pull the – as you lift the leg off the examining table or the podiatry chair. Subliminally, they know that they're going to feel a stretch and they increase tone in their hamstrings.

    And you're not going to get a fully – you're not going to get a true picture. Alright? It's much easier to put the patient prone. Whether you do this, if you're effective doing it that way, I always thought that way, more power to you. What I'm telling you is I find it much more repeatable and predictable if I assess it this way. Keep the patient prone. They don't anticipate anything. You're keeping them on – they're all stretched, and then as you extend, they have no idea what you're doing so that subliminal tone doesn't go into their hamstrings.

    And that will give you – you'll get a lot less false positives in terms of a limitation of ankle joint dorsiflexion. If it's limited this way, it's limited. Then you have to make a clinical assessment. Alright. Let's move on. Again, we're talking about why might you do or not do a recession or something proximally in the context of a pes planus? Well, what if the patient's compensation is mostly in their angle of gait?


    What if they are mostly abducted in their gait? If their gait is predominantly abducted, then they were not really using their ankle joint. They're rolling through from lateral to medial because of their angle of gait. And they may be symptomatic in the foot but doing a recession or doing something to lengthen the posterior structures there is irrelevant because they're not walking in a way that's creating the demand on their ankle. So, this patient's flat foot has to be treated differently because of where the foot is in space relative to the body.

    Again, these are clinical decisions that can't be made on – with radiographs. They have to be made by watching somebody walk. What if the patient has genu recurvatum? They have a hyperpronatory condition but look where the leg – look where – they're almost in heel contact where the swing phase limb is almost in heel contact there. The superstructure is adequately anterior to the planted foot, to the stance phase foot.

    The foot where you can't see it with the sock on, the foot's hyperpronatory but look where the compensation in this patient occurred? At the knee in hyperprone – in genu recurvatum. There's no reason for me to do a posterior release, a recession or anything posteriorly here because of the way this patient's compensating. I'm just going to do my hyperpronatory correction, surgical correction at the foot level. This patient doesn't need it. Manual muscle testing. Okay? We ask you to look at – and be confident in manual muscle testing.


    I cannot tell you how bad practitioners are doing this. Can a physical therapist do manual muscle testing better than you can? Yeah, they're doing it all day long. Can a physiatrist do it better than you? I'll give you that. They're not operating on people, you are. You need to become confident in your assessment of muscle. And here's a few reasons why. Alright? If you're going to consider doing tendon transfer work, and I'm not suggesting that you're necessarily going to get into the work that I do, not to say that you shouldn't.

    I hope you do. I hope you're inspired to do it. But you may not be getting into patients that are neurologic and so forth, but still, you're going to be doing procedures like STAT procedures, PT, tenderness, function, patients are well within the bell curve or the things that you might want to do tendon transfers. Digital stabilizations, and I'm not a lover of tendon transfers in the toes but there are very simple ways you can make that work with many anchors and things to restore the dynamic imbalance to get proximal stability in the toe.

    So, there's reasons that you folks, that – in what I say, the podiatrist that's doing the "normal patient bell curve" will be doing tendon transfer work. Well, if the muscle is weak, is the weakness innate to the muscle? In other words, if there's true paresis in the muscle, or is the weakness positional? If I've got the – if I'm muscle testing the patient and I put the muscle or the foot in the wrong attitude and ask the patient to go ahead and fire whatever the muscle I'm interested in. It will seem new – it will be weaker or stronger just because I repositioned the foot in that position.


    So, the first thing you need to know is how to do muscle testing to determine whether the muscle is truly weak or not because if the muscle is truly weak, then you need to make a determination of what are the prospects of having that patient rehabbed before you either take him to surgery if you want to use the muscle like a stat procedure for transfer or an FDL or peroneus brevis, whatever it may be that you're going to use to transfer or peroneus longus for whatever the procedure is.

    What is the – what are the prospects for rehabbing that muscle? If they're there, then you rehab the patient before you do the procedure because after you do the procedure, you put him in a cast. It's going to get weaker yet. So, you need to do the muscle testing in advance to know that. Or, is the muscle not weak at all and the only reason it's weakened is because you tested it in the wrong position? You got to test the foot. You have to test the muscle with the foot in the correct position.

    So, it's incumbent upon you to know what you're doing if you want to get involved in muscle tendon transfer work. Okay? And after you do that, will the dynamic imbalance still be present when you take that tendon and transfer it or the hemi-tendon. Let's say you're doing a stat procedure. You take the hemi-tendon and take it and sink it into the third cuneiform of the cuboid, will that dynamic imbalance in the foot still be present because you've got paresis proximally or hyperpronation proximally to require additional procedures?

    And you got to factor that in before you even do the surgery, or do you need the staged surgeries? And in that case, you got to know what to tell the parents, or if it's an adult patient, you got to explain this to a patient. They're relying on your knowledge. We talked about ligamentous laxity. We talked about that. So, there's a variety of cases that you might want to consider, right?


    FDL transfer for PT tendon dysfunction. I'm not a major fan of it, but I'm not going to editorialize. There's other – I'd rather use the peroneus longus for that because it's a phasic transfer. Were any of you here when Dr. Shaun Phil – Shaun House spoke about muscle function? Alright. It's apropos. It's apropos. It's not an intellectual exercise. We use this when we do surgery, alright? So, you want to do an in-phase transfer if you can. There are times when you have to do an out-of-phase transfer for certain patients.

    Mostly, you're going to get a better outcome if you do an in-phase transfer. Well, I'd rather do as an example, and this is not to talk about what I would do but as an example of applying biomechanics to what you're doing is I'd rather use the peroneus longus if I can because it fires sooner in the gait cycle. So, I'm going to stabilize the medial column better if I'm doing a PT tendon dysfunction by using the peroneus longus to stabilize the medial column.

    Then, the FDL which fires later on in the gait. Well, my problem is occurring sooner. I may want to transfer both. If I need it that badly and I may want to embellish it with an arthrodesis to neutralize the hindfoot, but you've got to understand what that given foot is doing. Alright? Split peroneus brevis transfer if you need to. If you've got a lot of paresis on the medial side, we use it a lot. Split peroneus, you take the peroneus brevis, you already have a dynamic imbalance where the peroneus brevis is over pulling the tibialis posterior. Well, I can enhance the pull on the medial side by splitting the brevis, rerouting it retrotibially and bringing it in to the medial compartment.


    So, when it fires, I now have PT firing and I've got peroneus brevis firing to shore up the arch, and you may want to do some adjunctive work like an arthrodesis. You may want to do a calcaneal displacement. Bottomline is you've got to get the foot lined up with the leg but that just helps in stance. You want muscle firing to continue to work through gait. Then again, gastroc soleus, I don't want to beat that to death. We talked about it. You may or may not need to do something proximally. And where there – and again, I'll just, so you don't forget, what's the patient doing in propulsion?

    Are they gripping with their toes? Do you think everything you've done proximally is enough that you can just watch the toes and the phasic activity over time and maybe at a later time, you advise your patient, we're going to watch this, see what happens to the toes. If we neutralize your foot properly, you're gripping with your toes, it may just go away on its own. If not, be aware, Mr. Jones [phonetic]. Mr. Jones, that you are – if it's your child, might need some minor surgical procedure down the road but it will be far, far less surgery than what you're doing here.

    We talked about that. I just want to cover this about do – why we're asking residents to look at dual-limb support, okay? Let's go back to here. I'm concentrating on – I'm not interested in this case on the left. I'm looking at the foot on the right. These are feet that have – that are hyperpronated subtalar joint hyperpronation. One simple way to assess integrity of the mid tarsus clinically is to have them get up off their heels.


    And if when a hyperpronatory person comes up onto the ball of their foot, if the hindfoot reduces from its – a more pronated state to a less pronated state, there's a good chance that you've got a reasonably good locking mechanism at the midtarsus, and you need to factor that in to the cohort of surgical procedures that you're doing. Very simple, you're going to do this with single limb support. You're going to do it with dual-limb support, and find out, this tells you more than anything you can assess in a non-weight-bearing attitude in a chair.

    Hence, it's an absurdity not to factor in closed chain kinetics with open chain kinetics in gait before you touch a patient surgically. We talked about gait. I just want to say, in stance or gait, if there's significant medial, lateral offset of the foot to the leg, you need to handle that. It's not the varus-valgus. It's the medial, lateral offset of the foot to the leg that you need to deal with. And whether you do it with calcaneal displacement osteotomy, arthrodesis, some combination, I don't care what combination you're using as long as you do the assessment and you do the right thing to realign.

    Pediatric patients, you may not be able to do something, you can do an adult like a cotton or a Lapidus because you don't want to do premature arthrodesis of a growing growth center and create iatrogenic deformity, so there are certain cases where it's too early to do a certain procedure, and then you got the timing of how you do the hyperpronatory foot correction comes into play. And you as the expert need to know that too, when to do surgery, when not to do surgery.


    And once again, and I'm just about done, I cannot emphasize the importance of looking at shoes on any patient because this tells you the wear pattern over time. And you need to in your own time to go through it because Matt's giving me a dirty look. But you need to learn what shoe wear patterns mean relative to your patient and always, always, always have your patients bring in old shoes, not new shoes, so you can make that assessment. It tells you what's really going on. X-rays don't. Thank you.

    TAPE ENDS [01:04:34]