Total&angle&and&Philip&Fowler&angle:""

• Normal"Calcaneal&Inclination"angle"is"basically"he"plantar"contour"of"the"calcaneus"versus"the"horizontal"surface,"the"Philip&
Phowler"angle"is"the"angle"between"the"plantar"and"the"posterior"aspects"of"the"calcaneus,"and"the"Total&angle"is"the"sum"
of"the"calcaneal"inclination"angle"and"the"Philip"fowler"angle.""
• What"does"this"mean?"In"surgical"planning"of"posterior"calcaneal"osteotomies,"there"are"procedures"which"take"a"wedge"out"
of"the"dorsal"body"of"the"Calcaneus."A"procedure"such"as"that"would"change"the"structure"of"the"Calcaneus"intrinsically,"
comparing"that"to"procedures"which"simply"provide"exostectomy."With"a"high"total"angle,"you"may"be"forced"to"do"a"Kelly"
and"Keck"osteotomy"(CW"osteotomy"of"the"midFportion"of"the"body"of"the"dorsal"calcaneus"done"for"recalcitrant"posterior"
calcaneal"syndromes"around"the"insertion"of"the"tendon;"Chronic,"unremitting"pain,"bursal"formation,"tendinopathy."It"
shifts"the"previously"prominent"posteriorFsuperior"aspect"anteriorly"squeezing"the"Calcaneus"together,"and"by"closing"the"
angle,"you"are"changing"the"total"angle,"but"you"haven’t"changed"the"position"of"the"calcaneus"relative"to"the"floor.""
• The&majority&of&patients&with&Achilles&Tendinopathy&Recover&fully&when&treated&with&exercise&alone:&a&5&year&follow&up&
o Silbernagel"et"al,"2010"
• Are"we"doing"the"wrong"thing"when"we"inject"areas"of"degeneration"with"corticosteroid?"Are"we"negligent?""
o Efficacy&and&safety&of&corticosteroid&injections&and&other&injections&for&management&of&tendinopathy:&a&systemic&
review&of&randomized&controlled&trials"(Coombes"et"al.,"Lancet"210).""
This"is"a"compilation"of"a"huge"number"of"trials"with"a"huge"number"of"participants,"and"you"would"conclude"that"
corticosteroid"has"a"use"as"a"utility"in"the"short"term"for"managing"these"conditions,"maybe"not"in"the"long"term."
Patients"that"have"tendinopathy"DO"benefit"from"corticosteroid"injections"but"over"the"long"term,"this"effect"seems"
to"have"been"reversed."Interestingly,"the"incidence"of"tendon"rupture"was"very"rare;"Achilles"tendon"
rupture/tendinitis"associated"with"Quinolone"antibiotic"is"much"higher"in"the"group"that"you"prescribed"
Ciprofloxacin"or"Levaquin."
o Polidocanol"F"sclerosing"agent,"Prolotherapy"is"the"tem"given"to"a"paradigm"given"to"musculoskeletal"therapeutics"
which"advocates"for"the"injection"of"chemicals"which"will"cause"sclerosisF"this"could"mean"anything"from"ethyl"
alcohol"to"phenol,"a"variety"of"substances"are"used,"the"advocates"of"this"paradigm"hope"to"create"areas"of"fibrosis"
and"scarring,"and"will"have"significant"effect"on"areas"of"neovasculrization"within"tendon.""
! Prolotherapy&is"considered"outside"the"standard"of"practice"in"the"US,"most"insurance"companies"will"not"
pay"for"it."This"is"on"the"list"of"practices"that"might"be"dubious.""
• Achilles"tendon"pathology"with"a"foot"orthoses"What"can"we"hope"to"do?"
o Where"is"the"indication?"
! Presence"of"structural"equninus"
! Hypermobility"states"
! Conditions"creating"calcaneal"eversion/plantarflexion""
! History"of"Achilles"tendon"injury"
o Equinus"is"a"significant"driver"of"hindfoot"eversion,"unlocks"the"midfoot"and"subjects"it"to"instability"that"leads"to"
adverse"effects"on"the"first"ray"and"others.""
o But"wait:"CFFO"can"cause:"
! Intrinsic"causes"of"pronation"will"cause"shortening"of"the"Triceps"
! An"intrinsic"shortening"of"the"Achilles"may"cause"pronation"
! In"either"case,"an"orthosis"will"INCREASE"tension"in"the"tricpeps"
o Individuals"who"present"with"AT"pathology"may"well"be"treated"with"an"orthoses,"but"when"you"utilize"any"means"
to"invert"the"Calcaneus"(prevent"it"from"PF)"you"are"actually"going"to"increase"tension"within"the"Achilles"tendon."
At"a"minimum,"when"your"plantar"heel"pain"patient"comes"back"and"says"the"heel"pain"is"better"but"the"calf"is"tight,"
you"know"why,"and"some"patients"can’t"tolerate"that."If"you"are"taking"a"very"hypermobile"foot"and"taking"it"out"of"
eversion"and"putting"it"more"vertical"or"even"in"varus,"you"are"going"to"create"increased"tension"in"the"Achilles"
tendon"that"may"lead"that"patient"to"report"that"back"to"you."

Medial&Stress&Syndromes:"

• Medial"stress"syndrome,"more"commonly"known"as"shin"splints,"is"nothing"more"than"periostitis.""
• There"may"be"associated"myositis"(inflammation"of"the"muscular"compartment),"and"tendinitis.""
• Medial"stress"syndrome"is"Periostitis"at"the"medial"posterior"border"of"the"distal"half"of"the"tibia."Symptoms"usually"diffuse"
4F8"cmF"pain"is"not"localized"to"one"particular"area"(if"so"you"should"be"more"suspicious"of"stress"fracture).""
• This"is"the"classic"“posterior"shin"splint.”"
• Prevalence"is"reported"13.2%"of"high"school"runners.""
• Incidence"is"quite"high;"this"used"to"be"considered"to"be"related"to"impact,"shin"splints"sought"soft"surfaces"because"of"the"
misinterpretation"of"the"syndrome"in"the"70sF80s"was"that"this"was"associated"with"hard"surfaces,"this"has"not"been"proven"
to"be"the"case."
• What"is"proven"to"be"linked"or"at"least"associated"in"terms"of"the"literature"are:"
o Hypermobile"states"of"the"STJ""
o Increased"navicular"drop."
o FF"varus"to"RF"deformities"
o LLDF"variable,"there"has"not"been"a"clear"association."You"would"assume"that"an"individual"on"the"long"side"might"
be"more"prone"to"development"of"a"medial"syndrome,"this"is"not"necessarily"true."
o Equinus"
o Female&athletes&are&at&riskF"diet,"amenorrhea,"and"osteoporosis."Prevalence"of"amenorrhea"in"young"female"
athletes"is"very"high"and"the"hormonal"changes"related"to"that"have"a"direct"effect"on"bone"mass."These"patients"
need"a"far"more"intensive"review"of"the"pathology"than"their"male"counterparts.""
st
o 1 "MPJ"ROM"NOT"associatedF"****Q*****MSS&is&generated&very&early&in&stance&phase,&and&hallux&ROM&is&a&late&
occurring&event,"medial"stress"syndrome"at"the"early"¼"of"the"stance"phase"compared"to"first"MPJ."Posterior"tibial"
tendon"(driver"of"medial"stress"syndromes)"acts"at"heel"contact"to"decelerate"internal"tibial"rotation."This"makes"
sense"that"this"is"a"very"early"event"in"stance.""
o Marrow"abnormalitiesF"patients"have"marrow"edema"on"MRI.""
o Pronation&of&the&foot&is&linked,&but&earlyJ&critically&early,&<50ms&of&contact.&&
o So"this"is"an"area"that"can"be"affected"by"the"use"of"FFOs."&
• Missing"etiologic"factorF"Training"error!!"
o Duration"of"sporting"activities/habits"linked"to"prospective"development"of"the"conditions"in"runners."F"Longer"
period"of"time"is"more"likely"to"develop"these"syndromes.""
o Paradoxically,&use&of&orthotics&positively&correlated&to&the&development&of&the&condition."
! Orthotics"don’t"“cause”"but"perhaps"individuals"who"had"this"clinically"diagnosis"had"already"been"fitted"
for"an"orthoses"for"one"reason"or"another.""
• Assessments"and"differentials:"
o Trace"and"track"the"area"of"symptoms"overlying"the"tibia"(Manual"palpation).""
o You"can"stress&the&PT&tendon,"you"can"isolate"the"tendon"easily,"may"recreate"symptomatology"by"having"an"
individual"stress"the"limb"as"you"would"in"an"AAFFDF"single"and"double"heel"raise.""
o Specific"history"that"you"take"will"lead"you"to"rule"in"/out"the"possibility"of"compartment"syndromeF"different"than"
compartment"syndrome"associated"with"traumaF"this"is"an"emergency"because"it"is"an"event"that"results"from"
engorgement"of"a"muscular"compartment"and"you"can"carry"out"fasciotomies"in"order"to"decompress"the"
compartments"and"prevent"neurovascular"damage."The"compartment"syndrome"that"we"are"talking"about"now"is"
much"different"than"thatF"This"particular"presentation"involves"an"athlete"whose"medial"leg"symptoms"correlate"to"
specific"intervals"of"trainingF"these"individuals"walk"around"with"normal"neurovascular"tone"90%"of"the"time,"but"
when"they"go"to"run"they"are"developing"the"symptoms"of"compartment"syndrome,"and"there"are"instances"where"
fasciotomies"have"had"to"be"performed"in"order"for"these"athletes"to"function"pain"free.""
o Mary"DeckerF"dominant"middle"distance"runner"that"suffered"from"compartment"syndromes"and"had"fasciotomies"
that"can"be"performed"percutaneouslyF"very"different"from"the"fasciotomies"that"patients"will"undergo"when"they"
have"compartment"syndrome"due"to"trauma."""
o How"to"distinguish"MSS"from"stress"fractureF"CT"scan"is"the"gold"standard."MRI?"MR"often"does"not"successfully"
distinguish"a"stress"fractureF"will"show"you"periostitis"but"fail"to"give"you"the"definition"that"you"need"to"rule"out"
stress"fracture.""
! RadiographF"Invasive"tumor"of"the"tibia,"US"
o Technitium"scanF"brightness"along"the"medial"anterior"aspect"of"the"tibia.""
• LoudonJ"Use&of&foot&orthoses&and&calf&stretching&for&individuals&with&medial&tibial&stress&syndrome:&With"an"orthosis,"you"
are"not"doing"the"wrong"thing."Theraband"has"a"place"for"rehabilitating"the"posterior"medial"musculature."Subjective"
improvement"of">50%"with"a"visual"analog"scale"is"not"altogether"definitive."
• Rx:"
o Correct"postingF"high"varus?"
o Inverted"limb"mechanicsF"inverted"cast"techniques"
! What"happens"to"the"gait"as"an"individual’s"velocity"increases?"Increased"velocity"increased"varus"attitude"
of"the"limb"(Richard"BlakeF"“limb"varus”)F"an"angle"drawn"between"the"hip"joint"and"the"point"of"contact"
of"the"foot."You"can"recognize"that"limb"varus"will"increase"and"the"BOG"will"become"negative"(the"right"
foot"striking"on"the"other"side"of"the"line"of"progression)"patients"will"develop"high"angles"of"varus"contact"
if"they"are"still"contacting"at"their"heel."This"led"him"to"develop"a"whole"paradigm"around"inverted"positive"
cast"manipulation."Rich"Blake’s"casts"were"often"inverted"25,"35,"40"degrees,"and"the"orthotic"was"made"
over"that"modified"position"to"try"to"capture"or"counter"the"effect"of"limb"varus."A"traditional"orthotic"is"
made"encompassing"the"features"and"the"motion"of"the"STJ"as"it"exists,"STJ"motion,"in"terms"of"eversion"is"
probably"in"single"digits"for"most"patients,"so"a"FFO"that"is"designed"to"restrict"motion"by"4F8"degrees"of"
motion"cannot"hope"to"overcome"a"limb"varus"that"will"require"compensation"that"may"be"as"high"as"20F
30"degrees."The"whole"concept"of"inverted"casting"and"inverted"foot"orthoses"was"developed"around"that"
perceived"inability"to"correct"alignment.""
o Adequate"heel"control"
o FF&postingF"if"applicableF"part"of"the"discussion"on"athletes"at"higher"speeds"who"are"going"to"run"on"the"FF"or"
midfoot"in"terms"of"strikingF"anything"that"you"try"to"build"into"the"hindfoot"will"be"ineffective"because"that"part"of"
the"foot"has"been"redacted"from"the"gait"cycle.""
! Higher"speed,"naturally"more"on"the"FF,"anything"on"the"hindfoot"will"be"ineffective."The"only"opportunity"
that"you"may"have"to"intervene"with"these"individuals"will"need"a"forefoot"post."May"need">1"foot"
orthosis,"one"for"long"distance"training"where"they"do"have"a"significant"RF"gait"pattern"on"one"that"will"be"
utilized"during"high"intensity,"high"velocity"training.""
o RememberJ&may&be&a&FF&strikerJ&then&what?&
! Individuals"running"at"high"speeds"don’t"have"a"normal"heel"strike"component"to"their"running"gait."Some"
would"actually"advocate"for"that"through"barefoot"running"technique"or"barefoot"running"shoes,"these"
individuals"may"be"at"less"risk"for"medial"stress"syndrome"because"the"motion"of"the"hindfoot"is"
essentially"deleted"from"the"running"gait."If"you"advance"the"pace"of"the"runner,"if"you"advance"the"footF
plant"from"the"heel"to"the"midfoot,"to"the"forefoot,"you"are"going"to"put"the"runner"on"the"ground"for"
shorter"periods"of"time"and"you"are"going"to"uncouple"the"STJ"from"the"pathomechanics"of"the"problem,"
at"least"theoretically.""
• Management:"
o RICEF"nutritional"factors"
o NSAID"
o Injection??F"probably"no"harm"to"be"created"by"the"injection"of"a"phosphate"steroid"into"the"posterior"tibial"muscle"
compartment"or"along"the"periosteum"of"the"tibia."
o Functional"analysis"FFO+"shoes?""
o NWB"training"
o Kinesio"taping:"originated"in"the"70s"by"a"Japanese"chiropractor,"advocated"to"be"a"way"of"facilitating"the"action"of"
muscles."It"is"not"taping"that"you"would"traditionally"do"that"is"meant"to"restrict"motion."It"is"applied"with"little"
tension"and"it"is"meant"to"increase"proprioception."The"makers"say"that"the"tape"lifts"the"skin"off"of"the"muscle"
belly"and"allows"for"more"increased"lymphatic"draining"and"reduction"of"inflammation."Dr,"Eckles"could"find"no"
literature"that"supports"that,"but"that"doesn’t"mean"that"it"is"worthless:"
! Unique"because:"100%"cotton"with"an"acrylic"adhesive,"doesn’t"have"a"traditional"gum/resin"adhesive,"and"
it"can"stretch"130%"of"its"length,"it"is"possible"to"put"this"tape"on"starting"at"the"plantar"medial"heel"and"
bring"it"up"over"the"malleolus"and"have"different"segments"of"tension"in"it."You"can"tack"it"down"to"the"
plantar"foot"and"maximally"stretch"it"around"the"heel"and"tack"it"down"inferior"to"the"malleolus,"so"you"
 have"a"zone"of"high"tension"round"the"heel,"then"you"can"come"above"the"malleolus"and"again"stretch"that"
tape"and"tack"it"down"with"no"tendon"proximally."
o TherabandF"the"colors"reflect"resistance"to"stretch,"good"modality"for"rehabilitation"of"muscle"groupsF"
evert/invert/PF/DF.""
o Cold"laser/ECSWTF"may"be"an"option"

Posterior"Tibial"Tendon"Dysfunction"and"AAFF"

• Assumptions"we"make:"not"necessarily"valid"
o PTTD"is"the"leading"cause"of"AAFF"
o The"PTT"is"a"supinator"of"the"footF"not"true!"It"is"a"decelerator"of"internal"tibial"rotation"
o Failure"of"the"PTT"is"the"primary"cause"of"postural"changeF"may"not"be"true,"the"ligaments"around"the"hindfoot"
may"be"far"more"important."""
o The"treatment"of"PTT"should"be"aggressive.""
• How"do"we"define"PTTD?""
o Defined"by"at"least"five"things:"Rupture,"Attenuation,"Gait"abnormality,"Inflammation,"and"pain.""
o There"are"at"least"two"classification"schemes,"are"they"important?""
! Johnson"and"Strom:"1989."Originally"were"only"3"stages."
• I:"Pain,"tenderness"in"the"area"of"the"PT"tendon"without"postural"changeF"no"asymmetry"(no"talar"
bulge,"too"many"toes"sign,"etc.)."Often"occult"defect"at"this"stage."
• II:"Elongation"and"disruption"of"the"PTT,"deltoid,"and"spring"ligament"complex;"postural"
asymmetry"present."
• III:"All"of"the"above"plus"rigid"hindfoot"deformityF"heel"stays"in"valgus."
• IV:"All"of"the"above"plus"valgus"ankle"and"DJD.""
! Radiographic"evaluation"of"these"patients:"Hindfoot"alignment"views"
• Allows"you"to"determine"where"the"axis"of"the"rotational"pathology"is,"the"more"proximal"the"
axis,"the"more"proximal"your"therapy"has"to"be.""
! Mueller"classification:"
• I."Direct"injury,"laceration,"trauma"
• II:"Pathological"rupture"secondary"to"coFmorbid"condition"(corticosteroids,"etc.)"
• III:"Idiopathic"
• IV:"FunctionalF"Abnormal"biomechanical"causes"or"malFinsertion"of"the"PTTF"most"of"the"patients.""
• Who"is"at"risk?"Roger"MannF"studied"epidemiology"
o Obese"and"sedentary"individualsF"high"percentage"female,"50F60"
o PreFexisting"flexible"flatfoot"
o CoFmorbiditiesF"RA,"DM,"HTN"
! DMF"not"only"have"high"BMI"and"are"of"this"age"range,"most"of"them"have"glycosylation"of"tissue"that"
makes"them"more"likely"to"develop"equinus"and"more"susceptible"to"attenuation"and"rupture."""
o Basically"most"of"the"people"in"our"waiting"rooms""
• Implications"of"Loss:"
o Wacker,"Jeurget"et"al.F"MR"Morphomety"of"Posterior"Tibialis"Muscle"
! Effect"on"the"muscle"belly"of"AAFF:"You"would"suspect"that"if"you"denervate"a"muscle,"that"that"muscle"
would"rapidly"go"through"atrophy,"but"interestingly"from"this"study"in"2003,"almost"total"replacement"of"
the"PT"muscle"compartment"with"fat"in"individuals"who"had"a"rupture"of"the"PTT."""
! “All"patients"had"atrophy"of"the"PT"muscle"compared"to"the"normal"leg…"in"those"patients"with"a"
complete"rupture"of"the"PTT,"there"was"replacement"of"PT"muscle"by"fat.”"
! Reversibility"of"this"could"be"argued."
! This"pathology"is"far"more"complex"and"therefore"the"rehabilitation"should"be"equally"dynamic"and"should"
involve"the"muscle"belly."
• Counterpoint:"Why"it’s"not"just"the"PTT:"
o Chu,"Myerson"et"al.:"Sectioning"the"PTT"alone"is"not&sufficient&to&cause&flatfoot"
 ! Cadaver"studyF"cut"the"PTT"and"loaded"the"foot"with"the"intention"of"creating"the"model"flatfoot."The"
flatfoot"could"not"be"created"unless"other"structures"were"severed.""
o Yeaps,"et"al:"Patients"who"had"undergone"transfer"of"the"PTT"and"had"intact"peroneals"did"NOT"develop"flat"foot.""
! PTT"transferred"to"the"other"side"of"the"foot:"patients"did"NOT"develop"flatfoot"when"all"other"structures"
besides"the"PTT"were"intact.""
o Jahss:"Nearly"100%"of"patients"in"series"had"preFexisting"flatfoot""
• InFshoe"orthoses"for"AAFF:"
o Correlates"with"stage"IF"your"mission"is"to"prevent"patients"from"progressing"to"stage"II"utilizing"a"foot"orthosis.""
o No"good"role"in"stage"II"PTT"or"AAFF"disordersF"postural"changes"have"already"occurred,"attenuation"of"the"tendon"
is"already"happened,"disruption"of"the"deltoid"has"probably"already"occurredF"no"value.""
! Possibly"a"UCLB"or"a"device"with"flanges.""
o If"you"are"going"to"make"a"device"for"an"individual"at"stage"I:"
! Correct"casting:"reduction"of"supinatus"
! Mitigate"equinus"
! Close"contourF"placement"
! Correct"posting"
! Medial/Lateral"Flanges"
! "Kirby"skiveF"deep"heel"cup"
! Inverted"cast"techniqueF"maybe"ten"degree"total"varus"to"the"prescription"
! Material"selectionF"compatible"with"height"and"weight"(overweight"patients)"
o Medial"sweet"spot"aka"Medial"Navicular"flap"
! Affect"a"reFdirection"of"the"force"from"the"plantar&surface&to&the&medial&surface"of"the"foot"
o Kirby"Skive:"Positive"Cast"Modification"
! Permits:"
• Medial"force"against"the"calcaneus"by"compressing"the"fat"pad"
• Requires:"a"deep"enough"heel"cup"so"that"fat"pad"impingement"is"not"an"issue">20mm"
• Don’t"want"the"calcaneal"fat"pad"to"overflow"the"heel"cup"of"the"orthotic"and"pinch"the"skin"
o Reduction"of"FF"Supinatus"
! A"Critical"issue"is"stage"IFII"deformities"
• As"you"move"from"stage"I"to"stage"II"the"hindfoot"everts"and"you"will"develop"FF"supinatus"
! The"first"ray"may"be"PF"via"direct"dorsal"to"plantar"pressure"or"through"hallux"dorsiflexion"
o Essentials"of"posting:"
! Function:"Change"functional"position"of"the"STJ"axis."Prevents"compensatory"rearfoot"motion."
! Should"correspond"to"known"hindfoot"position."
! Must"not"attempt"overFcorrection."
! Forefoot"posting"is"not"a"substitute"for"failing"to"control"the"rearfootF"UNLESSF"forefoot"varus"exists"of"if"
the"PTT"pathology"is"related"to"FF"strike"issues"in"athletes."
o Flanges:""
! Function"of:"
• Medial"flangeF"inhibit"ADDUCTION"
o Not"a"huge"flange"of"medial"flanges"because"any"time"you"increase"pressure"under"the"
medial"longitudinal"arch"the"you"have"the"possibility"of"the"patient"sliding"off"the"
orthotic"
• Lateral"flangeF"inhibit"“pronation"of…”"via"ABDUCTION"
! Caution:"minimize"use"of"flangesFespecially"medial,"in"the"presence"of"high"rearfoot"posting"angles."""
o Inverted"Cast"technique:"aka"Blake"orthosis"
! Limited"indications"
! Compliance"issuesF"footwear"
! Adverse"effects"
• Successful"use"of"a"foot"orthosis"balances"compliance"issues,"symptomatic"relief,"and"the"
necessity"to"halt"progression"of"the"deformity."
 o Appropriate"time"for"AFO"therapy:"
! Failure"of"prior"therapy"
! Classification"warrantsF"stage"II"individuals"cannot"be"managed"by"FFOs.""
! Poor"surgical"candidate"""
• Why"foot"orthoses"fail:"Hintermann,"Sommer,"Nigg"
o PhysicsF"Mechanical"disconnect"between"the"foot"and"leg"develops"if"the"deltoid"ligament"is"severed"
o Stage"II"PTTD"involves"attenuation"of"the"deltoid"ligament"as"well"as"the"TC"ligament."
• Prescription"Pedorthic"modifications:"
o "Medial"buttressing"increases"leverage"against"the"deformity""
• Are"AFOs"worth"the"effort?"
o Chao"et."Al"
o 67%"of"patients"using"AFO"devices"reported"foodFexcellent"results"
o Selection"of"patients"critical"factorF"elderly,"nonFoperable,"sendentary"
o Pitfalls"of"AFO"therapy:"
! Failure"to"adequately"educate"patient:"
• Duration"of"therapyF"this"is"it!"They"are"not"getting"better."Abandoning"hope"of"rehabilitation.""
• Consistency"of"use"
• Footwear"requirements"
! Failure"to"mitigate"equinus"
• Heel"liftF"surgery"
! Loss"of"sagittal"plane"mobility"
• Conclusions:"
o Look"for"early"signs"of"lossF"remember"what"is"lost"is"not"easily"recovered"
o Be"aggressiveF"prevent"progression"from"stage"I"
o Educate"your"patient"
o Make"clinical"choices"both"you"and"the"patient"can"live"with"
o Don’t"rule"out"surgical"reconstructionF"gait"and"symptomatic"outcomes"have"been"proven"to"be"excellent.""

Biomechanics"and"Diabetes""

• Side"note:"articles"sent"about"treating"anterior"compartment"syndrome"by"modifying"running"gait"from"heel"to"toe,"to"
midfoot"to"toe,"resulting"in"success"in"their"small"study"of"patients"without"having"to"resort"to"fasciotomies.""
• Other&article:&management&of&knee&OA&by&FFOsJ&recent&evaluation&of&valgus&heel&wedging&for&the&management&of&medial&
compartment&knee&OA."It"represents"a"quandary"for"us"because"you"would"not"want"to"valgus"post"a"foot"orthosisF"this"is"
counterintuitive,"unless"the"hindfoot"is"in"rigid"valgus"for"some"other"reason"(coalition,"traumatic"arthritis),"there"is"little"
indication"for"doing"that,"and"yet"this"data"actually"supports"this"as"a"methodology"for"managing"medial"knee"OA."Maybe"it"
is"a"question"is"which"hurts"the"patient"more,"if"the"person"is"not"necessarily"a"patient"for"knee"replacement,"maybe"this"is"a"
reasonable"strategy"for"you"to"employ."Simply&the&action&of&the&valgus&wedge&on&the&hindfoot&causes&the&tibia&to&evert,&
and&that&unloads&or&decompresses&the&medial&compartment&of&the&knee.&We"tend"to"think"that"we"should"always"correct"
the"pronated"foot,"but"if"you"take"a"grandmother"with"mild"to"moderate"foot"pain,"this"patient"may"also"have"mild"to"
moderate"knee"pain."If"you"induce"a"varus"force"on"the"limb,"you"may"actually"compress"the"medial"knee"more"than"it"was"
and"induce"symptoms"in"this"age"group,"in"these"susceptible"people"who"will"not"at"all"be"happy"that"you"did"that."&

Geriatric&MedicineJ&Metabolic&syndrome&(Obesity,&Hyperlipidemia,&HTN,&DM)&

• 44%"of"patients"are">50"y/o&
• The&Diabetic&Foot:&the&goal&is&to&prevent&amputations&
o To"prevent"amputations,"we"must"prevent"ulceration."Ulcerations"are"never"accidents."You"should"be"able"to"look"
at"every"foot"and"evaluate"risk"for"ulceration"based"on"position"of"the"FF,"ankle"joint"ROM,"mobility"of"the"first"ray,"
etc."Even"Charcot"changes"in"the"diabetic"foot"are"never"randomF"people"ulcerate"where"you"expect"them"to"
ulcerate.""&
• OffloadingF"varieties"
 o TCC"
o CROW"walkers"
o Darco"shoeF"Company"started"by"Darryl"Darby"(podiatrist"in"west"VA),"first"person"to"make"a"postFop"shoe"that"
wasn’t"wooden."Cut"out"either"the"forefoot"or"the"RF."The"problem"is"that"it"is"unstable"and"people"tend"to"rock"on"
it"and"crash"into"the"forefoot.""
• TCC&is&the&gold&standard&in&managing&woundsF"redistributes"the"GRF"up"onto"the"calf,"clearly"wins"in"terms"of"number"of"
days"it"takes"to"heal"a"wound."Have"to"be"changed"frequently,"are"difficult"to"do,"have"to"be"screened"(ABI,"edema),"it"is"a"
very"intensive"process.""
o –Armstrong:"evaluated"use"of"CAM"walkers"versus"TCC"in"patients"utilizing"pedometersF"found"that"patients"were"
taking"the"CAM"walkers"off.""
o Now"he"puts"the"CAM"walkers"on"and"wraps"them"in"fiberglass"casting"tape"so"they"can’t"take"it"off.""
• Remember:"“It’s"not"what"you"put"on"wounds"it’s"what"you"take"off"wounds.”""(Armstrong)"
o “Taking"off"from"wounds”"does"not"mean"just"pressure"reduction"from"a"device"
! Aggressive"debridement"
! Surgical"excision"of"boney"prominences"
! Gait/COP"modifications"
! Patients"are"going"to"bleed"and"measure"much"larger"postFdebridement.""
! Have"to"be"clear"with"the"patients!"(Have"them"sign"consent?)"
• The&Effect&of&Callus&Removal&on&Dynamic&Plantar&foot&pressures&in&Diabetic&Patients:&
o Young,"Cavanaugh&
o “Seventeen"diabetic"patients"had"dynamic"foot"pressure"measurements"made"before"and"after"the"removal"of"a"
total"of"43"FF"plantar"callosities."Peak"pressures"(mean"+/F"SE)"in"the"treated"areas"were"reduced"by"36%"from"14.2"
+/F"1.0"to"10.3"+/F"0.9"cmF2"(p<0.0001),"with"reductions"at"37"of"43"sites"and"in"all"patients.”"
! Removing"a"callus"is"one"of"the"most"effective"things"you"can"do"for"a"patient,"not"just"in"diabetic"patients.""
! This"is"limb"saving!"
• The"ground"must"push"up"against"the"foot"with"body"weight"force:"
o As"beings"that"interact"with"the"ground"under"the"force"of"gravity,"there"is"nothing"that"we"can"do"to"totally"offload"
a"limb,"if"you"weigh"200"lbs,"you"are"going"to"exert"200"lbs"of"force"against"the"ground"and"the"ground"will"exert"
200"lbs"of"force"against"you."There"is"no"magic"about"getting"rid"of"pressure,"we"can"only"do"two"things"with"force"
and"pressure:"
! Spread"it"outF"i.e."TCC"
! Move"weight"from"high"pressure"areas"to"low"pressure"areas:"
• Do"this"with"materials"that"are"complaint"and"are"moldable,"and"do"this"with"specific"designs."We"
can"accommodate"areas"of"peak"pressure"with"care.""
• “Foot"pressures"6"kg/cm2"were"considered"to"be"indicative"of"patients"at"high"risk"for"foot"
ulceration.”"–Armstrong"
o This"is"really"variable,"patients"who"are"dysvascular,"neuropathic,"obese,"have"fat"pad"
atrophy,"all"these"variables"will"change"whether"or"not"that"number"is"real"for"them.""
! Side"note:"CushioningF"changes"the"amount"of"time"over"which"the"force"is"applied"to"the"limb."Not"less"
force,"the"force"is"just"applied"to"the"limb"over"more"time"so"that"the"net"effect"is"the"perception"is"less"
force"(less"force"per"time"interval"in"terms"of"ulcer"formation"that"may"be"meaningful)."Cushioning"doesn’t"
change"the"amount"of"force"that"reacts"with"the"skeleton.""
• If"the"back"of"the"shoe"is"more"posterior"than"the"heel,"you"are"exerting"a"force"on"the"ankle"joint"
from"a"lever"arm"that"goes"posterior,"the"shoe"can"cause"anterior"compartment"syndrome,"
because"the"people"go"to"heel"strike"and"they"have"a"buttress"sticking"out"posteriorly,"and"it"
causes"the"foot"to"slap."Similarly,"back"in"the"70s,"Nike"wanted"to"make"their"shoes"really"wide"
(LD100)"which"actually"induced"a"pronatory"torque"on"heel"contact.""
• If"we"had"no"soft"tissues,"our"body"weight"would"be"concentrated"on"very"small"areas"of"bone."We"rely"tremendously"on"the"
density,"compliance,"and"the"resilience"of"the"soft"tissues"in"order"to"bear"weight.""
• Cutouts&in&and&insole/shoe:&Beware&of&the&edge&effect&
 o The"edge"effect:"Physical"mechanical"result"of"unloading"an"area"in"a"way"that"results"in"a"zone"of"increased"
pressure"at"the"margin.""
o Have"to"be"careful"when"utilizing"padding"for"offloading"that"you"are"not"going"to"produce"more"pressureF"skive!"
o Cutouts"in"the"insole"may"abnormally"increase"pressure"elsewhereF"for"example,"if"the"plastizote"insole"has"not"
been"molded"to"the"shape"of"the"arch,"there"is"no"pressure"under"the"central"metatarsals,"and"all"of"the"pressure"is"
on"the"first"and"fifth.""
o The"ideal"prevention"is"a"full"contact"device:"
! Rigid"material"that"can"push"upward"with"very"little"deformationF"needs"structural"stability.""
! Soft"covering"to"replace"any"soft"tissue"loss"
! ****&What&is&the&idea&total&contact&device?&A&hybrid****&
• Other"results"of"collagen"glycosylation"
o Decreased"ROM"of"all"joints"
o When"you"are"utilizing"devices"or"surgical"techniques,"physical"principles"always"apply,"and"force"applied"medial"to"
the"STJ"axis"will"create"supination,"and"force"applied"lateral"to"the"STJ"will"create"a"pronatory"force."
o This"is"important"to"us"when"we"look"at"patients"who"have"sustained"loss"through"amputation.""
o Post"status"first"ray"amputationF"creates"a"loss"of"inversion"moment"on"the"limb,"foot"is"pronated"due"to"loss"of"the"
principle"medial"weight"bearing"structure.""
o Patients"who"lose"their"first"ray"also"have"risk"for"flexion"deformity,"lesser"toes"start"to"claw"in"order"to"gain"
purchase.""
o TMAF"interesting"because"of"shear"force:"
! With"ambulation,"the"anterior"aspect"of"the"stump"is"subject"to"shear"forces"as"they"walk."This"creates"a"
potential"for"reFwounding.""
o Without"a"fifth"metatarsal"the"patient"loses"a"major"pronation"torque"on"the"rearfootF"supinated"foot."Risk"to"the"
fourth"metatarsal.""
• Practical"considerations"in"Orthosis"construction"for"diabetic"patients:"
o Consider"the"possibility"that"the"diabetic"patient"is"normal"in"most"respects"
! The"presence"of"diabetes"foes"not"necessarily"change"their"orthopedic"needs."
o Itemize"your"needs:"
! Accommodation"
! Functional"control"
! Protection"(neuropathic"states)"
o Consider"hybrid"devices:"
! Maintain"links"between"your"orthopedic"therapy"and"the"relevant"internal"medicine"
! And"don’t"neglect"2"critical"components"of"success:"
• The"shoe"
• Patient"compliance"
• Diabetes"and"Adult"Acquired"Flatfoot"
o AAFF"and"mechanical"consequences"of"diabetes"are"there"even"if"you"don’t"see"them.""
o A"triad"of"pathology:"
! Dysfunctional"gait"
! Sedentary"lifestyle"
! Failure"of"glycemic"control"
o Reduced"lifestyle/longevity"expectations"
• Epidemiology:"
o Holmes"and"Mann:"Possible&Epidemiological&Factors&Associated&with&Rupture&of&the&PTT"
! 52%"had"either"HTN,"DM,"or"obesity"
! The"prevalence"parallels"the"degenerative"process"of"aging,"HTN,"DM,"and"obesity.""
• Substrate"Pathology:"
o Grant:"Electron&Microscopic&Investigation&of&the&Effects&of&DM&on&the&Achilles&Tendon"
! Collagen"fibers"appear"twisted,"curved,"overlapping…"otherwise"highly"disorganized.""
! Changes"the"mechanical"functioning"of"the"limb"
 ! Structural"changes"contribute"to"the"tightening"of"the"Achilles"tendon"
! Tendon"shortening"causes"severe"equinus"and"may"precipitate"ulceration,"stress"fracture,"and"Charcot."
o Hsu,"TC,"et"al.:"Biomechanics&of&the&Hell&Pad&for&Type&II&DM&patients"
! Poor"unloading"(rebound"phenomena)"are"observed"in"compression"studies"
! Collagen"fibrils"were"ruptured,"uneven"distribution,"unclear"striation…""
• Attenuation"of"Motion:"
o Sukenik"et"all"in"1987"
o Glasoe"et"al"in"2004"
! Were"able"to"show"joint"ROM"uniformly"go"down"when"an"individual"has"DM.""
! Around"40%"
! No"doubt"that"this"exists"
• Neuropathic"Dysfunction:"relationship"to"changes"in"gait"
o Kwon,"OY,"et"al.:"Comparison&of&Muscle&Activity&During&Walking&in&Subjects&with&and&without&diabetic&
neuropathy"
! We"tend"to"think"that"people"with"DM"just"become"neuropathicF"but"they"also"stop"walking"“normally”"
! Less&ankle&mobility,&slower&walking&speeds,&longer&stance&phases,&more&overlap&in&double&support,&tend&
to&abandon&SS&phase&gait.&
! Muscles"fire"longer"during"stance:"Onset"times"to"heel"strike"for"soleus,"medial"gastro"and"medial"
hamstring"were"significantly"earlier"during"the"gait"cycle"versus"control"subjectsF"cessation&times&
significantly&prolonged.&
! CoJcontractions:&Antagonists"and"agonists"that"coFfire"at"the"same"time"in"people"with"DM"to"create"
stable"and"safer"gait?"We"don’t"know.&
o Arvanitakis,"et"al.:"DM&and&Progression&of&Rigidity&and&Gait&Distrubances&in&Older&Persons&
! For"up"to"9"years,"participants"had"uniform"annual"evaluations;"diabetes"was"associated"with"worsening"
rigidity"and"gait"disturbance."&
! Diabetes"may"be"a"previously"unrecognized"risk"factor"for"progression"of"ParkinsonianJlike"signs"in"older"
persons.""&
! Because"people"don’t"die"of"DM"anymore"thanks"to"medications,"these"people"live"long"enough"that"we"
may"start"to"see"CNS"changes"to"gait"that"are"similar"to"Parkinsonian"changes."&
• Opportunity:&
o Studies"show"that"in"nonFdieting,"overweight"subjects,"a"higher"amount"of"activity"is"necessary"for"weight"
maintenance."The"positive"caloric"imbalance"in"the"control"group"can"be"reserved"with"a"modest"amount"of"
exercise,"most"accomplish"this"with"30"minutes"per"day"of"walking."&
o Main"idea:"Diabetics"that"participate"in"walking"programs"do"NOT"ulcerate"as"often"as"their"sedentary"
counterparts."Our"job"to"encourage"activity"and"walking"in"patients."&
o Low"fitness"obese"men"had"a"5.6"fold"higher"risk"of"death"than"the"reference"group."&
o Patients"who"walked"130"minutes"a"week"(not"even"30"minutes"per"day)"were"considered"moderately"fit."&

Biomechanics"of"flatfoot"surgery:"

• Hiller"and"Pinney"(Foot"and"Ankle"International,"2003)"
o 97%&would&utilize&a&bony&procedure&
o 80%"would"preserve"the"STJ"and"TN"jointsF"would"not"destroy"the"joints.""
o 73%"would"medialize"the"Calcaneus"
o 41%"would"lengthen"the"lateral"column"(Evans)"
o 98%&would&add&a&soft&tissue&procedureJ&i.e.&tendoachilles&lengthening,&gastroc&resection,&capsulotomy.&&
o In"the"community"of"foot"and"ankle"surgeons,"there"appears"to"be"a"fairly"evidence"based"approach"to"doing"these"
types"of"procedures.""
• Surgery"is"Biomechanics"
o Joint"axes"are"modified"by"all"positional"changes"effected"by"surgery"
! We"can"decompress"joints,"change"the"functions"of"intrinsic"and"extrinsic"muscles"significantly"
 ! For"example,"if"we"perform"a"fusion"of"the"medial"column"at"the"CN"or"the"NC"joint,"and"if"we"PF"the"first"
metatarsal,"we"are"going"to"affect"the"action"and"the"forces"around"the"first"MPJ.""
o Angular"deformities"causing"compensation"can"be"mitigated"by"surgery"
o Action"of"muscles"and"tendons"are"affected"by"surgery"
o ReFpositioning"of"structures"affects"intrinsic"compressive"and"tensile"forces"
• Why"invest"the"surgical"decision"with"biomechanics?"Not"every"flat"foot"is"the"same.""
o Correct"understanding"of"the"true"anatomical"pathology"
o Correct"understanding"of"the"WB"analysis"of"the"anatomyF"fundamental!""
o Application"of"the"correct"procedureF"in"terms"of"anatomy"and"function"
! More"aggressive,"more"conservative?""
o Understand"sequellae"of"procedures"and"need"for"aftercareF"post"op"needs"(shoes,"foot"orthosis,"AFO,"etc.?)"What"
is"the"durability"of"the"procedure?"
• Indications"for"FF"surgeryF"revolve"around"symptomatology!"
o Predictive"postural"signsF"symptomatology"
! Abnormal"pronation"
! Symptomatology"
! Predictive"postural"signs"
! These"all"may"be"mediated"by"surgery"
o We&don’t&treat:&
! Pes&planus&
! Flat&feet&
! Valgus&feet&
o Remember"that"not"all"flat"feet"are"pronated,"all"require"careful"analysis"and"etiology."Pronation"implies"a"triplanar"
motion,"so"a"pronated"foot"implies"that"it"has"gone"through"all"of"these"motions"to"get"to"where"it"is.""
• What"do"you"see?"
o MTJ"collapse,"talar"bulge"
o Lateral&extrusion&of&the&fat&padJ&the"calcaneus"may"not"necessarily"be"in"valgus"even"though"it"is"maximally"
pronated."&
• Inversion"of"the"FF"on"the"RF"produces"Eversion"of"Pronation"of"the"rearfoot…a"1:1&compensation&response!"
o Deformities"in"the"forefoot"are"directly"transferable"to"the"hindfoot"
• Eversion"of"the"FF"on"the"rearfoot"produces"Inversion"or"Supination"to"the"hindfoot.""
o The"very"mobile"flexible"FF"mobile,"PF"first"ray"is"not"represented"by"this"slide"at"all,"that"compensatory"motion"is"
that"the"first"ray"motion"mitigates"the"position"you"may"have"a"functional"FF"varus"when"on"clinical"evaluation"you"
would"agree"that"the"patient"actually"has"a"FF"valgus.""
• FF"varusF"see"only"when:"
o Subtalar&jointJneutral&
o Midtarsal&jointJ&fully&pronated&
o Some"people"think"that"it"doesn’t"exist."–"seen"when"the"STJ"is"in"neutral"the"MTJ"is"fully"pronated"AND"when"the"
medial"column"resists"your"manipulation"to"bring"it"to"the"groundF"there"is"pressure"dorsally"on"the"medial"column"
trying"to"bring"it"down"to"the"floor"but"it"cannot."–"FF"supinatus"looks"the"same"but"is"able"to"be"reduced"with"
dorsal"pressure"to"the"medial"column.""
o If"you"fail"to"reduce"the"FF"supinatus"of"the"patient"when"casting"for"an"orthotic:"It"will"be"a"lower"arch"compared"
to"the"one"that"would"have"been"correctly"taken"when"you"PF"the"first"metatarsal"during"the"casting"processF"in"FF"
supinatus,"you"can’t"do"that."If"you"make"an"orthotic"with"a"cast"in"the"absence"of"this"correction"you"will"give"the"
patient"an"orthotic"that"has"a"lower"arch"contour"than"the"patient"actually"has,"and"secondly,"because"it"was"made"
over"this"varus"profile,"the"lab"would"have"corrected"this"and"produced"a"device"that"has"an"extrinsic"and"intrinsic"
FF"varus"post"on"it."This"orthotic"may"cause"first"MPJ"arthrosis"and"hallux"limitus"because"you"are"artificially"
elevating"the"first"metatarsal"and"preventing"the"hallux"from"DF"on"the"on"the"metatarsal"and"not"allowing"the"first"
metatarsal"to"PFF"it"will"give"them"pain"in"the"big"toe"joint.""
o Number&one&casting&error&that&is&generated&is&a&supinated&longitudinal&MTJ&axisF"casts"will"come"into"the"labs"
with"varus"deformities"of"the"FF"which"don’t"exist.""
• Inverted&FF&deformities&that&we&can&ID:&
o FF&varus&
o FF&supinatus&
o PF&cuboid&
o Metatarsus&primus&elevatus&
o RF&varus&–&may"exist"in"such"high"dimension"that"the"FF"simply"cannot"evert"to"the"ground,"that"functionally"the"FF"
is"unable"to"meet"the"ground"on"the"medial"side.""
• Where"does"the"FF"invert?"Matters"for"surgical"treatmentF""do"you"PF"the"medial"column"at"the"head"of"the"metatarsal,"the"
MC"joint"(Lapidus),"or"more"proximally?""
o The"3"cuneiformFnavicular"joints"can"rotate"to"invert"the"FF"against"the"RF"
o The"first"CNJ"can"invert"and"DF"to"move"the"first"metatarsal"up"to"the"level"of"the"second"metatarsal."This"is"where"
the"majority"of"first"ray"motion"occurs.""
• And"finally…"Contribution"of"the"lateral"column""
o There"is"an"etiology"of"lateral&column&declinatusF"not"to"be"confused"with"FF"varus."
o LCD"is"a"Pathology"which"originates"within"the"cuboid,"and"when"you"see"these"patients,"you"will"be"able"to"note"
that"you"can"isolate"the"fourth"and"fifth"rays"specifically"as"being"primarily"plantarflexed."Not"every"foot"with"this"
kind"of"bowed"lateral"arch"has"the"deformity,"but"it"is"one"of"the"telltale"signsJ&notch&of&the&cuboid"is"one"of"the"
indicators"that"you"are"dealing"with"a"foot"that"has"this"deformity.""
o These"deformities"like"the"Flexible"FF"valgus"may"be"negligible"and"nonFcontributory"towards"foot"posture"if"the"
ROM"that"exists"at"the"fourth"and"fifth"met"–cuboid"joints"is"sufficient"to"allow"the"columns"to"DF,"there"will"be"no"
or"little"net"effect"on"the"foot,"however"if"the"fourth"and"fifth"metatarsals"are"rigidly"PFed,"this"is"a"very"strong"
pronator"and"everter"of"the"foot.""
o Cuboid&osteotomyF"alternative"to"medial"fusion"or"transposition"procedures."
! Involves"removing"a"straight"wedge"(cylinder)"of"bone,"from"the"center"of"the"cuboid,"and"this"allows"for"
the"approximation"of"the"fourth"and"fifth"metatarsals"to"the"cuboidF"this"is"reduction"of"PF"by"shortening,"
which"is"a"very"significant"physical"principleF"if"you"want"to"reduce"the"effect"of"the"lever"arm,"shorten"it.""
! Not"commonly"done"on"the"East"coast.""
o Young’s&tenosuspensionF""
! This"is"a"good"example"or"surgical"technique"to"create"a"very"specific"anatomical"endpoint."This&is&a&very&
powerful&PF&of&the&first&metatarsal"
! This"study"in"particular""compares"the"post"op"outcomes"to"that"of"patients"who"had"tendoachilles"
lengthening"plus"Arthroereisis,"specifically"highlighting"the"fact"that"you&are&able&to&reduce&FF&supinatus&
to&a&much&greater&extent,&certainly&more&than&any&other&soft&tissue&procedure&that&is&out&there&
******Q******"
! Dragonetti:"Compares"TAL"and"Arthroereisis""
! Superior"FF"supinatus"reduction"
• Young"tenosuspension:"Results"
o Prevents"First"ray"DF"
o Does"not"prevent"long"axis"MTJ"supinationF"encourages"the"opposite"
o Precautions:"
! Careful"when"long"axis"in"patient"has"limited"ROM"
! Need"to"be"very"careful"to"understand"the"soft"tissue"corrections"of"FF"deformities"almost"always"require"
an"orthoses.""
! Ensure"adequate"EHL"strengthF"it"is"possible"to"PF"the"first"metatarsal"so"greatly,"that"you"may"create"a"
tendency"to"foot"drag"(the"hallux"won’t"clear"the"ground).""
• Medial"Column"Evaluation:"what"joints"move?"
o Evaluate"how"much"the"FF"can"invert"against"the"RF"at"
! The"LAMTJ"
! The"NC"joint"
! The"first"metFcuneiform"joint"
• The"Mechanical"effects"of"fusions:"these"are"irrevocable!""
 o Individual"or"combination"fusions"truly"produce"stability"IF"the"fused"joints"were"truly"the"sites"of"hypermobility"
preFoperatively."
o TN&fusion&prevents&LAMTJ&supinationJ&effectively&fuses&the&entire&LA,&may&even&effectively&fuse&the&entire&OA.&
The"independent"movement"of"the"CC"joint"is"very"modest."&
o Make"sure"FF"can"make"contact"with"the"ground"
o Obviously"are"irrevocable."Measure"twice,"cut"once!"
• First"MPJ"motion:"Tail"wagging"the"dog"
o Effect"of"functional"hallux"limitus"
o The"flatfoot"that"you"may"be"seeking"to"mediate"may"be"flat"because"of"the"presence"of"functional"hallux"limitus."
You"should"not"assume"that"just"because"the"symptoms"are"at"the"NCJ"or"the"TNJ,"that"that"is"where"the"problem"
begins"and"ends.""
o If"you"fuse"the"first"Met"cuneiform"joint"in"the"presence"of"functional"hallux"limitusF"this"may"lead"to"various"
adverse"effects.""
o Retrograde"force"acts"on"the"Medial"column:"patent"whose"compressive"forces"are"so"significant"that"they"
retrograde"back"to"create"a"rockerFbottom"foot.""
• STJ"Axis:""
o Runs"posterolateral"to"anteriorFmedial"
o ManterF"medial"side"of"the"first"ray,"KirbyF"Lateral"side"of"the"first"ray.""
o Have"to"find"where"the"axis"is!""
o Mapping"the"position"of"the"STJ"Axis:"Place"the"foot"in"what"you"believe"to"be"a"neutral"position."Start"from"the"
heel"and"using"two"thumbs"begin"to"exert"pressure"from"proximal"to"distal"with"your"thumb,"knowing"that"the"foot"
supinates"if"you"are"pushing"medial"to"the"STJ"axis,"and"the"foot"pronates"if"you"are"pushing"lateral"to"the"STJ"axis,"
so"you"are"trying"to"find"that"place"down"the"foot"where"your"continuous"thumb"pressure"results"in"neither"the"
supination"or"the"pronation"of"the"foot."(Kirby)."Put"dots"on"the"foot"as"you"go"to"map"the"functional"position"of"
the"STJ.""
• ****Q***Subluxed,&plantarflexed,&abducted&first&cuneiform&is&the&hallmark&of&a&patient&whose&STJ&axis&is&more&medial."
The&functional&effect&is&to&negate&the&action&of&the&peroneus&longus."
o The"peroneus"longus"cannot"act"on"the"medial"column"if"the"axis"is"too"far"medialF"the"lever"arm"is"too"far"and"
there"isn’t"enough"strength.""
• Recognition"of"the"STJ"axis"is"shown"in"the"development"of"the"Evans"procedure:"
o Load&on&the&medial&column&decreased&from&37%&BW&to&10%&BW.&&
o If"the"dominant"plane"of"the"deformity"is"the"TV&planeF"this"is"the"procedure."&
• Surgery"for"Subtalar"(Calcaneal)"Valgus:&
o Silver"procedure&
! Not"carried"out"anymore,"this"is"an"opening"wedge"of"the"Calcaneus"with"the"intention"of"creating"STJ"
varus."&
o Medializing"Calcaneal"OsteotomyF"posterior"aspect"of"the"Calcaneus&
• Triple"ArthrodesisF"indicated"when"there"are"multiplanar"deformities"coFexisting"with"significant,"destructive"OA"
o These"are"not"commonly"performed,"was"considered"to"be"the"top"of"the"ladder"of"reconstructive"procedures.""
o RF"Pell:"
! 183"Triple"arthrodesis"procedures:"Authors"noted"high"correlation"between"patient"satisfaction"and"
postoperative"foot"alignmentF"though"shall"not"varus!""
! 91%&of&patients&indicated&that&they&would&have&the&procedure&again.&
! Postoperative"ankle"arthritis"clinical"and"radiographic)"as"common"but"did"not"seem"to"affect"patient"
satisfaction"
o Hindfoot"alignment"view:"position"of"determining"where"the"lines"intersectF"identifying"the"CORA"
• Proximal"pathologies:"
o Center"of"rotational"angulationF"CORA"
o Patient"B,"even"though"the"patient"may"have"a"similar"set"of"symptoms,"has"an"altogether"different"kind"of"
deformity"than"patient"A"(with"a"different"CORA).""
o You"need"to"come"as"close"to"the"CORA"as"possible"when"doing"surgery.""
 o Same"concept"as"choosing"an"AFO"over"a"FFO"depending"on"where"the"pathology"is.""
• Reduction"of"Ankle"Valgus"via"Osteotomy:"
o If"you"follow"the"principle"of"reduction"at"the"CORA"in"the"diabetic"patient,"you"may"find"that"your"Charcot"
reconstruction,"attempt"to"medialize"the"calcaneus,"or"to"stabilize"the"medial"column,"is"so"far"distal"to"where"the"
CORA"is,"that"perhaps,"maybe"your"surgical"efforts"should"be"addressed"much"more"proximally.""
o May"be"preferred"to"RF"fusion"procedures"especially"in"patients"with"neuropathy."
o In"patients"with"neuropathy"who"are"in"for"a"bumpy"ride"following"their"reconstructions,"in"light"of"their"
neuropathy"that"forces"can’t"be"made"to"go"away,"and"that"isolated"fusions"of"the"joints,"even"medicalization"o"the"
calcaneus,"only"pushes"the"forces"somewhere"else,"and"patients"that"are"neuropathic"are"unable"to"respond"or"
even"sense"these"different"forces,"so"you"may"be"creating"short"term"rectus"alignment"but"in"the"long"term,"
creating"the"potential"for"more"Charcot"deformity.""
o The"fundamental"principle"as"close"to"CORA"as"possible"should"not"be"neglected.""
• The"Importance"of"Managing"Equinus"Deformity:"
o Equinus"is"the"number"one"reason"for"everted"foot"deformities."It"is"the"largest,"most"significant"pronator"acting"on"
the"foot,"depending"on"the"age"of"the"patient,"you"may"find"yourself"able"to"management"and"prevent"the"onset"of"
very"significant"compensation"effects"or"you"may"not."
o You"can"address"equinus"in"numerous"waysF"distally"or"proximally."""
o If"treated"early"enough,"may"permit"recovery"of"normal"functionalityF"with"an"orthosis"
o Older"patients"will"have"accumulated"compensation"effects"
o Sites"for"surgical"management"varus"

Subtalar"Arthroereisis:"

• An"anecdotal"“report”"following"STJ"Arthroereisis""
o “…reports"no"pain"from"the"20"minute"outpatient"surgery,…"following"the"surgery,"doctor"X"said"that"she"has"some"
exercises"she"needs"to"do"in"order"to"stretch"out"the"tendons"in"her"foot"in"leg.""
o Patient"said"she"“still"walks"a"little"on"the"side"of"her"foot"and"her"big"toe"sticks"up.”"
o With"exercise,"“she"expects"to"eventually"stretch"those"tendons"and"walk"normally.”""
• What"happened"to"this"patient?"Let’s"say"the"patient"had"a"TAL,"uncompensated"RF"varus"and"hypermobility"in"the"STJ."
Would"you"expect"this"after"the"surgery?""
o If"the"Arthroereisis"procedure"works"as"designed,"changes"the"ROM"of"the"STJ,"supinates"the"hindfoot."If"this"
patient"has"FF"supinatus,"and"had"FF"supinatus"before"the"surgery,"which"is"the"result"of"a"hindfoot"position,"then"
this"doctor"is"right,"and"the"medial"side"of"her"foot"will"come"down."If"she"has"FF"varus,"her"toe"will"stick"up"forever"
because"she"can’t"PF"the"first"metatarsalF"this"is"why"you"have"to"correctly"ID"the"cause"of"the"pronated"footF"it"has"
to"be"RF"oriented.""

""

Subtalar"Arthroereisis:""

• Currently,"many"insurance"companies"still"regard"this"procedure"as"experimental,"even"though"you"can"see"data"that"goes"
back"decades."The"earliest"decades"don’t"involve"the"implantation"of"exogenous"materials,"but"the"insertion"of"autogenous"
boneF"the"elevation"of"the"floor"of"the"calcaneus"to"block"the"motion"of"the"talus."In"the"old"days"the"surgeons"would"carve"
this"out"of"highFgrade"silicone"in"the"ORF"put"it"in,"see"what"it"did."It"wasn’t"until"the"70s,"80s,"and"90s"that"these"devices"
became"somewhat"consistent"with"their"design"and"their"application,"and"their"outcome"started"to"be"more"meaningful."
• When"you"look"at"the"literature"on"this,"it"is"popular"in"Europe"among"orthopedic"surgeons,"and"is"barely"done"by"them"in"
US."Domestically"it"is"done"in"by"podiatrists.""
• History:"first"literature"reference"on"this"was"in"1946"in"a"journal"of"gynecology.""
• How"does"the"Implanted"Device"Function?"
o Direct"physical"blockade"of"motion."
! Range"in"size"from"6F12"mm"
o Known"complications"
 ! Under/over"correction,"malFposition,"synovitis,"foreign"body"reaction,"sinus"tarsi"pain,"shearing"of"early"
“peg”"devices,"etc."prove"the"mechanical"stresses"the"implants"and"adjacent"structures"are"under.""
• Roth"et"al.:"Minimally"invasive"CalcaeoFstop"method"for"idiopathic"flexible"pes"planovalgus"in"children:"
o "“Stimulating"the"proprioceptive"receptors"around"the"sinus"tarsi…”"
o “This"effect"is"proved"by"weak"screw"penetration"into"the"calcaneus"and"a"lower"than"expected"rate"of"screw"
failure.”"
o Inserted"a"very"large"cancellous"screw"across"the"axis"of"the"STJ"without"the"intention"of"grabbing"any"bone"with"
the"intention"of"limiting"the"motionF"but"a"number"of"these"broke"at"the"screwFthread"junction.""
o There"may"be"something"to"be"said"about"proprioceptionF"some"devices"come"in"absorbable"(nonFpermanent)"
forms."
! If"you"implant"an"absorbable"device"in"a"young"child,"who"has"a"deformity,"you"are"hoping"for"something"
to"occurF"osseous"and"cartilaginous"adaptation"around"the"implant,"maybe"also"hoping"for"proprioception"
to"take"over"and"gait"train"the"individual"around"the"implant"during"the"time"that"the"implant"will"be"
present"in"the"foot.""
• What"evidence"exists"regarding"the"Mechanical"effects"of"STJA?"
o There"are"a"number"of"articles"that"try"to"quantitatively"define"what"these"devices"do."
o Hussain:"the"bigger"the"implant"you"put"in,"the"more"you"will"restrict"STJ"motion.""
! Most"importantly"from"this"article:"talked"before"about"how"supinating"the"foot"increases"the"tension"on"
the"Achilles"tendon."When"the"authors"measured"this,"they"found"that"the"length"of"the"AT"increased"by"
6.33%","suggestive"of"increased"tension,"because"the"calcaneus"could"not"PF"with"the"implant"in"place.""
o Clinical"Biomechanics"2004:"Insertion"of"a"6mm"cylinder"into"the"sinus"tarsi"shifts"the"load"to"the"lateral"column,"
decreasing"the"load"on"the"first"metatarsal"to"6%"of"body"weight"(from"17%)"and"decreases"moment"around"the"TN"
joint"to"6.0Nm.""
! Shifting"weight"from"the"medial"to"the"lateral"side"of"the"foot.""
o Jeff"Christensen:"effect"of"implant"in"placeF"
! The"implant"effectively"inverted"and"slightly"DF"the"navicular"
! Talar"position"was"affected"significantly"in"one"planeFsagittal"only."
! Calcaneal"inversion"moments"were"observed"in"all"specimens,"no"significant"changes"in"transvers"or"
sagittal"plane"positions"was"noted.""
o NeedlemanF"comparison"of"surgical"proceduresF"Evans"and"Arthroereisis"among"children"
! Significant"outcomes"in"terms"of"discomfort"pre"and"postoperatively."Don’t"quite"reach"the"same"
percentages"of"the"use"of"the"Evan’s"osteotomy,"but"come"very"close."The"Evans"is"a"far"more"invasive"and"
permanent"procedure.""
! Increasingly,"Arthroereisis"is"being"promoted"as"a"solution"in"adults."If"you"have"55"year"old"mildly"obese"
female"patient"present"to"you,"with"medial"foot"pain"and"you"correctly"assess"the"onset"of"AAFF"then"you"
propose"what"is"evidence"based"for"that"individual"which"may"be"TAL,"isolated"medial"column"fusion,"may"
be"medial"calcaneal"osteotomy."Keep"in"mind"that"you"are"also"proposing"6"months"of"""surgery"and"
rehabilitation,"minimum."If"you"had"the"option"of"putting"this"device"into"the"foot"and"voila!Fthere"is"a"
trend"towards"using"these"devices"amongst"adults."There"is"one"company"in"particular"called"Hyprocure"
that"markets"a"particular"design"of"an"Arthroereisis"device"for"adults.""
! Good"AOFAS"scores"compared"to"Evans,"etc."perhaps"this"isn’t"misguided.""
! Make"sure"you"assess"the"cause"of"the"deformity!"
• Results:"
o Kite’s"angle"decreased"from"29.1"degree"to"19.8"post"op"
o Talar"declination"decreased"
o Navicular"coverage"increased"from"48.1%"to"71.5%"
o Calcaneal"pitch"did"not"significantly"change"
o 15"of"21"children"indicated"at"least"90%"improvement"in"pain"
• Absorbable"vs."NonFabsorbable:"
o There"is"substantial"documentation"that"the"great"majority"of"implants"do"not"require"removalFat"least"not"for"
many"years."
 o There"is"evidence"that"36F48"months"of"utilization"creates"longFlasting"effect.F"more"rectus"position."Would"it"have"
gotten"there"anyway?"
o Absorbable&implants&appear&unsuitable&for&many&adults.&Does"not"have"the"potential"to"respond"to"the"device"
and"change."&
• Giannini"et"al:"Insertion"of"14"implants"in"patients"with"tarsal"coalition"
o 8"excellent,"3"good,"and"3"fair"results"on"AOFAS"score"
o These"aren’t"very"good"statistics"6/14"are"good"and"fair,"and"8/14"are"excellent"
• Saxena:"Use"MRI"to"size"the"sinus"tarsiF"people"may"be"overFsizing"their"implants.""
o Few"negative"changes"observed"via"MRI"in"adjacent"structures"
o Recommends"imaging"for"sizing"if"tarsal"canal,"concludes"metallic"implants"on"the"market"may"be"larger"than"the"
tarsal"canal"configuration.""
• Adjunctive"or"Alternative"Procedures"in"Flat"foot"correction:"
o Management"of"Equinus"deformity:"
! "TAL,"Gastroc"recession"
o Management"of"FF"issues:"
! FF"varus/Supinatus"
! Lateral"Column"Declinatus"
o All"comes"to"what"is"driving"the"pronation?"If"you"put"a"plug"in"a"patient"with"FF"varus,"you"will"penalize"that"
patient"forever"by"permanently"inverting"their"FF."They"will"be"unable"to"evert"to"the"ground"and"their"first"
metatarsal"will"be"free"floating.""
o Indications:"Futura/Nexa"guidelines:"not"very"instructive"
! Calcaneal"valgus"deformity"
! Plantarflexed"talusF"how"much,"when,"caused"by"what?""
! Severe"pronation"
! Congenital"and"painful"Flatfoot"deformity"
! Failed"correction"with"long"term"orthotic"treatment"
! Post"tarsal"coalition"repair"
! Supple"deformity"in"posterior"tibial"tendon"dysfunction"
! Paralytic"flatfoot"deformity"
! Subtalar"instability"
o Contraindications:"
! Superstructural"alignment"deformitiesF"agree.""
! Inadequate"bone"stock"
! Metal"allergies"
! Patient"unable"to"comply"with"postFop"care"instructions"
! Active"sepsis"
o Not"very"accurate"in"giving"info"to"individuals"who"are"using"their"devicesF"too"broad.""
• STJA:"Biomechanical"contraindications"****Q****"
o RF"varusF"while"everyone"may"have"some"RF"varus,"if"you"totally"limit"eversion"to"the"point"that"the"medial"FF"
cannot"come"to"the"ground,"you"have"created"a"problem.""
o FF"varus"
o Internal"rotation"problemsF"femoral"antetorsion"and"ITT"
• Effect"on"sports?"Any"strategy"will"have"a"negative"impact"on"the"foot"through"limitation"of"pronation."Pronation"is"
necessary,"if"you"remove"this,"you"will"functionally"harm"them.""
• Conclusions&STA:&
o STA"is"a"valid"option"when"appropriate"biomechanical"analysis"indicates"that"the"STJ"is"the"primary"site"of"
pathologyF"and"that"acting"on"it"will"achieve"a"desired"effect."
o STA"appears"well"tolerated"in"children"
o STA"may"prove"less"successful"in"the"treatment"of"adult"acquired"FF"
o Accessory"procedures"provide"necessary"biomechanical"support"
o Long"term"follow"up"may"indicate"that"the"device"may"activate"intrinsic"proprioceptive"mechanisms.""
Aging"and"Gait"Dysfunction:"Podogeriatrics"

• The"median"age"group"in"the"year"2000"is"between"54"and"30,"projected"to"occur"by"2025F"more"people"will"enter"their"70s,"
80s,"and"90s.""
• From"2000"to"2040,"the"number"of"people"age"65"or"older"is"projected"to"increase"from"34.8"million"to"77.2"million."For"
people"over"85,"the"relative"growth"rate"is"even"faster.""
• 2010"censusF"36"million"people"over"85.""
• What"we"know:"
o Cadence"decreases"with"ageF"really"doesn’t""
! In"some"ways,"absent"a"NM"event,"cadence"may"be"hardwiring"that"gait"velocity"decreases"in"the"elderly,"
but"not"because"they"take"fewer"steps"but"because"their"steps"are"shorter."
! Cadence&stays&the&same!&
o Stride"length"decreases"with"age"
o Base"of"gait"increases"with"age"
o Gait"velocity"decreases"15%"per"decade">age"50"
! Increased"double"support"phase"percentage"
o Angle"of"gait"changesF"seeking"stability,"because"of"adaptation"and"compensation"of"ankle"equinus:"externally"
rotates"the"lower"extremity""
o Walking"posture"changes:"
! Anterior"pelvic""
! Kyphosis"
! Abdominal"Fat/Weakness"
o Joint"ROM"decreases:"
• Apart"from"DJD/RA,"decreased&ankle&ROM&is&a&key&pathological&component"
o Decreased"AJ"ROMF"if"the"posterior"column"becomes"too"tight,"patients"can"develop"a"rocker"bottom"foot."
o Dominant"loss"of"motion"in"the"LE"is"the"AJ"
• Rational&effects&secondary&to&Ankle&Equinus:&
o FF"abduction"on"the"Tarsus"
o External"hip"rotation/Abduction"
o SwayF"forces"us"to"consider"loss"of"ROM"at"the"AJ"may"trigger"a"superstructural"change"in"the"way"people"move."
Following"the"center"of"mass"around"and"down"a"single"line"of"progressionF"elderly"people"tend"to"move"from"one"
side"to"the"other."If"you"are"solely"looking"at"their"feet"and"their"knees"you"won’t"see"this,"but"when"you"do"a"gait"
examination,"even"when"you"watch"this"patient"come"into"the"office"or"your"treatment"room,"look"where"their"
shoulders"are.""
o This"comes"down"to"AJ"equinus."
• SummaryF"What"happens"with"aging:"
o Decreased"velocityF"but"not"because"of"cadence"
o Cadence"stays"the"same"
o Decreased"joint"motion"
o Decreased"step"length"
o Increased"angle"and"base"of"gait"
o Decreased"strengthF"even"though"you"can"manage"your"weight,"that"isn’t"the"same"thing."Best"evidence"shows"
building"strength"with"high&weight,&low&repetition&exercise."Muscles"need"to"work"under"high"load"to"reverse"the"
effect"of"aging.""
o Increased"double"support"during"gait"
• Why"gait"changes"matter:"population"change"
o Relevant"population"trendsF"cost"the"healthcare"system"a"huge"amount"of"money"
! Most"elderly"individuals"are"sedentary"
• The&cardiac&risk&associated&with&being&inactive&is&comparable&to&the&risk&of&smoking&cigarettes&
• Direct"medical"costs"attributable"to"inactivity"and"obesity"account"for"more"than"10%"of"all"health"
care"expenditures"in"the"US.""
• Percentage"of"Americans"participating"in"vigorous"activity:"
o Not"even"10%"over"the"age"of"75"participate"weekly"in"vigorous"activity"
o “Vigorous”"to"them"means"approaching"¾"of"the"maximal"predicted"HR"that"they"might"have."
! Fewer"than"10%"of"people">75"push"their"HRs"to"110F120"BPM"once"a"week.""
• Older"people"tend"to"fall"
o Falling"is"an"extraordinary"determinate"of"disability,"loss"of"independence,"and"death.""
o More"than"1/3"of"adults"ages"65"and"older"fall"each"year."
o Fall"is"the"leading"cause"of"injury"death"among"persons"65"years"and"older"
o Approximately"3%"to"5%"of"older"adults"falls"cause"fractures""
o Based"on"the"2000"census,"this"translates"to"360,000"to"480,000"fallFrelated"fractures"each"year"
o In"2000,"direct"medical"cost"totaled"$179"million"dollars"for"fatal"and"$19"billion"dollars"for"nonFfatal"fall"injuries"
(Stevens,"2005)"
o This"figure"is"expected"to"increase"to"more"than"$32"billion"by"2020"
• There&will&be&more&obesity&in&our&elderly&populations&in&the&future:&
o The"fastest"growing"segment"of"the"obese"population"is"the"severely&obese&segment."The"prevalence"of"obesity"in"
the"elderly"has,"since"1990,"increased"more"than"50%."Disability"due"to"obesity"and"obesity"related"issues"is"rising"
among"18F59"year"olds,"with&the&50J59&year&old&group&showing&the&most&marked&change&in&the&rate&of&increase.&
o A"study"following"obese"patients"with"arthritis"who"underwent"successful"weight"management"protocol"was"
noteworthy:"each"weightFloss"unit"was"associated"with"an"approximately"4"unit"reduction"(one"pound"="4"pounds"
in"terms"of"force)"in"knee"joint"forces.""
o You"get"tremendous"benefit"from"very"little"effort:"you"get"400%"clinical"improvement"in"the"knee"joint"when"you"
just"lose"one"pound"of"weight.""
o The"concept"that"joint"replacement"surgery"leads"to"a"less"sedentary,"less"obese"population"is"likely"incorrect."
Recent"work"reports"that"“successful"treatment"of"lower"extremity"arthritis"does"not"lead"to"weight"loss,"and"
obesity"should"be"treated"as"an"independent"disease"that"is"not"the"result"of"inactivity"from"arthritis.”""
• Etiologies:"
o Substrate"modificationsF"when"we"talked"about"DM,"inevitably"this"comes"back"to"chemistry"and"physiology:"
! Collagen"bundles"become"dense,"less"flexible,"more"irregular""
• When"you"pick"up"the"phone"and"it’s"your"grandmother"(or"an"older"person),"you"just"know%that"
it"is"not"a"person"in"their"twenties,"the"collagen"in"the"vocal"cords"just"like"any"other"collagen"in"
any"other"part"of"the"body"changes"as"you"age.""
! The"problem"is"worsened"by"inactivity;"this"leads"to"a"decrease"in"collagen"turnover"which"causes"
decreased"stress"resistance.""
• We"can"see"that"there"is"an"element"of"personal"control"over"this,"there"is"an"ability"of"a"patient"
or"doctor"to"influence"the"degree"to"which"collagen"turnover"is"improved"or"delayed."
• Fat"Pad"constitution"and"distribution:"
o Fat"pads"have"important"attenuation,"accommodation,"and"protective"roles."This"is"particularly"important"within"
the"calcaneal"fat"pad"where"the"integrity"of"the"fat"pad"envelope"has"a"vital"role"in"not"only"shock"absorption"but"in"
facilitating"the"transfer"to"midstance.""
o All"these"characteristics"will"progressively"deteriorate"with"age.""
o Fat"pads"are"both"protective"and"enabling"of"gait."The"calcaneal"fat"pad"and"the"plantar"forefoot"fad"pad"has"both"
protective"role"in"terms"of"attenuating"shock"but"also"a"role"in"the"mechanical"sense"that"the"normal"sagittal"plane"
progression"of"gait"cannot"occur"unless"the"fat"pad"is"robust"and"functional."Not"just"because"of"the"fat,"but"
because"of"the"collagen"septae,"the"internal"structure"of"the"fat"pad."You"have"dissected"the"fat"pad"and"know"that"
it"is"not"just"an"amorphous"blob"of"tissue.""
o It"is"possible"to"fracture"the"soft"tissue"articulation"of"the"calcaneal"fat"pad"to"the"calcaneus.""
• Neural"Pathology:"
o Neurology"in"people"with"diabetes."We"can"make"this"better"or"worse!"People"who"study"falling"and"elderly"gait"
can"teach"us"interesting"thingsF"when"we"“do"the"right"thing”"–"give"them"diabetic"shoes,"a"lace"oxford,"even"a"
running"shoeF"even"though"they"might"be"more"comfortable,"the"other"side"of"this"is"that"we"are"blinding"their"
sensory"abilities"when"we"do"that.""
 o Sensory"insulation"
! Frey"and"Kubasak…"a"retrospective"study:"Of"over"100"individuals"who"had"fallen,"42%&were&wearing&
thick,&softJsoled&shoes.""
• The"percentage"of"elderly"patients"wearing"diabetic"shoes"(and"similar)"is"going"up,"and"so"we"
may"be"actually"making"the"elderly"more"prone"to"falling"because"of"the"density"of"the"midFsoles,"
the"thickness"of"the"midFsoles,"etc."that"we"are"creating.""
! Execution"of"balance"activities"suffered"dramatically"with"running"type"shoes…"thinFsoled"shoes"best"
performance."Barefoot"was"rated"even"lower"than"the"running"shoe.""
• Studied"patients"with"three"different"characteristics:"barefoot,"thinFsoled"shoes,"and"wearing"a"
running"type"shoe."They"put"them"through"a"course"of"different"walking"activities"(going"up"steps,"
balancing,"walking"on"an"incline,"etc.)"and"tested"their"ability"to"propriocept"and"utilize"agonists"
and"antagonist"muscles,"and"found"that"barefoot"was"not"very"good,"and"that"a"thinJsoled&shoe&
performed&the&best,"and"through"that"shoe"there"was"more"sensation"and"more"proprioceptive"
feedback,"but"more"importantly,"the"patients"that"performed"the"worst"on"this"course"were"the"
patients"that"were"wearing"the"running"shoe.""
o In"neuropathic"states,"all"phases"of"gait"are"impacted,"and"muscle"activity"is"distorted"as"proprioceptive"feedback"
prevents"proper"agonist/antagonist"activity.""
o In"response"to"poor"sensory"input,"compensatory"anatomic"and"functional"changes"occur"which"may"include"
clawing"of"the"digits,"loss"of"propulsive"phase,"increased"double"support"intervals,"and"significant"slowing"of"gait"
velocity.""
o Equinus&becomes&the&norm.&&
o Keep"in"mind"that"proprioception"may"also"play"a"role"depending"on"the"surface"on"which"one"walksF"carpet"versus"
tileF"a"significant"percentage"of"falls"has"been"related"to"a"combination"of"sneaker"(high"friction"outsole"shoe)"and"
high"pile"carpet."&
• What"if"proprioception"is"lost"independent"of"diabetes"or"other"coFmorbidity?"
o Is"proprioception"related"to"OA?"Is"the"loss"of"proprioception"one"of"the"key"elements"in"the"development"of"OA?"
! OA"leads"to"less"proprioceptive"acuity."
o Loss"of"proprioception"plays"a"role"in"the"initiation"of"OA."Knee"proprioception"in"middleFaged"and"elderly"persons"
with"advanced"knee"arthritis"is"reduced"in"comparison"with"that"in"middleFaged"and"elderly"persons"without"
arthritis."
o Loss"of"proprioception"is"independent"of"the"severity"of"knee"arthritis"and"may"foretell"the"development"of"
arthritis."In"cases"of"unilateral"OA,"proprioception"was"noted"to"be"diminished"in"both"knees."
th th
• Degenerative/Rheumatic"pathology:"these"types"of"changes"will"most"certainly"be"present"in"individuals"in"their"7 "and"8 "
decades"of"life"
o ROM"decreases"
o Deformation"of"jointsF"principally"the"knee/genu"valgum"
o Inflammatory"processes"create"edema"which"further"restricts"motion"
o Pain"creates"hesitation,"guarding,"an"across"the"board"decline"in"strode"length,"power,"and"balanceF"pain"changes"
how"people"walk!"Fear"and"hesitation"is"related"to"fall!"
o Patients"develop"an"urgency"about"walking;"fear"of"pain,"of"falling,"becomes"habitual.""
• Total"knee"and"hip"joint"replacement"has"become"routine"but…"
o Residual"knee"valgusF"may"be"a"component"of"OA"and"can"still"remain"after"surgery.""
o Limb"length"may"be"altered"
o Full"extension"of"the"knee"may"not"be"possible"following"implantation."
o Unstable"external"ROM."""
o These"are"being"done"less"and"less"invasivelyF"why"replace"the"whole"knee"if"only"the"medial"compartment"is"bad?""
• Osteoarthritis:"
o Shimada"et"al:"46"medial"compartment"knee"OA"patients"were"assessed"
! It"is"known"that"in"OA"transverse"plane"rotations"and"rotational"accelerations"are"affected"
! Here,"with"lateral"RF"wedging,"both"the"peak"acceleration"and"the"rotational"movements"were"decreased.""
• Psychological"issues:"
 o Chamberlin,"et"al.""
! Fear"of"falling"influences"spatial"and"temporal"gait"parameters"such"as"gait"speed,"stride"length,"increased"
stride"width,"and"prolonged"double"support"time.""
! Fear"of"falling"is"an"isolated"and"independent"variable"that"will"influence"how"these"people"move.""
o Yanagita,"et"al."
! 283"men"were"analyzed"for"gait"speedF"time"to"walk"ten"feet"
! Men"with"depressive"symptoms"tool"significantly"longer,"and"when"assessed"for"handFgrip"strength,"were"
noted"to"have"markedly"lower"capacity.""
! Is"the"depression"causing"the"changes"or"are"the"changes"causing"the"dpepression?"
o Wilson,"et"al."
! Authors"examined"relationship"of"“harm"avoidance”"to"disability."
! Persons"with"high"levels"of"harm"avoidance"reported"nearly"three"times"the"level"of"mobility"limitation"as"
others…..reflects"fatigability"and"uncertainty."
! This"was"not"explained"or"modified"by"frailty,"physical"conditioning"depression"or"cognition."
• Practical"Application:"the"Role"of"footwear"
o High"heeled"shoes"should"be"forsworn"
! Gabell,"(Ergonomics,"1985)"Incidence"of"falls"in"elderly"patients"related"to"a"history"of"having"become"
habituated"to"high"heeled"shoes."Electromyographic"evidence"suggests"that"switching"abruptly"to"a"high"
heeled"shoe"creates"altered"muscle"firing"patterns"in"the"lower"leg"–"as"would"be"expectedF"but"that"
women"who"wear"high"heels"consistently"demonstrate"an"accommodation"to"this"heel"height."
! LeeF(Archives"of"Physical"Medicine"and"Rehabilitation,1990),"….men"placed"in"high"heels"had"higher"levels"
of"Tibialis"Anterior"activity,"while"women,"habituated"to"this"footwear,"demonstrated"an"underFactivity"of"
the"muscle."
! As"much"as"we"may"like"to"maintain"high"fashion"sense"as"we"age,"high"heeled"shoes"offer"a"disabilityF"
they"create"a"true"functional"disability"among"individuals"who"wear"them."According"to"this"study,"wearing"
high"heels"creates"a"NM"habituationF"it’s"not"just"your"heels"off"the"ground,"you"actually"begin"to"reFtrain"
the"muscle"compartments"to"fire"differently"based"on"the"shoe"wear"that"is"being"worn.""
• Critical"evaluation"of"midsoles"and"outsoles:"
o A"small"percentage"of"falls"are"generated"by"excessive"slip"resistance…..the"combination"of"tread"construction"and"
inherently"nonFslip"surfaces"intersectF"using"such"shoes"on"thick"carpet.""
o Lloyd"and"Stevenson:"The"use"of"a"beveled"heel"increases"nonFslip"performance"over"the"use"of"a"traditional"square"
heel"design.""
o Imagine"both"of"these"shoes"in"swing,"about"to"touch"down,"and"you"can"see"in"the"squareFheeled"shoe"you"have"
just"one"point"of"contact,"a"small"surface"area"touch"the"ground,"and"the"sneaker"(beveled"heel)"you"will"have"a"
much"broader,"wider"surface"area"that"will"interact"with"the"surface.""
o We"can"only"modify"surface"area"and"velocity"through"which"impact"is"transmittedF"shock"absorbing"materials"
(such"as"running"on"grass)"don’t"decrease"your"body"weight,"they"simply"decrease"the"time"factor"in"which"the"
impact"is"absorbed.""
• Designing"orthoses"for"the"elderly:"
o The"indications"for"the"use"of"a"functional"orthosis"in"the"geriatric"population"are"the"same"as"in"any"other"
population."
o The"question"of"whether"a"patient"requires"a"rigid"device"should"be"independent"of"what"age"the"person"is."
o The"texture"of"the"device"becomes"an"important"issue."The"“sense”"of"hardness"may"be"less"tolerated"than"
structural"rigidity."
o May"require"the"same"prescriptionFjust"because"they"are"older"doesn’t"mean"that"their"plantar"heel"pain"is"any"
different"than"yours!"Just"keep"in"mind"that"you"may"be"dealing"with"individuals"who"have"an"atrophic"fat"pad,"so"
you"might"need"some"soft"tissue"supplementationF"they"want"the"orthotic"to"feel"“more"friendly.”"
o We"can"easily"design"for"these"features:"
! “Friendly”"topFcovers"–"leather."Poron,"PPT"underlays"
! Specify"that"the"lab"“fill”"the"positive"cast"a"little"more"than"normal."
! Slightly"evert"the"foot"from"neutral"during"casting."
 • Conclusion&
o Gait"alteration"in"aging"matters."
o Multiple"physiologic,"cultural"and"pathological"entities"conspire"to"make"the"geriatric"population"less"mobile,"more"
likely"to"sustain"(and"not"recover"from)"injury,"and"more"likely"to"develop"disability"that"displaces"them"from"their"
homes."
o Podiatrists"draw"on"a"wealth"of"skills"F"orthopedic"and"consultative"strategies"to"enable"our"aging"patients"to"do"so"
with"less"risk,"less"pain,"and"more"enjoyment."
"

Barefoot&runningJ&a&primer&and&a&validation?&

• Definitions:"Barefoot"running"is"not"truly"barefoot"
• This"is"implied:"
o Minimalist"or"FF"striking"footwear"
o Footwear"with"minimal"or"no"heel"“offset”"
o FF"as"opposed"to"RF"contact"
o Lack"of"“motion"control”"or"“stability”"feature"
o Designed"to"encourage"a"midfoot"or"FF"strike"
o Lightweight"with"a"curved"last"
! Not"having"a"boardFlast:"something"done"if"you"want"to"give"the"shoe"stability"
o The"current"modern"running"shoe"is"a"combination"of"many"densities"of"materialsF"bridges,"highly"rigid"areas"
through"the"arch,"with"different"kinds"of"densities"of"materials"being"used"of"the"medial"versus"the"lateral"heel,"a"
lot"of"things"have"been"built"into"shoes."In"the"late"80sF90s"they"even"endeavored"to"build"in"a"kinetic"wedge."The"
modern"running"shoe"is"an"evolution"of"technology.""
o The"minimalist"running"shoe"has"none"of"these"issues"or"featuresF"its"principle"goal"is"to"be"light,"to"fit"well,"to"be"
snug,"to"unencumber"the"runner;"no"effort"at"all"is"made"to"decrease"pronation,"supination,"support"the"arch,"etc."
One"key"terminology"point"is"the"heel"offset."""
o DefinitionF"****Q****Heel&offset:&&is&the&difference&between&the&thickness&of&the&midsole&of&the&heel&and&the&
thickness&of&the&midsole&at&the&forefoot.""
o Higher"heeled"shoes"induce"heel"strike;"they"do"not"encourage"forefoot"striking.""
• Why"do"this?"
o Dissatisfaction"with"current/dominant"statusF"this"is"a"model"which"is"not"evidence"based,"running"companies"
make"new"shoes"every"year"regardless"of"evidence"of"making"it"better."Consumers"want"something"“new.”"People"
who"barefoot"run"do"not"like"this"pattern.""
o Recurring"injury"
o Frustration"with"care"professionals"
o Because"they"can…"because"they"sense"that"their"injury"rates"have"not"changed"as"a"result"of"the"shoes"that"they"
are"running"in.""
o Currently">75%"of"runners"heel"to"toe"gait"in"shoes"designed"around"this"traditional"paradigm:"high"heel"offset,"
thick"midsole"for"cushioning,"some"stability"focused"design,"but"the"evidence"does"not"support"this!""
• Let"us"keep"in"mind:"the"evidence"supports"that"the"mechanics"within"a"stability"shoe"are"different,"for"example,"the"velocity"
of"heel"eversion"is"reduced.""
o Evidence"supports/describes"the"mechanical"effects"of"footwear"and"FFO"
o Evidence"does"NOT"support"the"theory"that"motion"control"shoes"intervene"successfully"in"prevention."
o From"an"evidence"based"point"of"view"looking"at"injury"rates,"Richards,"et"al."showed"that"the"presence"amongst"
high"mileage"runners"is"not"associated"with"lower"injury"rates,"in"fact,"it"may"be"the"opposite."This"is"not"to"suggest"
that"people"should"not"wear"stability"shoes,"it"is"only"to"suggest"that"if"you"look"at""the"numbers"of"individuals"who"
get"posterior,"anterior"compartment"syndromes,"medial"stress"syndromes,"plantar"fasciitis,"Achilles"tendinitis,"
doesn’t"go"down"when"you"give"them"$150"shoes."
• Purported"Advantages:"
o More"“natural”"
o Fewer"injuries"
 o Current"footwear"promotes"injuries"
o The"heel"is"not"made"to"absorb"shock"
o Christopher"McDougalF"Born&to&RunJ&Chronicles"his"experience"with"a"tribe"of"people"who"run"without"traditional"
shoes,"and"propose"that"Nike"has"“ruined”"the"running"world"forever"by"being"the"first"shoe"company"to"create"a"
significant"shoe"offset.""
o In"the"early"70s,"all"running"shoes"were"thin,"lightweight,"and"had"no"stability"features"whatsoever.""
! Abebe"BikilaF"Ethiopian"man"and"Olympian"in"1960s,"ran"barefoot"and"won"the"gold"medal.""
! Zola"BuddF"South"African"ran"barefoot.""
• Possibly"true:"
o Less"shock"transmissionF"more"shock"attenuation""
o Known"changes"to"gait"are"validF"it"is"absolutely"true"that"there"are"well"defined"changes"in"gait"when"someone"
converts"from"shoes"to"barefoot"running."""
o Heel"to"toe"running"gait"is"not"necessarily"a"native"conditionF"it"is"determined"by"the"shoe.""
o Current"footwear"promotes"injuries"
• Gait"modifications:"
o Is"this"driven"by"the"shoe?"
! Data&indicate&that:&
• Runners&who&never&wore&shoes&do&not&heel&strike&when&they&run&
• Runners&who&convert&to&“modern”&shoes&heel&strike&
• Runners&who&convert&to&barefoot&running&then&gradually&adopt&a&FF/MF&strike&pattern&based&
on&the&proprioceptive&feedback&
o Evidence"out"there"shows"that"barefoot"running"causes"more"shock"to"be"transmitted"through"the"tibia,"and"more"
shock"to"be"transmitted"through"the"FF"than"if"you"are"wearing"a"shoeF"you"have"to"understand"that"it"takes"time"
to"make"this"conversion!"If"someone"is"an"experienced"runner"you"can’t"just"put"them"on"a"treadmill"and"tell"them"
to"run"differently."6F8"weeks"of"continued"use"of"the"shoe,"you"might"see"changes."Make"sure"you"look"at"people"
who"are"TRAINED"barefoot"runners"when"looking"at"injuries,"etc.,"not"brand"new"barefoot"runners.""
o Side"notes:"faster"runners"tend"to"have"a"more"forward"strike,"the"average"runner"heel"strikes.""
• Lieberman:""
o Took"high"speed"imagery"of"people"both"in"shoes"and"without"shoes.""
o Notice&that:&&
! In&heel&strike,&the&ankle&is&in&dorsiflexion.&&
! In&the&barefoot&condition,&the&ankle&is&plantarflexed.&&
• What"about"impact?""
o Heel"to"toe"gait:"
! Although"the"ankle"may"flex"a"little"(plantarflex)"during"the"impact"period,"the"vertical"momentum"of"the"
lower"le"is"mostly"absorbed"by"the"vertical"component"of"the"collision"force."
! The"heel"contacts"the"ground"with"the"knee"fully"extended"and"there"is"a"direct"transmission"of"force"up"
the"axial"skeleton"that"is"unmitigated"by"ankle"or"knee"flexion."All"of"that"impact"goes"proximally"from"the"
heel"into"the"skeleton."Take"the"same"person"and"convert"them"to"barefoot"running,"they"have"both"the"
ankle"and"the"knee"being"flexed"at"contact"and"are"able"to"use"that"musculoskeletal"resilience"to"absorb"
shock.""
o FF"strike:"
! In"the"barefoot"running"gait,"unlike"the"traditional"heel"to"toe"gait,"the"runner"has"ankle"PF"to"use"in"terms"
of"attenuating"impact"and"shock"because"the"ankle"is"PFed.""
! When"the"ankle"is"DF"at"strike,that"is"lost.""
! Because"the"individual"has"decreased"their"stride"length,"the"knee"is"flexed"in"barefoot"running"compared"
to"shod"running."""
! Much"of"the"vertical"momentum"of"the"rearfoot"and"lower"leg"is"converted"into"rotational"momentum.""
• Rearfoot"motion:"DeWit,"B,"et"al."
o Traditional"early"contact"phase"mechanics"are"absent."
o Eversion"of"the"hindfoot"between"contact"and"peak"impact"was"significantly"smaller"in"the"“barefoot”"cohort."
 o This"means"that"because"the"hindfoot"has"been"disarticulated"from"the"gait"cycle,"there"is"less"Subtalar"motion"
occurring."This"is"one"reason"why"lack"of"heel"control"is"not"an"issue"(causing"pronation,"etc.,)"because"it"WOULD"
matter"if"the"heel"touched"the"ground"but"it"doesn’t.""

Gait"Characteristic" Barefoot" Heel"to"toeF"shod"

Stride"length" F" +"
Stride"frequency" +" F"
Ankle"PF"at"contact" +" F"
Ankle"DF"F"contact"to"Midstance" +" F"
Knee"Flexion"at"Midstance" +" F"
Knee"Varus"Torques" F" +"
Peak"Heel"Pressures" F" +"
Knee"Flexion"at"Midstance" +" F"
StretchFshortening"cycle" +" F"
Hip"Internal"rotation" F" +"
Knee"Flexion"Torques" F" +"
"

• Energy"costs:"
o Running"barefoot"has"been"shown"to"use"5%"energy"than"shod"running.""
• Heel"to"toe"offset:"
o High"offsetsFMizuno"(9),"the"Vibram"shoes"have"an"offset"of"0F2"mm."You"can"see"that"these"are"fairly"lightweight"
shoes,"the"average"men’s"stability"running"shoe"is"well"over"11F12"ounces.""
• The"Vibram"Bikila:"in"terms"of"Vibram,"this"is"their"flagship."This"almost"meets"the"criteria"for"definition"of"being"a"shoeF"has"
a"heel"counter,"increase"FF"padding,"but"still"nothing"rigid"underneath;"weighs"almost"nothing.""
• Newton"shoe"is"designed"to"move"you"forward"on"to"the"FF.""
• Eccentric"Contraction"Based"RehabilitationF"MidFportion"Achilles"tendinosis"
o People"who"barefoot"run,"because"they"run"and"induce"eccentric"contraction"into"their"running"cycle"and"into"their"
Achilles"tendons"which"shod"runners"s"do"not"have,"that"people"who"run"barefoot"style"can"kill"themselves"with"
Achilles"tendinosis."""
o Challenge"to"traditional"paradigm"for"management"of"tendinosis:"Rest!"
! PT!"
! Heel"lift!"
! ESWT/Sclerosis!"
! PRP!"
! Surgical"Debridement!"

Have"we"gotten"Biomechanics"Wrong?"

! Reflections"on:"
o Neuromuscular"Tuning"
o Preferred"Pathway"of"Motion"
o Sagittal"plane"facilitation"via"Dr."Ed"Glaser"
• [Video"cuts"out"about"4"minutes"of"lecture]"
• Key"Points:"MASS"
o STJ"neutral"is"fictitious"
o Intervention"in"pronation"should"begin"early"and"aggressively"
o Soft"tissue"compression"of"the"plantar"foot"is"necessary""
o Sagittal"plane"mechanicsF"specifically"prevention"of"calcaneal"plantarflexion"is"critical"
o Posting"is"a"waste"of"time"
• The"MASS"theory:"Maximal"Arch"Subtalar"Supination"
o When"he"does"this,"when"he"casts"you,"he"is"relying"on"the"device"compressing"soft"tissue."Patient’s"weight"is"very"
important"to"him,"because"he"has"to"calibrate"the"rigidity"of"the"device"based"on"how"much"you"weigh.""
 o These"are"amazingly"dynamic.""
• Key"principles"in"Neuromuscular"Tuning"
! Muscles"work"to"dampen"vibration"
! Consistent"vibration"patterns"promote"adaptation"
! TuningF"is"a"natural"sequence"seen"in"all"forms"of"activity"
! Barriers"to"tuning"inhibit"adaptation"
o The"proposed"muscle"tuning"reaction"to"impact"affects"muscle"activation"before"ground"contact…"
o The"muscle"adaptation"to"provide"a"constant"joint"movement"patter"affects"muscle"activation"during"ground"
contact.""
o Benot"NiggF"well"known"researcher,"developed"a"principle"ideology"known"as"NM"tuning."His"story:"he"was"called"to"
investigate"a"troop"of"dancers"in"Canada"who"work"for"Circe"de"Soleil."These"people"do"phenomenal"things"and"
defy"physics"when"they"are"on"stage"and"are"very"athletic,"and"they"do"a"lot"of"jumping"and"landing."These"dancers"
were"getting"injured,"they"were"having"Achilles"problems,"stress"fractures,"leg"pains,"shin"splints,"etc."which"they"
didn’t"normally"had"and"he"showed"up"to"investigate."What"he"found"was"that"the"place"that"these"individuals"
were"training,"the"floor"was"unevenly"rigid,"in"other"words,"for"the"average"individual"it"was"smooth"and"level"but"
underneath"it"some"areas"of"the"floor"had"greater"give"and"flex"than"others."He"moved"this"group"of"dancers"to"
another"site"which"was"uniform"in"its"rigidity"and"density"and"their"injuries"went"away."From"this"he"developed"
insight"into"what"he"calls"NM"tuning,"which"is"that"consistent&vibration&patterns&promote&adaptation&and&promote&
activity."In"other"words,"people"who"are"subject"to"similar"stresses"all"of"the"time"adapt"to"those"stresses,"and"
people"who"encounter"highly"variable"levels"of"stresses,"with"high"level"impact"and"so"forth,"may"in"fact"become"
injured."This"kind"of"touches"something"from"before"about"running"on"grass"versus"pavement."Running"on"grass"or"
the"beach"is"a"highly"variable"terrain,"it"is"uneven"and"moves."People"are"far"more"likely"to"be"injured"running"on"
grass"or"turf,"or"the"beach,"running"on"pavement,"which"is"uniform,"and"it"promotes"neuromuscular"tuning.""
• Implications"of"NM"Tuning"Theory:"
o Rigid"orthoses"may"be"overFprescribed"
! If"you"want"the"body"to"be"able"to"adapt"to"the"forces"it"encounters,"you"should"allow"the"foot"to"move,"so"
that"the"muscles"can"vibrate"and"tune"the"limb"accordingly."""
o Orthoses"may"be"over"posted"
o Motion"control"and"shock"attenuating"footwear"may"be"overprescribed"
o Clinicians"may"need"to"devote"more"time"to"rehabilitation"strategies.""
o Keep"in"mind"that"it"has"been"very"well"documented"that"at"least"50%"of"sports"injuries"are"training"related"and"
have"nothing"to"do"with"shoes"and"biomechanics."People"make"errors"in"their"trainingF"it’s"that"last"set"of"
repetitions"that"you"knew"you"shouldn’t"do"but"you"did"it"anyway.""
• Key"Principles"of"PPM"
o There"is"a"natural"pathway"which"force"follows"during"gait"
o This"is"unique"to"the"individual"
o This"may"not"correspond"to"assumptions"about"“normal”"
o Factors"which"cause"force"to"deviate"from"this"pathway"are"pathological"
o Preferred"pathway"is"a"theory"that"says"that"everyone"has"a"unique"and"“normal”"pathway"for"them,"and"that"our"
job"is"not"to"normalize"patients"aro0und"a"certain"degree"of"rearfoot"motion,"but"rather"to"normalize"them"around"
their"own"intrinsic"structure"that"you"may"heel"to"toe"strike"or"you"might"have"an"everted"heel"and"a"functional"
hallux"limitus,"but"everyone"has"a"unique"barrier"to"sagittal"plane"motion,"and"that"our"job"is"not"to"try"to"make"
every"foot"the"same.""
• Normal:"Effective"Gait"
o Putting"all"of"these"things"together"as"there"being"a"more"appropriate"term"rather"than"normal"gait,"effective"gait,"
and"that"you"can"take"sagittal"plane"stuff"and"triplane"mechanics,"NM"tuning,"preferred"pathway,"and"put"it"all"into"
your"head"at"once"and"keep"these"in"mind"when"you’re"evaluating"patients."""
• Shoes:""
o Anatomy"of"shoes:"
! VampF"the"top"of"the"toe"box"where"a"lot"of"patients"get"in"trouble"fitting"into"shoes.""
! WeltF"the"seam,"the"glue,"the"interface"between"the"sole"and"the"shoe.""
 ! StiffenerF"the"Counter"is"the"back"of"the"shoe,"the"stiffener"is"what"is"inside"it"(cardboard,"plastic)."
! ShankF"This"is"what"gives"the"shoe"rigidity."Most"good"shoes"have"a"steel"shank,"or"a"metallic"shank."It"
means"that"the"shoe"won’t"bend"if"you"fold"it"in"the"middle.""
! EyeFrowF"the"lace"pattern.""
o The"Blucher"moccasin:"interesting"because"of"the"way"it"laces."The"two"pieces"of"leather"(on"the"front"of"the"shoe)"
are"not"stuck"together"so"it"accommodates"a"relatively"wider"foot.""
o The"classic"Penny"loafer"or"any"kind"of"shoe"that"is"a"slip"onF"how"does"it"stay"on"the"foot?"It"exerts"a"force"on"the"
foot"medially"and"laterally."Patients"with"hallux"valgus"and"tailor’s"bunions"cannot"fit"in"these"shoes,"and"a"vamp"in"
these"shoes"rubbing"against"a"metatarsalFcuneiform"exostosis"will"cause"pain.""
o Be"able"to"use"these"words!""
o Running"shoes:"the"most"common"material"is"ethyl"vinyl"acetate"(EVA)"which"comes"in"many"durometers."Very"
sensitive"to"heat"and"climatic"conditionsF"the"dynamics"of"the"shoe"will"change"depending"how"hot"it"is."EVA"does"
that.""
! Polyurethane"doesn’t!"Polyurethane"is"what"is"most"likely"to"be"found"in"soFcalled"stability"shoes"(New"
Balance"uses"a"lot"of"polyurethane)."""
o Lasts:"the"mold"around"which"the"shoe"is"built."Every"shoe"company"builds"their"shoes"around"certain"kinds"of"lasts."
For"years"Nike"made"shoes"called"PreFlast"which"was"actually"Steve"Prefontaine’s"foot.""
! On"the"last,"the"leather,"the"fabric"is"sewn"onto"this,"and"the"last"will"be"determined"not"just"by"the"shape"
from"heel"to"toe"but"what"the"shoe"company"puts"on"that,"in"other"words,"when"they"sew"the"fabric"onto"
this,"do"they"leave"I"open"or"put"a"board"on"it,"or"just"at"the"heel?"A"fully"board"lasted"shoe"will"be"one"
that"is"stable"from"heel"to"toe."Most"running"shoes"are"partially"board"lasted"meaning"that"the"board"goes"
only"up"to"the"metatarsal"heads.""
! Sprinting,"high"speedFshoes"have"curved"lasts"because"it"matches"the"position"of"the"foot"during"those"
high"speed"gait"patterns.""
o MBT"shoeF"it"is"not"quite"a"rockerF"it"encourages"you"to"forefoot"or"midfoot"strike,"because"the"heel"is"absent,"but"
also,"what"IS"there"give"way."If"you"heel"strike"in"the"shoe"you"sink"into"the"shoeF"they"want"you"to"move"onto"the"
midfoot.""
o Reebok"toner"shoeF"recently"fined"by"the"federal"trade"commission"for"false"advertising."

Doctor"Patient"Communication:"

• Studies"which"examine"physicians"who"have"been"sued"versus"physicians"who"have"never"been"sued."
o Most"of"the"time"there"is"no"differences"in"quality"of"care,"charting,"or"negligence."""
o Bad"outcomes"+"patient"dissatisfaction"="litigation"
o Communication&is&the&#1&reason&patients&sue!&
• Why&Patients&litigate:&
o Physician"communication"problems:"35%"&
o Physician"attitude:"35%&
o Financial"incentives"10%&
o Other"20%&
• Will"send"the"rest"of"the"file"(ran"out"of"time)F"need"to"understand"what"good"communication"skills"are"defined"as."&

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