Richard Schuster trained many fellows in biomechanics. The fellows have left their marks in a variety of specializations from running injuries, dance, baseball, pediatrics, neurological to gait impairments. Schuster in many senses was an ideal clinician. We examine what makes an ideal clinician and set Schuster in his time and locale.
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Richard Schuster: Life Lessons and Legacy
1. Lifetime Lessons
Learned
The Legacy of Richard O Schuster
Stephen M. Pribut, D.P.M., FAAPSM, FACFAS
Past President, AAPSM
Clinical Assistant Professor of Surgery
George Washington University Medical School
2. Financial and Conflict Disclosure
I have no relevant financial relationships or
conflicts to disclose.
I have no conflicts of interest.
3. Thanks
• NYCPM for education, Fellowship,
Residency
• special thanks to the Department of
Orthopedics and Dr. D’Amico
4.
5. Where Are We
Headed
• Introduction
• Schuster
• Lessons
• Case Studies
• Models, What’s real, what’s not
6. Thoughts
• “If in the last few years you haven’t discarded a
major opinion or acquired a new one, your
critical thinking capacity may be broken.”
• “All models are wrong, but some are useful.”
(George Box)
• Master the art of “what works”
9. Wisdom of the Ages
• Over 600 years of experience
• Average over 35 years of experience
per practitioner
• Wisdom of the ages or wisdom of the
aged
• Eyes to the future
11. Richard O. Schuster,
DPM:
A Biomechanics Icon An up-close look at a man who helped shape this discipline
by Joseph C. D’Amico, DPM
Biomechanics
Podopediatrics
Sports Medicine
Mandatory background reading
12. Fellowship Lessons
• Learning and Leading By Example
• Case Studies
• Learn what works
• Be curious
Learn from treatment successes and failures
18. When you want to give your feet
a rest, the NY Subway is the
very best.
19. Knowledge
Gathering: Sports
Medicine 1977
• Journal articles - few on specific sport related topics
• Conferences
• Biomechanics Fellowships
• Preceptorships
• Orthopedic/Biomechanics Residency
• Reading Runner/Runners World
• Reading Physician & Sports Medicine
• AAPSM / ACSM
21. Early Articles
• Runner’s Knee - Sheehan
• Survey of running injuries -
Stanley James
• Immunity to heart disease
for marathoners - Tom
Bassler
–Jim Fixx ultimately
disproved an incorrect
theory.
23. 1
: a gift by will especially of money or other personal property :bequest
2
: something transmitted by or received from an ancestor or predecessor or from the
past <the legacy of the ancient philosophers>
3
:
anything contributed or created by someone who is no longer living or active and which continues to be
of influence or impact.
Examples:
This esteemed university is the great legacy of its enlightened founder.
The introduction of the term "rock 'n' roll" is part of the legacy of famous disc jockey Alan Freed.
Synonyms
bequest, birthright, heritage, inheritance, patrimony
Related Words
heirloom; bestowal, gift, offering, present
Origin:
24. The Wisdom Pyramid
Wisdom: the ability to identify truth and
make correct judgments on the bases of
previous knowledge, experience and
insight.
25. Podiatric Sports Medicine
Podiatric sports medicine was an important force in
putting modern podiatric medicine on the map.
26. Dr. Schuster’s Special Role In Sports Medicine
Richard Schuster receives the Robert Barnes Service Award
27.
28. Great Moments In Running History
“Dr. Schuster gives George
Sheehan his first pair of
orthotics.” (1971)
29. “Never trust a thought that comes to you while
sitting.”
30. Lore of Running: Tim Noakes
“Only when I attended the 1976
New York Academy of Science
Conference on the Marathon
and heard the presentations by
George Sheehan, Richard
Schuster, and Steven
Subotnick did I begin to
appreciate that attention to my
running shoes and the use of
an orthotic might cure my injury.
These measures worked.”
31. New York Academy of Science:
1976 Symposium on the Marathon
Schuster
Subotnick
Sheehan
Bassler
Noakes
33. Runner’s Handbook: Bob Glover
...George Sheehan’s writings
about podiatrist Dr. Richard
Schuster’s pioneer work with
orthotics for runners led me to
Schuster’s office.
“Then came the great
discovery: My knee pain didn’t
need surgery, just exercises
and orthotics.
It Worked!”
34. Many go too far too fast too soon. Then, explains
Schuster, 62, "the body begins to break down. It's
like an old jalopy: good enough to get you to the
supermarket, but if you try to run it in the Grand
Prix, it'll fall apart."
Working out of a small office in Queens,
Schuster uses a tape measure, a
carpenter's level and a mirror, among
other tools, to amass 80 pieces of
information about the ailing foot.
Schuster also has worked extensively with brain-damaged children
whose balance system is not functioning properly. His shoe
modifications and inserts allow many afflicted children to walk with
increased stability. "That's the exciting work," he says.
36. The Runner Magazine 1978-1987
Dr. Schuster was the “Podiatric Editor” and Dr. Sheehan
was the “Medical Editor”.
Also featured: George Hirsch, David Costill, Hal Higdon,
Tom Fleming, Edwin Moses, Bill Rodgers, Frank Shorter,
Craig Virgin, Nina Kusick, and Marty Liquouri.
Sold by Ziff-Davis to CBS to Rodale which merged it with
Runner’s World.
Many hoped the April, 1987
issue was an April Fool’s Issue.
37. The Runner Magazine: Foot Works
Case studies, tips on injuries, analysis of new
features in shoes, insoles, socks, running trends.
If you did everything as Schuster did 30 years ago,
you’d be a great clinical practitioner.
If you made clinical observations as he did, you’d
do far better than you do now.
38. The Runner Magazine: Foot Work
Topics:
Bad habits of running
Morton’s neuralgia
Tarsal tunnel syndrome
Ankle sprains
Blisters
Stress fractures
Forefoot running
Shoe changes
Shoe cushioning
Shoe insoles
Women’s injuries
Children’s injuries
Recurrent stress
fractures
Stretching
39. The Runner Magazine: Foot Work (April 1984)
Bad Habits of
Running:
Too much, too soon.
Changing running
style.
Not stretching.
Faulty stretching.
40. Compared pre-1978 and post 1978
• Second metatarsal most often
• Moments of force (bending
forces)
• Practical means of treatment
• Early diagnosis - bone scan
Still used term
“pre-stress
fracture”.
Stress Fractures 1972-1982
41. "Runners with low-arched feet generally don't
have to worry," says Schuster. "The runner
with high-arched feet is usually the one with
more problems.”
Authored many “Body Works” columns
Overtraining
Limb length discrepancy
Practical & educational
42.
43. Biomechanical Forces of Good and Bad
What did long experience imply in this mysterious field?
Did pop culture have an impact in1977?
44. The Force:
Newton v. Lucas
• Forces may be good or
evil
• Injunction to measure
and determine abnormal
forces
• Train sense of intuition
• An eternal battle
47. Full Definition of CLINICIAN
1 : a person qualified in the clinical practice of medicine, psychiatry, or
psychology as distinguished from one specializing in laboratory or research
techniques or in theory
2 : a person who conducts a clinic
Origin: 1870-1875; from “clinic” + ian
Word Origin & History
clinician
1875, from Fr. clinicien, from L. clinicus (see clinic).
48. Schuster: Respected For
His
• PatiCenltsin anicd aAtlh lEetexspertise
• Print media
• Running Books
• Running Magazines and Columns
–Runner Magazine
–Runner’s World
• Inspired athletes to become podiatrists
49. Ideal Clinician
• Dr. Schuster exhibited many of the
characteristics of an ideal clinician
• His example stood as a life lesson to
many
51. Confident: “The doctor’s confidence gives me confidence
Empathetic: “The doctor tries to understand what I am feeling and experiencing.”
Humane: “The doctor is caring compassionate and kind.”
Personal: “The doctor interacts with me and remembers me as an individual.”
Forthright: “The doctor tells me what I need to know in plain language and forthrightly”
Respectful: “The doctor takes my input seriously and works with me.”
Thorough: “The doctor is conscientious and persistent.”
52. Standards in Clinical
Skills
Project Professionalism of the American Board of Internal Medicine
has outlined:
specific values, including humanistic and communication
behaviors expected of their membership
The Outcome Project of the Accreditation Council for Graduate
Medical Education requires all accredited residency programs:
to address the training of physicians in 6 core competency
domains:
patient care
medical knowledge
practice-based learning and improvement
interpersonal and communication skills, professionalism
systems-based practice
53. Seven Habits of Highly Effective Clinicians
Demonstrate aspects of ideal
physician behaviors.
The traits described are from
the interview transcripts and
patient focus groups.
Personal observations of the
research team are included.
54.
55. Confident
• Makes use of state-of-the-art medical practices
• Applies experience in treating specific medical
conditions or performing procedures
• Is not disturbed by patient's queries about
medical information acquired from other
sources (regardless of accuracy or inaccuracy)
Is at ease in the presence of patient, family
members, and medical colleagues
56. E•mMakpesa etyhe ceonttiacct with the patient as
well as family members
• Correctly interprets patient's verbal and
nonverbal concerns
• Repeats patient's concerns
• Shares personal stories that are
relevant
Speaks in a sympathetic and calm tone of
voice
• Makes eye contact with the patient as
well as family members
57.
58. Humane
• Uses appropriate physical contact
• Is attentive, present to the patient and
the situation
• Indicates willingness to spend adequate
time with patient through unhurried
movements
59.
60. Personal
• Asks patients about their lives
• Discusses own personal interests
• Uses appropriate humor
• Acknowledges patient's family
• Remembers details about the patient's
life from previous visits
61. Forthright
• Doesn't sugarcoat or
withhold information
• Doesn't use medical
jargon
• Explains pros and cons of
treatment
• Asks patient to recap the
conversation to ensure
understanding
62. Respectful
• Offers explanation or apology if patient is kept
waiting
• Listens carefully and does not interrupt when the
patient is describing the medical concern
• Provides choices to the patient as appropriate but is
also willing to recommend a specific course of
treatment
• Solicits patient's input in treatment options and
scheduling
• Takes care to maintain patient's modesty during the
physical examination
63. Thorough
(most often mentioned)
Handwrite
highlights and
• Provides detailed explanations
• Gives instructions in writing
• Follows up in a timely manner
• Expresses to patient desire to consult
directions and use
handouts as
needed.
other clinicians or research literature on
a difficult case
64. Patients as Detectives:
Clues About The
Office
• Functional clues
–Lab reports - accurate, not “missing”
–Check on allergies before Rx
• Mechanical clues
–Comfort, sights, sounds, smells, textures
• Humanistic
–Behavior and appearance of physician
• Word choice, tone, enthusiasm, body language,
appearance
These Clues
create the
service
experience.
65. Practical Suggestions
1. Eye contact—is a basic sign of connecting, listening and caring.
2. Partnership—in a healthcare relationship is not a one-way proposition.
3. Communication—also works in two directions. Understanding needs. Understanding solutions.
4. Time—is what physicians have little of, and what patients want from physicians. They do not want to feel rushed.
Rapport begins before you say hello…
Shake hands
Apologize if you are late
Introduce yourself by first and last name “Good
morning Mr. Smith, I’m Billy Ray Cyrus.”
71. Other Tools:
Old & New
• EDG - Father of EDG - M. Polchaninoff/Langer Labs (1977 -
NYCPM Fellow)
–F Scan
–Dartfish
• Internet forums
–PM Magazine, Podiatry Online, Podiatry-Arena, Bartold
–Social media: bane or blessing?
• iPhone
–Data & programs in your hand
• Online forums
• Traditional Journals
72. Schuster:
Used Careful and Methodical
Evaluation
• Skepticism of unsubstantiated research
–Bayes theorem
• First to note problems of over-stretching
73. Clinical Observations
& Problem Solving
• Listen
• Observe
• Think
• Solve
• Fix
“If I had an hour to solve a problem, I’d spend 55 minutes
thinking about the problem and 5 minutes thinking about the
solutions” – Einstein
76. Gait As Revealer of
Aging & Alzheimer's
• Mayo Clinic: N= 1341, followed over 15 months
– Lower cadence, velocity and length of stride
correlated with significantly larger declines
in global cognition, memory and executive
function.
• Basel, Switzerland: N= 1153, mean age of 78
– gait became "slower and more variable as
cognition decline progressed."
– Cognitively healthy, mild cognitive
impairment or Alzheimer's dementia.
– Those with Alzheimer's walked slower than
those with MCI, who walked slower than
those who were cognitively healthy.
77. Simplicity &
Simplexity
• Scale Test
– Shoe flexibilty
• Scaled down
– Finger Test
• Diagnostics Use Occam’s Razor. Select the
simplest of all competing hypotheses. The one
with the fewest assumptions.
78. Measurements
• Navicular drop
• Total varus (Dr. Skliar
discussed earlier)
• Shoe flexibility
–Peter Cavanaugh
–Richard Schuster
79. Orthotics:
What are they? How do they work?
“An in-shoe medical device which is
designed to alter the magnitude and
temporal patterns of the reaction
forces acting on the plantar aspect of
the foot”
Kevin Kirby
80. Kirby on Schuster
• Kirby mentioned R O Schuster as a
major influence on his choosing
podiatric biomechanics as a field of
interest.
• Kirby calls Schuster one of the important
historians of the profession. (Schuster
1974. JAPA History of Orthopedics in
Podiatry)
81. Orthotics:
What are they? How do they work?
How do they work? By altering force application, direction,
magnitude.
Thoughts: Kinematics (motion) or Kinetics (forces)
Conformity of orthotic to foot (foot orthotic conformity and
orthotic topography)
Frictional characteristics
Deformation of device under load
83. They changed the thinking of many in one journal article...
But, I look to Magritte for the answer!
84.
85. Old Orthotic Rx
• Material
• Top-cover
• RF Posting
• FF Posting
• Accommodations and modifications
86. Old School Root
Orthotic:
Rohadur
• The cast is altered significantly during
manufacturing process
• Too narrow to be truly effective
• Very often there was too much arch fill
• Forefoot balancing
–With bad casting technique
87. Modern Orthotic: Features
(What Dr. Schuster Used In His Orthotics)
• Deep heel cup
• Minimal cast correction
• Good contour to foot
• Wide enough to do the job
• Functions also at talo-navicular and C-C joint and midfoot
• Anatomically correct accommodations
–Sesamoid/1st Met
–Sweet spots - navicular/heel
• Bevel rear foot post when needed
88. The Clash of the
Cast(ing) Technique
Text
Old: Semi weight bearing or non-weight bearing
New: Wipe out or enhance a plantar flexed first ray
89. Negative
Impression
Capture
Earlier: Tracings, Trays of Plaster or
Grease.
Plaster Bandage
Casting
Reed E.N.: A simple method for making
plaster casts of feet. JBJS (1933).
17:1007
90. New Orthotic Rx
• Kirby Skive
• Inversion of cast (Blake or less than Blake)
• RF posting material
• RF post
• Thickness of shell, material choice
• Additions/Modifications
• Plantar fascial groove
91. Schuster: Impact
On Orthotic
Modifications
Modifications below polypropylene shell. Adding felt or other
material to increase “arch support” and firmness. (Kirby:
Newsletter (Aug 2013))
Thinning shell by grinding in area of arch to make it more
flexible.
(Medial or lateral) Decrease bevel of heel.
Orthotic design has ultimately swung around to many of what
Schuster proposed and practiced
92.
93. 3 Things That Don’t
Exist
(as described)
Or are less commonly seen than diagnosed
• Unicorns
• Metatarsalgia as a Condition (It is a
symptom not a diagnosis.)
• Cuboid Syndrome
96. 3 Things Not To Miss
• Plantar plate injury - symptomatic, low
grade
• Peroneal tendinopathy brevis behind fibula
& longus tendinopathy (below foot)
• Lisfrank injury - symptomatic, low grade
• Today: Skipping Lisfrank and looking at
Sever’s
97. Internet Research:
Metatarsalgia
Definition
Metatarsalgia is a condition marked by pain and inflammation in the
ball of your foot.
Metatarsalgia is caused by the compression of a small toe nerve
between two displaced metatarsal bones. Inflammation occurs when
the head of one displaced metatarsal bone presses against another
and they catch the nerve between them. With every step, the nerve is
pushed together by the bones and then rubbed, pressed again, and
irritated without relief. Consequently, the surrounding nerve tissue
becomes enlarged, with a sheath of scar tissue that forms to protect
the nerve fibers.
We can do better than this.
101. Case Study: Forefoot
Pain
• 57 year old master triathlete, 5k and
martial arts competitor. 9 months of
forefoot pain interfering with sports and
ADL.
102. Clinical History &
Evaluation
• Chief complaint: 9 months of
undiagnosed and unresolved pain
below his second metatarsal.
• HPI: 2nd MTP & 2nd digit pain,
weakness at toe off. Trail running and
martial arts are difficult and painful for
this long time high level athlete.
105. Take Aways
• It isn’t always “just a hammertoe”
• Pay attention to signs, symptoms, exam
• Metatarsalgia is a symptom (like angina)
not a diagnosis
107. Pre-dislocation
Syndrome
Gerard Yu et. al., JAPMA 2002
“idea of idiopathic pain and instability of the
metatarsophalangeal joint is relatively new”
“can develop following jogging, tennis and
basketball or minor trauma.”
Can be viewed as intermediate level plantar plate
injury
108. Presentation
Late antalgic gait
Mistaken diagnoses are common
Feel “lump” or bruise at met head
Plantar plate involved (rather than “bursa”)
Yu et. al. 2002
109. Pathomechanics
Review • Anatomy: Second Digit - 2 dorsal interossei, no
plantar interossei, medial first lumbricale
• Primary (chronic) deforming force: EDL
• Primary digital flexor: Interossei
• Dynamic digital stabilizers: Interossei and
lumbricales
• Static digital stabilizers: PLANTAR PLATE,
collateral ligaments (also capsule and plantar
fascia)
110. Key: Role of Plantar
Plate
• Plantar plate is the primary static
stabilizer
• Dynamic stabilization is by intrinsic and
extrinsic muscles
–But is dependent upon intact plantar
plate
Must Read: Yu JAPMA April 2002 182-199
111. Function of Digits
• Assist balance, proprioception
• Aid in force transfer forward
112. Plantar
plate/Predislocation
Syndrome
• Pain localized to plantar MTPJ
• Negative tuning fork test
• X-rays - no change in early stage
• Bone scan can show uptake at MTPJ
113. Evaluative Process
• Minor trauma may be recalled
• Onset acute or subacute (occ. chronic)
• Digital contracture - late stage
• Positive vertical drawer test
• Absent Moulder sign
• Subtle malalignment of toe
118. Intermediate Stage
Plantar Plate Injury: Tx
• Immobilization
–6 to 12 weeks
• Plantar flexion exercises
• Splinting
• Orthotic
–Control abnormal biomechanics
–No anterior bevel
–Poron added from mets to sulcus
• Surgery
Resolved with conservative
therapy. Resumed 5Ks and
martial arts.
119. Case 2: Mild Plantar Plate
Injury
57 year old female runner with a 30 year running
streak.
Pain below right 2, 3 metatarsals
Began after sprint training. Worsened by toe pull
ups and toe press against wall stretch.
120. Negotiated Treatment
(Case 2)
Relative rest. Decrease running from 6 to 4
miles.
Toe curls - strengthen flexors, intrinsics
No sprints, speed work
Avoid awful stretches
Midfoot/heel contact - not forefoot
400’s in future: at sustainable speed with
rest between 400’s not sprint straightaways,
walk curves.
121. Summary:
Metatarsalgia
• Less than optimal diagnosis
• “Like saying ‘headache’ - S. Bartold
• Under-diagnosed: Plantar Plate Injury
• Lumbricale tendinopathy
123. Case Study: Juvenile
Heel Pain
• Presentation: 8 year old child, student,
and basketball player presents with 6
months of pain in both heels, with the
right foot more symptomatic than the
left.
• He is hoping for an NBA career.
125. Clinical History &
Evaluation
• Chief complaint: 6 months of undiagnosed
and unresolved pain both posterior and
plantar heels.
• HPI: Reports pain during jumping and
running. It has minimally improved with
short term rest, but returns.
• Mom will not let him run cross country due
to pain and fear of he may need orthotics.
Dad thinks it may be Achilles tendinopathy.
126. Physical Examination
• Thorough examination - examine area
of chief complaint and nearby
structures.
• Look for biomechanical risk factors
• Evaluate for equinus, Achilles and
hamstring tightness and pronatory
forces.
suggested readings: JAPMA September
2013
127. Left foot
“Sclerosis is
often seen but
not
diagnostic.
Likewise
fragmentation
.”
Right foot
128. Sever’s “Injury”, Disease, or Phenomena?
Growth center abnormality
is not always present
may be present in normals
associated with athletic activity
recent articles call it a “clinically diagnosed disorder”
Inadequate Classical treatment:
Wait until growth plate fuses
Rest
Heel Lift
Seaver the phenomena
129. Lifespan of Misinformation: Endless
Juvenile Osteochondroses, Stammel,
CA Radiology Oct 1940
The opportunity for education, is always present.
130. Is Sever’s likely another -opathy not an -itis?
Calcaneal Apophysopathy
No biopsy material
No evidence of “inflammation”
Clearly traction related
After tendinopathy, fasciopathy, why not?
131.
132. Calcaneal Apophysopathy
Heel pain on one or both sides with 60% having bilateral symptoms
Heel pain with running, jumping
Antalgic gait
Pain elicited when the heel is compressed medially and laterally at
the apophysis
Often classical radiographic signs are present
Growth center appears in boys aged 7-8 and fuses at 15-17
Growth center appears in girls aged 4-6 and fuses at 12-14
133. Calcaneal Apophysopathy
Acute Care:
Rest, Ice, Elevation.
Relative rest - allow pain free activity
Limit motion using: Heel lift or Pneumatic Walker
In The Long Run:
Evaluate biomechanics carefully
Heel lift
Gentle calf stretching
Intrinsic muscle group strengthening (toe crunch)
Tibialis anterior strengthening
Custom orthotics may be needed
Gradual return to activity
134. Case Comparison: The Runner
March 1984
cc: 25 yo♀Lateral ankle and leg pain while running
•Ankle sprain - untreated 10 days
•Brief use of soft cast
•5-6 week rest
•Pain
135. Case Comparison: The Runner
March 1984
Schuster (Footwork Column):
•Warned of the danger of waiting for
treatment of ankle injury.
•Used lateral wedge below insole.
•Lateral buttress on counter and lateral
aspect of shoe.
•Recommended exercises for the ankle.
•Felt further evaluation and surgery might
be needed if this did not work.
136. Case Comparison: The Runner
March 1984
30 years later..
The lateral wedge holds up and the buttress also.
137. Case Comparison: The Runner
March 1984
Areas for improvement:
• Improved assessment of ankle injury via better
physical examination, anterior drawer test,
imaging.
• Pneumatic cast boot = better immobilization
• Longer immobilization
•Wobble board training - muscle strength,
balance, proprioception
138. Case Comparison: The Runner
March 1984
Orthotic Improvements
No lateral bevel
Forefoot - Valgus wedge 3°
Orthotic for contour to foot not insole
(Reverse Kirby skive and -Inversion casting)
Exercise Improvements
Wobble board not just rubber bands and ROM
Bracing or taping
Shoes - avoid mushy, over-cushioned shoes
139. Case Study:
Lateral Ankle Pain in Olympic Triple
Jumper
• 26 year old elite Triple Jumper
• Lateral foot and ankle pain for nearly a
year
140. Case Study:
Lateral Ankle
• Symptoms present in training shoes,
running on grass
• Shoe role in pain causation - Mizuno -
soft & squishy
• Previous treatment: Injection at PB
tendon behind ankle: FAIL
141. Case Study:
Lateral Ankle
• Physician suggestion via phone: Sinus
tarsi injection
• My suggestion before examination:
“Let’s check it out and see if it is
something else and we can do
something mechanically.”
142. Case Study:
Lateral Ankle
• Somewhat tender at peroneus brevis below
ankle
• My suspicion: Training Shoes
• Symptoms present in training shoes, running
on grass
• Symptoms not present in competition flats and
track work.
• Shoe role in pain causation - soft & squishy
(miz)
143. Treatment
• Change to more solid shoe, different brand
• Add 1/8 to 1/4” heel lift to decrease forces
on PB tendon
• Wobble board therapy + Calf/Posterior
muscle group stretching
• Consider orthotic as discussed above:
–No lateral bevel, 2 degree valgus post to
sulcus for training shoe only
144.
145. Belief Systems
“Beliefs held by patients about their health and
illness are central to how they present, (and)
respond to treatment”...
Beliefs are pre-existing notions and typically
involve strong personal endorsement for a
proposition considered true and beyond
further inquiry.
e.g. Mom of 8 year old whose “feet are still growing”
Peter Halligan, (2007) The Psychologist, 20:6 358
148. Schuster on Root
–“...research by Inman, Strauss, Elftman,
Manter, Hicks, Hibbs, and many others
was put together in a meaningful
biomechanical concept by Dr. Merton L.
Root”
–“Root...emphasized the relationship of the
forefoot to the rearfoot and provided
..validity for the comparatively hazy
balance concepts of earlier years.
149. Misunderstanding
Root
• There is a difference between the
Aristotelian average and the Platonic
ideal.
• Ideal normal is different from average
findings.
• The ideal was lost to the mundane.
150. Kirby
• Foot orthoses have effects
on Midtarsal/Midfoot Joints
• Plantar Ligaments and
muscles cause a
longitudinal arch raising
moment
• Longitudinal arch stops
lowering at position of
rotational equilibrium
• Foot orthosis acts to
reduce tensile stress on
plantar soft tissue
structures
illustration: Kevin Kirby
152. And More
cop: position 1; mtj: position a; STJ axis i =?
cop position 2; mtj: position a; STJ axis i =?
cop position 3; mtj: position a; STJ axis i =?
cop position 1; mtj: position b; STJ axis i =?
cop position 1; mtj: position c; STJ axis i =?
Simon Spooner trying to make
Kevin Kirby think hard
153.
154.
155. What would Dr. Schuster say today?
New paradigms in shoe design lead to new injuries.
Don’t wear more shoe than you need or less
shoe than works.
156. Schuster on The Future of Running
Shoes
“running injuries vary year to
year in response to the latest
“advances” in running shoes. “
Changes in flexibility of the
shoe and the rigidity of the
heel counter may help some
runners but cause problems
for others.
157. Schuster on The Future of Running
Shoes
“As shoes get lighter with the use
of new materials, injuries may
result from less support and
cushioning.”
“Shoes must offer flexibility,
cushioning, support and they must
fit your feet.” (feel comfortable)
158. Schuster on Running
Injuries
Over cushioned shoes can create
problems.
Shorter strides can help hip and
gluteal problems.
Calcium balance and hormonal
issues contribute to women’s
stress fractures.
Heel lifts are not evil.
Stretch wisely.
And Dr. D’Amico who also provided valuable and important life lessons
I won’t be saying anything over and over. We’ll be looking at many things from many perspectives.
People are said to only be able to have 3 take aways in a 30 minute lecture or perhaps in any one lecture. But who knows what these three things might be. I’ll try to let you pick your own three from an amalgamation of diverse material.
Over-stretching - data
Thinking and evaluation must continue.
In biomechanics, we have often dealt with models and criticism of models.
Most important to our patients, if not posterity, is “what works”. This is probably the most useful bit of information I picked up from Dr. Schuster & the Biomechanics Dept.
Biology is too important to leave to the biologists” (Robert Nerem, PhD 1996)
When I first heard of the seminar and Jerry Seinfeld’s involvement. I thought wonderful: Especially considering what Jerry is doing today: I like coffee and I like comedians.
Podiatry Fellows in Jimbo’s Getting Coffee
But somehow it reminded me of days gone by. And I see that Jimbo’s has lived longed and prospered.
Wisdom of the aged?
Many ways to look at Schuster as an educator, administrator, advocate for neurologically impaired children, runners. Early participant in the sports medicine boom.
Wore many different hats as we all do, and may have done it much better:
Father, grandfather, husband, doctor.
Part I in current issue (September 2013). Part II in October 2013.
Only looking back recently and for general principles.
october 1973
1976
"the Shot Heard 'round the World" is the term given to the game-winning home run by New York Giants outfielder Bobby Thomson off Brooklyn Dodgers pitcher Ralph Branca at the Polo Grounds to win the National League pennant at 3:58 p.m. EST on October 3, 1951. As a result of the "shot", the Giants won the game 5-4, defeating the Dodgers in their pennant playoff series, 2 games to 1.
But the giants lost to the Yankees in 6 games.
Mickey Mantle shown on the back 'front page' of the New York "Daily News” newspaper, April 18, 1953. Mantle is holding the home run ball he hit out of Washington, D.C.’s Griffith Stadium, estimated to have gone a distance of some 562 feet.
1979 rogers and greta
When you want to give your feet a rest, the NY Subway is the very best.
Jim Fixx image
http://www.trainmor-knowmore.eu/FBC5DDB3.en.aspx
Data: a set of discrete objective facts about an event or a process which have little use by themselves unless converted into information. Data for example are numerical quantities or other attributes derived from observation, experiment, or calculation. Cost, speed, time and capacity are quantitative data.
Information: data endowed with relevance and purpose. It has meaning and it is organized for some purpose. Information for example, is a collection of data and associated explanations, interpretations, and other textual material concerning a particular object, event, or process.
Data could be converted into information using 5 main processes [3]:
Condensation – items of data are summarized into a more concise form and unnecessary depth is eliminated;
Contextualization –the purpose or reason for collecting the data in the first place is known or understood;
Calculation - data is processed and aggregated in order to provide useful information
Categorization – is a process for assigning a type or category to data;
Correction – is a process for removal of errors.
Knowledge: a fluid mix of framed experience, values, contextual information, expert insight and grounded intuition that provides an environment and framework for evaluating and incorporating new experiences and information. It originates and is applied in the minds of people. In organizations, it often becomes embedded not only in documents or repositories but also in organizational routines, processes, practices, and norms [3].
Knowledge is based on information that is organized, synthesized, or summarized to enhance comprehension, awareness, or understanding. Knowledge represents a state or potential for action and decisions in a person, organization or a group. It could be changed in the process of learning which causes changes in understanding, decision or action. A visual definition relates knowledge with a bite from a red apple - ‘a bite (of information) should be taken, chewed, digested, and acted upon so that it becomes knowledge’ [6].
Typical questions in relation to data and information include who, what, where and when, while questions relating to knowledge include how and why.
Wisdom: the ability to identify truth and make correct judgments on the bases of previous knowledge, experience and insight. Within an organization, intellectual capital or organizational wisdom is the application of collective knowledge.
Podiatric sports medicine was an important force in putting modern podiatric medicine on the map.
One of Founding fathers of AAPSM
Dr. Richard Gilbert, AAPSM’s second president (1979-80), presents award to Dr. Richard Schuster
Long before journalists went on a barefoot rampage Schuster gave Sheehan orthotics and sports podiatry and treating running injuries took off like a shot.
“George typed while seated, but composed his thoughts on the road.
”
I first heard George speak in 1973 at NYCPM.
I consider that talk one of the defining and direction giving moments for my career.
It took all these years though to figure out “how did Sheehan come to speak at NYCPM?”.
As a freshman I knew little about the powers that be. But in this case the power that was was the friendship of Schuster and Sheehan.
In the late 1960s and early 1970s, endurance running was gaining popularity at an exponential rate. Paul Milvy organized the scientific and medical conference entitled ‘The Marathon: Physiological, Medical, Epidemiological, and Psychological Studies’ associated with 1976 New York Marathon and sponsored by the New York Academy of Sciences to provide a forum for scientists to interact and to publish the proceedings to serve as a resource for future sports medicine research. The conference was a major success and the published proceedings have continued to be a significant resource for those in exercise science and sports medicine over the past 30 years. The challenge for this meeting is to bring forward the many new findings on marathon running and fill many of the gaps in our knowledge of exercise performance and human health that have occurred since 1976.
“Dr. Richard Schuster has been a pioneer in the field of sports podiatry and a good friend. He developed orthotics for my feet that saved me from injury. Without his professional and personal encouragement I wouldn’t be running today.” Bob Glover
Ali MacGraw and Kris Kristofferson were young.
Steve McQueen was alive and Ali’s ex-husband.
The Runner March 1981
Later Runner’s World
Used the new diagnostic tool of bone scan.
Still used the archaic and awful term pre-stress fracture. I prefer “stress reaction”.
http://www.runnersworld.com/running-shoes/leveling-flat-feet?page=single
"Runners with low-arched feet generally don't have to worry," says Schuster. "The runner with high-arched feet is usually the one with more problems. This is a highly complex situation, but generally a low-arched foot is a fairly strong foot. A lot of runners probably have low-arched feet and don't even know it."
Had the luck to only have one person in the room for my podiatry school interview. And it was a warm and welcoming meeting.
Star Wars - May 1977
Schuster while writing and thinking academically for many years, represented to me a nearly intuitive and clear thinking approach to patient problems.
Another gray haired gentleman taught similarly, not much later.
“Go with the force Luke” could have been an injunction to measure and determine abnormal biomechanical forces.
And so began an eternal battle against the evil and abnormal biomechanical forces encountered during running, walking, and other lifetime and sporting events.
Some people saw Obie Wan Kanobie....
Over the years I came to know more about Schuster and see his character consistently demonstrated.
Patients' Perspectives on Ideal Physician Behaviors
Neeli M. Bendapudi, PhD, Leonard L. Berry, PhD, Keith A. Frey, MD, MBA, Janet Turner Parish, PhD, William L. Rayburn, MD
. Interviews focused on the physician-patient relationship and lasted between 20 and 50 minutes. Patients were asked to describe their best and worst experiences with a physician in the Mayo Clinic system and to give specifics of the encounter. The interviewers independently generated and validated 7 ideal behavioral themes that emerged from the interview transcripts. The ideal physician is confident, empathetic, humane, personal, forthright, respectful, and thorough. Ways that physicians can incorporate clues to the 7 ideal physician behaviors to create positive relationships with patients are suggested.
Physicians need to be clue conscious in how they provide service, and this, too, represents an educational opportunity. The management of customer experience is being taught more frequently in business schools, and it could be taught to physicians and medical students as well. Table 2 illustrates how physicians can effectively manage humanic clues in support of the ideal physician behaviors. The clue examples described are from the interview transcripts, from patient focus groups also conducted at Mayo Clinic, and from the personal observations of the research team. Educational sessions that incorporate role playing and participant feedback can be built around the ideal physician behaviors and clue management concepts.
Physicians need to be clue conscious in how they provide service, and this, too, represents an educational opportunity. The management of customer experience is being taught more frequently in business schools, and it could be taught to physicians and medical students as well. Table 2 illustrates how physicians can effectively manage humanic clues in support of the ideal physician behaviors. The clue examples described are from the interview transcripts, from patient focus groups also conducted at Mayo Clinic, and from the personal observations of the research team. Educational sessions that incorporate role playing and participant feedback can be built around the ideal physician behaviors and clue management concepts.
7 ideals of physician behaviors
The opposite
Strangely most of the images about being humane on google were of animals.
Humor - use it carefully.
Take notes to jog your memory and ability to remember key events: trip, colleges of children, special interests
Clues carry messages.
They relate to the caregiver’s competence and caring.
Carry your tools with you:
Brain
Eyes
Ears
Hands
http://managewell.net/?p=1500
There is an interesting story about the famous Jefferson Memorial. A few years back, for no apparent reason, the monument was found decaying significantly more than other monuments. At the initial inspection, it seemed like it was acid rain or some such thing, but on detailed inspection, and after asking a series of ‘why’ questions, the root-cause was found to be completely unrelated to the original problem. Here’s roughly how the chain of thoughts proceeded:
Problem: Jefferson Memorial was found crumbling more rapidly then other similar monuments.
Question:Why was Jefferson Memorial crumbling faster than other monuments? Was it due to acid rain?
Answer: It was not acid rain. The monument was being cleaned both inside and outside twice a week with strong cleaning soaps. Upon further investigation, it was revealed that erosion was being caused by soap solution reacting with exhaust from jet fuel from the airport across the river.
Question: Why was the monument being cleaned twice with such strong cleaning agents?
Answer: Because there were lots of bird droppings, which were spoiling the monument, and to keep the monument clean, they had to wash it frequently.
Question: Why there were such high numbers of birds at this memorial compared to other memorials?
Answer: Because there were very high numbers of spiders at the memorial which birds like to eat!
Question: Why there were such high numbers of spiders at this monument?
Answer: Because there were a large number of midges (tiny aquatic inspects) that these spiders love to feast on.
Question: Why were there so many midges at this memorial?
Answer: Because midges were coming out for sex (yes, literally!) at dusk and were being attracted by light which was caused by the floodlights that were being put on just before the dusk – to make the memorial beautiful for the tourists! They would promptly die thus triggering the whole food chain.
So, that was the key. This was a long-lead food chain that had eventually turned into a problem. While the initial possible solutions included building a huge glass cover around the memorial, or even moving the airport far away (both of which seemed like very costly and complex solutions), eventually National Park Service delayed putting on the floodlights by one hour which led to midges population going down by 90% and the food chain was broken, and the problem was solved.
---
First, get all the data. In the absence of data, we are all only conjecturing, and as creative that might be, we need to back it up with objective data to eventually make meaningful and better decisions.
Whenever possible, involve other affected groups or individuals in the process at the earliest. No point second-guessing on their behalf.
If they haven’t been part of the original root-cause analysis, instead of shooting off an email to them asking them ‘what’ is to be done, walk them through the entire process and ask them for validation. At this point, get an agreement on the problem without telling them your view of the solution.
Once there is an agreement on the problem, half the battle is already won. Now start asking them how would they solve it.
An ideal situation is when their solution is same as yours. But that might not always happen. If their solution is different than yours, first understand what is it that they are telling you, and why do they think that will solve the problem.
At this stage, if you are not convinced of their approach, let them know so, and share what your original root-cause analysis exercise has come up with. The idea is not to confront them, but rather present another perspective and to compare and contrast what is better way to address the issue.
If there is a toss-up between these two approaches, it might make sense to go with their solution rather than yours for two primary reasons – they are the primary function owners and hence expected to have better subject-matter expertise and professional judgment than you, and secondly if you go with their perspective, you are likely to get a better buy-in in the long run.
However, if there is a deadlock, and quite often that is the case, one has to be accommodating. A very natural response is to go up the reporting chain and push for our solution, but I haven’t seen that is very productive in the long run. I would give benefit of doubt to the concerned group or the function and ask them to try for a reasonable and mutually agreed upon period of time till we see if the problem is resolved effectively. If it is not getting resolved, it’s time to once again get back to the drawing board.
Hopefully you have an agreement by now on a solution that actually addresses the core issue and solves it. God bless you.
Always remember – today’s solutions are tomorrow’s problems. While you might have solved the problem, in the bargain you might have inadvertently triggered-off another problem that is waiting to be manifest somewhere else in the organization in due course of time. So, keep your eyes and ears open if any new issues are reported – it is quite likely that they are regression effect of the current solution!
Mayo Clinic: researchers measured stride length, cadence and velocity of over 1,341 participants using computerized gait analysis during visits about 15 months apart.
Lower cadence, velocity and length of stride correlated with significantly larger declines in global cognition, memory and executive function.
Basel, Switzerland: 1,153 adults with a mean age of 78, found that gait became "slower and more variable as cognition decline progressed."
Groups: cognitively healthy, mild cognitive impairment (MCI) or Alzheimer's dementia.
Gait was measured using a walkway with 30,000 sensors. Those with Alzheimer's walked slower than those with MCI, who walked slower than those who were cognitively healthy.
Occam’s Razor - Use the simplest of all competing hypotheses. The one with the fewest assumptions.
Iconoclast Kirby
Nigg 1998
Five inserts identical shape but different materials designed to reduce pronation
• 12 subjects heel toe running at 4 m/s
• Foot eversion and tibial rotation measured using skin markers
Only 1 of the 12 subjects showed reduction in foot eversion and tibial rotation or no change for all conditions (7)
• One subject showed reduction in eversion but increase in tibial rotation in all insoles (4)
• One subject showed a reduction in foot eversion for all insoles conditions, but an increase in tibial rotation for only some (2)
Semi weight bearing or non-weight bearing
Wipe out or enhance a plantar flexed first ray
UFO’s
Honest Politicians
Always more complex than fairy tales.
http://www.podiatrytoday.com/article/3036?page=1
see review of plantar plate swf file:
http://www.blackburnfeet.org.uk/hyperbook/elective/lesserToes/lesserToes.swf
http://footandankle.mdmercy.com/research_pubs/pressitem32.html
1. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993; 14:385-388.
2. Bojsen-Moller F. Anatomy of the forefoot, normal and pathologic. Clin Orthop 1979; 142:10-18.
3. Hughes J, Clark P, Klenerman L. The importance of the toes in walking. J Bone Joint Surg 1990; 72B(2):245-251.
4. Lambrinudi C. Use and abuse of toes. Postgrad Med J 1932; 8:459-464.
5. Betts RP, Stockley I, Getty CJ, Rowley DI, Duckworth T, Franks CI. Foot pressure studies in the assessment of forefoot arthroplasty in the rheumatoid foot. Foot Ankle 1988; 8:315-326.
6. Bojsen-Moller F, Lamoreux L. Significance of free-dorsiflexion of the toes in walking. Acta Orthop Scand 1979; 50(4):471-479.
7. Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989; 20(4):535-551.
8. Mann RA, Coughlin MJ. Lesser-toe deformities. In: Jahss MH, ed. Disorders of the Foot and Ankle. Medical and Surgical Management, 2nd edn. Philadelphia: WB Saunders Co, 1991; 1205-1228.
9. Coughlin MJ, Mann RA. Lesser toe deformities. In: Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle, 6th edn. St. Louis: Mosby-Year Book Inc, 1993; 341-411.
10. Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg 1969; 51A(4):669-679.
11. Branch HE. Pathologic dislocation of the second toe. J Bone Joint Surg 1937; 19:978-984.
12. Myerson MS. Arthroplasty of the second toe. Semin Arthroplasty 1992; 3(1):31-38.
13. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg 1989; 71A(1):45-49.
14. Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop 1977; 123(Mar-Apr):63-69.
15. Bhatia D, Myerson MS, Curtis MJ, Cunningham BW, Jinnah RH. Anatomic restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique. J Bone Joint Surg 1994; 76A(9):1371-1375.
16. DuVries HL. Dislocation of the toe. JAMA 1956; 160:728
17. Lambrinudi C. The feet of the industrial worker. Lancet 1938; 2:1480-1484.
18. Morton DJ. Metatarsus atavicus: the identification of a distinctive type of foot disorder. J Bone Joint Surg 1927; 9:531-544.
19. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg 1951; 33B:539-542.
20. Snow RE, Williams KR, Holmes GB, Jr. The effects of wearing high heeled shoes on pedal pressure in women. Foot Ankle 1992; 13:85-92.
21. Soames RW, Clark C. Heel height-induced changes on metatarsal loading patterns during gait. In: Winter DA, Norman RW, Wells RP, Hayes KC, Patla AE, eds. Biomechanics IX-A, Champaign (IL): Human Kinetics Publishers, 1985; 446-450.
22. Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987; 8(1):29-39.
23. Jahss MH. Miscellaneous soft-tissue lesions. In: Jahss MH, ed. Disorders of the Foot, 2nd edn. Philadelphia: WB Saunders Co, 1982; 1514-1539.
24. Mann RA, Mizel MS. Monarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis? Foot Ankle 1985; 6(1):18-21.
25. Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle 1993; 14:309-319.
26. Garth WP, Jr., Miller ST. Evaluation of claw toe deformity, weakness of the foot intrinsics, and posteromedial shin pain. Am J Sports Med 1989; 17:821-827.
27. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics 1987; 10(1):83-89.
28. Mann RA. Pathological anatomy of claw and hammer toes [letter; comment]. J Bone Joint Surg 1990; 72A:305
29. Richardson EG. Lesser toe abnormalities. In: Crenshaw AH, ed. Campbell's Operative Orthopaedics, 8th edn. St. Louis: CV Mosby Co, 1991; 2729-2755.
30. Mizel M, Treppman E. Conservative treatment of second metatarsaophalangeal joint synovitis. Presented at the Annual Meeting of the American Orthopaedic Foot and Ankle Society, Ashville, NC, July 17, 1993.
31. Milgram JE. Office measures for relief of the painful foot. J Bone Joint Surg 1964; 46A:1095-1116.
32. Cameron HU, Fedorkow DM. Revision rates in forefoot surgery. Foot Ankle 1982; 3:47-49.
33. Hamilton WG. Foot and ankle injuries in dancers. In: Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle, 6th edn. St. Louis: Mosby-Year Book Inc, 1993; 1241-1276.
34. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle 1984; 5:67-73.
35. Girdlestone GR. Physiotherapy for hand and foot. J Chart Soc Physiother 1947; 32:167-169.
36. Newman RJ, Fitton JM. An evaluation of operative procedures in the treatment of hammer toe. Acta Orthop Scand 1979; 50:709-712.
37. Kuwada GT, Dockery GL. Modification of the flexor tendon transfer procedure for the correction of flexible hammertoes. J Foot Surg 1980; 19:38-40.
38. Parrish TF. Dynamic correction of clawtoes. Orthop Clin North Am 1973; 4:97-102.
39. Thompson FM. Disorders of the second metatarsophalangeal joint. In: Myerson MS, ed. Current Therapy in Foot and Ankle Surgery, St. Louis: Mosby-Year Book, 1993; 13-26.
40. Lillich JS, Baxter DE. Common forefoot problems in runners. Foot Ankle 1986; 7:145-151.
41. Cahill BR, Connor DE. A long-term follow-up on proximal phalangectomy for hammer toes. Clin Orthop 1972; 86:191-192.
42. Daly PJ, Johnson KA. Treatment of painful subluxation or dislocation at the second and third metatarsophalangeal joints by partial proximal phalanx excision and subtotal webbing. Clin Orthop 1992; 278(May):164-170.
43. Glassman F, Wolin I, Sideman S. Phalangectomy for toe deformities. Surg Clin North Am 1949; 29:275-280.
44. Sandeman JC. The role of soft tissue correction of claw toes. Br J Clin Pract 1967; 21(10):489-493.
45. Myerson M. Claw toes, crossover toe deformity, and instability of the second metatarsophalangeal joint. In: Myerson M, ed. Current Therapy in Foot and Ankle Surgery, St. Louis: Mosby-Year Book, Inc, 1993; 19-26.
46. Scheck M. Degenerative changes in the metatarsophalangeal joints after surgical correction of severe hammer-toe deformities. A complication associated with avascular necrosis in three cases. J Bone Joint Surg 1968; 50A:727-737.
47. Kelikian H, Clayton L, Loseff H. Surgical syndactylia of the toes. Clin Orthop 1961; 19:208-231.
48. McConnell BE. Hammertoe surgery: waist resection of the proximal phalanx, a more simplified procedure. South Med J 1975; 68:595-598.
49. Smith RW, Conklin MJ. Salvage of the atypical lesser toe deformity with a basal hemiphalangectomy. Presented at the 23rd Annual Meeting of the American Orthopaedic Foot and Ankle Society, San Francisco, CA, February, 1993.
50. Vanderwilde RS, Campbell DC. Second toe amputation for chronic painful deformity. Presented at the 23rd Annual Meeting of the American Orthopaedic Foot and Ankle Society, San Francisco, CA, February, 1993.
51. Ely LW. Hammertoe. Surg Clin North Am 1926; 6:433-435.
52. Goldner JL, Ward WG. Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment. Bull Hosp Joint Dis Orthop Inst 1987; 47(2):123-135.
Predislocation Syndrome
Progressive Subluxation/Dislocation of the Lesser Metatarsophalangeal Joint
Gerard V. Yu, DPM*, Molly S. Judge, DPM†, Justin R. Hudson, DPM‡ and Frank E. Seidelmann, DO‡
Progressive subluxation/dislocation of the lesser toes resulting from idiopathic inflammation about one or more of the lesser metatarsophalangeal joints is a common cause of metatarsalgia that is frequently unrecognized or misdiagnosed. The disorder results from a failure of the plantar plate and collateral ligaments that stabilize the metatarsophalangeal joints and is typically associated with abnormal forefoot loading patterns. The authors refer to this condition as predislocation syndrome and have devised a clinical staging system that is based on the clinical signs and symptoms present during examination. A thorough review of predislocation syndrome and an overview of the conservative and surgical treatment options available for this disorder are presented. (J Am Podiatr Med Assoc 92(4): 182-199, 2002)
Stability of the lesser metatarsophalangeal joint is derived from the plantar plate, the collateral ligaments, and the intrinsic and extrinsic foot musculature.15-17 Static stabilization of the metatarsophalangeal joint is derived primarily from the plantar plate and collateral ligaments. The plantar plate is described as a fibrocartilaginous thickening of the metatarsophalangeal joint capsule plantarly that is firmly attached to the base of the proximal phalanx but only loosely attached to the metatarsal head.15 It is composed of type I collagen that is histologically identical to the collagen present in the meniscus of the knee.16 The plantar plate acts as the major distal attachment of the plantar fascia and has attachments to the deep transverse metatarsal ligament and metatarsophalangeal joint collateral ligaments. It also serves as an insertion for both the interosseous and the lumbrical tendons. Inferiorly, the plantar plate has a smooth grooved surface for the passage of the flexor tendons.
sonogram showing completely normal anatomy of the plantar plate. This patient initially was diagnosed as having a Morton’s entrapment and was subsequently treated with a series of sclerosing injections. Compare with Figure 2.
Use of High-Resolution Ultrasound in Evaluation of the Forefoot to Differentiate Forefoot Nerve Entrapments
Brian R. Kincaid, DC* and Stephen L. Barrett, DPM, MBA†
JAPMA 2005+
Sonogram showing serious disruption of the plantar plate attributable to a series of sclerosing injections (arrow). This image was taken 90 days after the image in Figure 1. The patient had continued pain but from a different cause than the primary nerve entrapment.
http://www.japmaonline.org/content/95/5/429.full?sid=b0f9217d-481d-4a88-8d26-35c498765487
Control abnormal biomechanics
No anterior bevel
Poron added from mets to sulcus
see review of plantar plate swf file:
http://www.blackburnfeet.org.uk/hyperbook/elective/lesserToes/lesserToes.swf
http://footandankle.mdmercy.com/research_pubs/pressitem32.html
1. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993; 14:385-388.
2. Bojsen-Moller F. Anatomy of the forefoot, normal and pathologic. Clin Orthop 1979; 142:10-18.
3. Hughes J, Clark P, Klenerman L. The importance of the toes in walking. J Bone Joint Surg 1990; 72B(2):245-251.
4. Lambrinudi C. Use and abuse of toes. Postgrad Med J 1932; 8:459-464.
5. Betts RP, Stockley I, Getty CJ, Rowley DI, Duckworth T, Franks CI. Foot pressure studies in the assessment of forefoot arthroplasty in the rheumatoid foot. Foot Ankle 1988; 8:315-326.
6. Bojsen-Moller F, Lamoreux L. Significance of free-dorsiflexion of the toes in walking. Acta Orthop Scand 1979; 50(4):471-479.
7. Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989; 20(4):535-551.
8. Mann RA, Coughlin MJ. Lesser-toe deformities. In: Jahss MH, ed. Disorders of the Foot and Ankle. Medical and Surgical Management, 2nd edn. Philadelphia: WB Saunders Co, 1991; 1205-1228.
9. Coughlin MJ, Mann RA. Lesser toe deformities. In: Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle, 6th edn. St. Louis: Mosby-Year Book Inc, 1993; 341-411.
10. Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg 1969; 51A(4):669-679.
11. Branch HE. Pathologic dislocation of the second toe. J Bone Joint Surg 1937; 19:978-984.
12. Myerson MS. Arthroplasty of the second toe. Semin Arthroplasty 1992; 3(1):31-38.
13. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg 1989; 71A(1):45-49.
14. Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop 1977; 123(Mar-Apr):63-69.
15. Bhatia D, Myerson MS, Curtis MJ, Cunningham BW, Jinnah RH. Anatomic restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique. J Bone Joint Surg 1994; 76A(9):1371-1375.
16. DuVries HL. Dislocation of the toe. JAMA 1956; 160:728
17. Lambrinudi C. The feet of the industrial worker. Lancet 1938; 2:1480-1484.
18. Morton DJ. Metatarsus atavicus: the identification of a distinctive type of foot disorder. J Bone Joint Surg 1927; 9:531-544.
19. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg 1951; 33B:539-542.
20. Snow RE, Williams KR, Holmes GB, Jr. The effects of wearing high heeled shoes on pedal pressure in women. Foot Ankle 1992; 13:85-92.
21. Soames RW, Clark C. Heel height-induced changes on metatarsal loading patterns during gait. In: Winter DA, Norman RW, Wells RP, Hayes KC, Patla AE, eds. Biomechanics IX-A, Champaign (IL): Human Kinetics Publishers, 1985; 446-450.
22. Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987; 8(1):29-39.
23. Jahss MH. Miscellaneous soft-tissue lesions. In: Jahss MH, ed. Disorders of the Foot, 2nd edn. Philadelphia: WB Saunders Co, 1982; 1514-1539.
24. Mann RA, Mizel MS. Monarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis? Foot Ankle 1985; 6(1):18-21.
25. Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle 1993; 14:309-319.
26. Garth WP, Jr., Miller ST. Evaluation of claw toe deformity, weakness of the foot intrinsics, and posteromedial shin pain. Am J Sports Med 1989; 17:821-827.
27. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics 1987; 10(1):83-89.
28. Mann RA. Pathological anatomy of claw and hammer toes [letter; comment]. J Bone Joint Surg 1990; 72A:305
29. Richardson EG. Lesser toe abnormalities. In: Crenshaw AH, ed. Campbell's Operative Orthopaedics, 8th edn. St. Louis: CV Mosby Co, 1991; 2729-2755.
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active 8 year old
No biopsy material
No evidence of “inflammation”
Clearly traction related
J Pediatr Orthop. 2004 Sep-Oct;24(5):488-92.
Sever's injury: a stress fracture of the immature calcaneal metaphysis.
Ogden JA, Ganey TM, Hill JD, Jaakkola JI.
Source
Skeletal Educational Association, Atlanta Medical Center, Atlanta, Georgia 30305, USA. orthozap@aol.com
Abstract
Magnetic resonance imaging (MRI) in children with a presumptive diagnosis of Sever's apophysitis and with continuing pain after conservative treatment demonstrated bone bruising within the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Limited portions of the apophyseal secondary ossification center showed similar increased signal changes. MRI studies following treatment with immobilization showed subsidence or disappearance of the metaphyseal but not any apophyseal signal changes commensurate with improvement in symptoms. Accordingly, the disorder commonly referred to as Sever's ''apophysitis'' may be a metaphyseal trabecular stress fracture, similar to the toddler's calcaneal stress fracture that has minimal or no involvement of the apophyseal ossification center, and thus should not be referred to as an apophysitis. Rather, it appears to be an overuse injury causing microinjury within the developing metaphyseal "equivalent" trabecular bone that has not completely adapted to the changing biologic (biomechanical) requirements of the growing, athletically active child.
But it is a tongue twister that is nearly unpronounceable.
Longer immobilization than a few weeks in a drippy and gooey soft cast.
Your model should be a good one. Solidly constructed but not superficial.
This image was from a page that said “speed dating is not for the ugly”
Both the patient’s and physician’s belief systems impact the evaluation and treatment of clinical problems.
Some truth in both or are both just plain wrong?
Don’t let arrogance interfere with your communication.
Foot Orthoses Also Have Mechanical Effect on Midtarsal/Midfoot Joints
Ground reaction force (GRF), vertical force from tibia and Achilles tendon tensile force all cause a forefoot dorsiflexion moment and rearfoot plantarflexion moment (i.e. tend to cause longitudinal arch flattening)
Plantar Ligaments and Muscles Cause a Longitudinal Arch Raising Moment
Plantar ligaments, plantar fascia, plantar intrinsic and extrinsic muscles (PT, FDL, FHL, & PL) of arch all cause a forefoot plantarflexion moment and rearfoot dorsiflexion moment (i.e. tend to resist flattening of arch)
Longitudinal Arch Will Stop Flattening at Position of Rotational Equilibrium
Forefoot will dorsiflex on rearfoot (i.e. the longitudinal arch will flatten) until plantar ligaments and muscles all exert sufficient forefoot plantarflexion moment to counteract forefoot dorsiflexion moments from GRF, Achilles loading and tibial loading
Foot Orthosis Acts to Reduce Tensile Stress on Plantar Soft Tissue Structures
With orthosis supporting arch, ORF from orthosis will increase rearfoot dorsiflexion moment and forefoot plantarflexion moment which, in turn, will decrease tensile force on plantar ligaments and muscles
Kevin : “The analysis for rotational equilibrium would be around his "reference axes" of the midtarsal joint individually, yielding three separate sets of equations, one for each cardinal body plane (Nester CJ, Findlow AH: Clinical and experimental models of the midtarsal joint. Proposed terms of reference and associated terminology. JAPMA, 96:24-31, 2006). The illustration provided is only for MTJ equilibrium in the sagittal plane. I was supposed to write the paper for rotational equilibrium about all three reference axes of the MTJ after I finished my paper on SALRE theory, but something called "life" got in the way.”
From Bob Glover’s “Runner’s Handbook”
If we are going to use minimalist shoes, we need maximal analysis of what we are running on.
Concrete is not the answer.
We’ve got a lot to choose from.
If you want respect, you need to respect everything that goes into prescribing and crafting an orthotic. The cast is a part of this. Should your surgical assistant perform your surgery?