Thanks for joining us this evening. I am Richard Zell. I am a foot and ankle orthopedist who works near Baltimore, Maryland and a part of the University of Maryland system. I'm also a member of the education committee and with Lauren Gainey, we've been, and Chris Neville, we've been setting up a lot of these programs. And I'm glad everybody could join us tonight. You know, the workup and management of foot and ankle patients can often be difficult for people just getting going and foot and ankle. And also for those that have been at it for a little while, there's the diagnosis is not always straightforward and there are many different diagnoses you have to consider and many surgeries that you need to know about when you're seeing patients in the office. I've always found it helpful if I can categorize patients by their foot type or deformity because it allows me to entertain certain diagnoses. And I always think that when I see patients in the office I have them stand and I can get a good idea on whether they have a flat foot or a high arch foot and it sort of guides me for my diagnosis. So I think that a webinar or a meeting like this evening can allow us to think of patients in that way. And once we make a diagnosis we really also still take into consideration patient's foot type or their deformity when we decide what we're gonna offer the patients not operatively or operatively. And even the surgeries that we suggest really depend on what people's foot type or deformity is. So we have a great faculty this evening and I'm looking forward to their talks. First up is Dr. Iacobonis who's at Boston University. He was a resident there and did his fellowship at Mass General and recently returned to Boston University's Medical Center on the faculty. So I'll turn over the program to Mark. Great, thank you very much. Let me see if I can get this share screen to work here. All right, can everybody see this screen? Yep. Am I on display settings or can you see the, I think it's correct. Okay. Yep, looks good. All right. So thanks for the introduction. As Dr. Zell mentioned, my name is Mark Yakubonis. I'm a foot and ankle surgeon at Boston University. And I'm excited to talk about some foot deformities with you. And today I was tasked with discussing the cavus foot deformity. So I have no disclosures related to this topic. So pes cavus describes a foot with a high arch that maintains its shape and fails to flatten with weight bearing. The components of a cavus foot are an increased calcaneal pitch, a hind foot varus and plantar flexion of the medial midfoot or the first ray and adduction of the entire forefoot. The precise definitions are a little bit difficult because there are lots of different variations of this deformity. The term cavus foot goes back a long time. And it was described as early as the 19th century or the mid-1930s. It's fairly common to discuss this deformity in pediatrics because there are lots of neuromuscular causes. However, it's also uncommon in the foot and ankle world because of Charcot-Marie-Tooth and polio. And there's also a more common non-neuromuscular cause that has an incidence around 20% in the general population, which is more forefoot driven and is a little bit more subtle to pick up. Oh, let me just, give me one second. I'm gonna change, this is an old talk. Let me just switch, I'm sorry. Let me change this up here. There we go. I think this is better here. This is, cause I, okay, here we go. Let me just see, why is this? Sorry, guys, this is the wrong talk. I apologize. Let's see here. Hold on. I'm gonna stop the share for one second cause I just brought up the wrong talk. Let me just go into a little bit too much. Give me one second, I apologize. All right, let's try this over again. Okay, sorry about that. It's the same. Okay, so this is just describing Charcot-Marie-Tooth. There are lots of deformities, but in principle, there are lots of deformities that cause the high arched foot, which we won't go into. Polio is also another disease. It's an RNA virus that can attack the central nervous system. And as a result, you get a weak calf muscle and you get a weak tibialis anterior, and this can also cause a cavus foot. There are lots of other neurologic conditions which can cause this, which I think is a little bit beyond the scope of this talk. You can also get this from post-traumatic injuries, such as compartment syndromes, tail or neck malunions, calcaneal malunions, tibial plafon malunions, and you can also get this from a residual clubfoot as well. I think the importance is the reason why cavus feet can be problematic clinically is best explained by the normal gait cycle. So if you think about the gait cycle, as you go from heel strike to mid stance, the heel is everted and the two apart joints are unlocked, making the midfoot supple and flexible as a means of absorbing shock. As the foot goes from terminal stance to toe off, the action of the posterior tibial tendon inverts the hind foot, locking the chaupard joints in a non-parallel orientation, and it makes the midfoot more rigid as a functional lever for forward propulsion. So you can imagine in a cavus foot where the hind foot is naturally held in a varus position, the chaupard joints are locked and the midfoot is flexed, which limits motion and accommodation. So again, to repeat, in a cavus foot or a high arch foot, during gait, there's no hind foot eversion, meaning the chaupard joints are locked and there's no shock absorption that occurs with weight bearing. The deformity can be driven from the hind foot or the forefoot. So for hind foot driven cavus can occur from gastroc weakness, and its primary feature is an elevated calcaneal pitch. Forefoot driven cavus can occur from an overactive peroneus longus, which helps the plantar flex the first ray and exert a kickstand effect on the hind foot. The kickstand effect leads to increased intermedial contact stresses in the ankle, which can lead to long-term consequences such as arthritis. There's also an associated lateral column overload where patients can exert a disproportionate amount of weight in the lateral column of the foot. These abnormal biomechanics can lead to various associated sequelae, which can occur and are oftentimes a presenting complaint to patients. These include ankle instability, peroneal tendon pathology, distal tibial stress fractures, ankle arthritis, fifth metatarsal fractures, metatarsal stress fractures, first and fifth metatarsal fractures. Lateral column pain is oftentimes the most common complaint. However, again, patients can commonly complain of these sequelae such as instability or oftentimes a history of a failed repair for instability. On visual inspection, you can often find callosities underneath the first and the fifth metatarsals, the metatarsophalangeal joints, as well as the medial heel. It's important to perform a standing examination. And here you can see the obvious varus tilt of the hind foot. And then here from the front, if you can appreciate what's called a peekaboo heel sign, which was first described by Manoli in 1996. So in a normal aligned foot, you will not be able to see the heel on a straightforward standing examination. It's also important to perform a Coleman block test. And the key is to leave the first ray off the block on the medial side, and then evaluate the hind foot viewing from the posterior to anterior. If the hind foot corrects, then the forefoot is the cause of the deformity. And if the hind foot remains rigid, then it is hind foot driven. You'll also want to perform a silver skull test to evaluate the heel cord or the gastroc tightness. So if your ankle is tight to dorsiflexion, it will not dorsiflex beyond neutral with the knee straight. It could be either the gastroc or the heel cord itself. If you bend the knee, this will relax the gastroc. And if you're able to bring the ankle beyond neutral, then you've isolated it to a gastroc tightness. With a cavus foot, it's always important to perform a careful neurologic exam and consider referral to neurology, particularly if you find any asymmetry between the limbs, or if you find that the patient states they've had a rapid progression of their cavus deformity. Particularly weight-bearing radiographs of the ankle and foot are important for your initial evaluation. And what you'll find on the anterior posterior view of the ankle is that oftentimes you'll find increased tibiofibular overlap with the varus thrust. It's important to determine the extent to progression of any ankle arthritis if it's present, and any tilting of the talus. On the lateral radiographs, there's oftentimes an increased calcaneal pitch, which you can see in this image. And the fibula can oftentimes be present a little bit more posteriorly than you would expect. You can also see here who one of my mentors used to call the eye of the hurricane, which is in the sinus tarsi that you normally don't see in a well-aligned foot. There's also an increased Miri's angle that you can determine on the lateral. And you can imagine that as that first ray is driven into the ground, it exerts a kickstand effect, thrusting everything laterally in the hind foot. On the AP exam of the foot, the foot will oftentimes be supinated and you can find a component of adductus. And you can see here what's described as stacked metatarsals, where the x-ray beam will penetrate multiple metatarsal bases, and it gives the appearance that they're stacked on top of one another. So for treatment, it can range from conservative to operative. And the goal is to try to correct the deformity and eliminate the stresses. This is very important. So a cavus foot orthotic, which we'll probably talk about later, is not an arch-supporting orthotic. It's actually quite the opposite and it's intended to try to correct the deformity. So the correct orthotic involves a lateral heel wedge with a lateral forefoot post and a first metatarsal head recess. You can get this over the counter as well as custom fabricated. For patients that have an ankle concern, you can also get an ankle foot orthosis, which will help protect the ankle a bit. So we'll talk about operative treatment and it should be considered when there are signs of any tendon or joint degeneration, or if they're lateral column pain and they're having progressive deformity. But the basics are that you want to realign the foot so they have a more functional and evenly balanced foot to bear weight on. We'll talk about each of these in a bit more depth, but the basics are a transfer of a peroneus longus tendon to a brevis is designed to decrease the plantar flexion force of the first ray while preserving eversion strength. The dorsiflexion first metatarsal osteotomy eliminates the kickstand effect of the plantar flex first ray and calcaneal osteotomies can eliminate the various thrusts through the ankle joint by sliding the heel laterally or a Dwyer osteotomy, which again, we'll talk about in more depth. This is very important. So I mentioned that a lot of patients will present with associated sequela. And what's important is to recognize the shape of the foot when you're treating these sequela because if you don't recognize that they might have a recurrence of deformity or a failure of treatment. So this is a simplified diagram, but it just shows how to try to tailor the treatment to the deformity. So a four foot driven deformity will oftentimes need a peroneus longus transfer with a dorsiflexion osteotomy with or without a calcaneal osteotomy. Whereas a hind foot driven deformity will need the transfer with a calcaneal osteotomy with or without the dorsiflexion osteotomy. So it's important to know that these are not, you know, paint by numbers that oftentimes you need to tailor the treatment to each individual deformity in patient. So we'll talk about the peroneus longus transfer. There are a variety of ways to do it. And the key is to tenodese the peroneus longus to the peroneus brevis in order to preserve the eversion strength. And so the way you can accomplish that is by holding the hind foot in eversion and the first ray in dorsiflexion prior to the tenodesis where you sew them together, which effectively shortens the peroneus brevis and lengthens the peroneus longus prior to the transfer and then the release. Oftentimes, because these are chronic issues, you can find some degeneration of the tendons and that can also be addressed during this procedure. So for the dorsiflexion osteotomy, what you do is you do a dorsal approach to the first ray, about one centimeter distal to the first tarsometatarsal joint. And usually what you'll do is remove about a three centimeter block needed for correction. It's important when you do this to try to preserve the plantar hinge. So when you correct the deformity, it's not loose and it's well seated and stable. You can fix this with either plates or screws or a variety of devices. And one thing you can see on this diagram is oftentimes in order to get your correction, you're gonna have to release the plantar fascia, which is gonna be very tight in the high arch foot. So for a lateral calcaneal osteotomy, these can be performed with either a lateral slide or the Dwyer procedure, and both can be done through a lateral incision distal to the peroneals. The slide is pretty straightforward in where the osteotomy is oblique and then the calcaneal body is translated about one centimeter laterally. With the Dwyer, it's similar to the wedge osteotomy where through a similar incision, you remove about a five millimeter wedge from the lateral column. And these can be fixed with six, five screws, lag screws. Important to note, when you do this osteotomy, oftentimes this will place a great degree of tension on your tibial nerve. So some people advocate for actually being very careful in performing a tarsal tunnel release to take stress off the tibial nerve. Because you can imagine when you remove a varus hind foot and you correct it into neutral or a bit of valgus, all the medial structures will be under a tremendous amount of stress. For, you know, fusion should always try to be avoided to avoid adjacent joint stress and degeneration, but with a rigid deformity, this might be the best option. And oftentimes you'll have to perform some of these osteotomies to correct the deformity in addition to the fusion. So we talked about this before, the plantar fascia should be addressed and released in order to allow for the correction. This diagram only shows a partial release, but with the case of a cavus foot, oftentimes you have to release the full plantar fascia. It's also important to consider either a gastroc recession or Achilles tendon lengthening, particularly in the set after a hind foot correction and a very tight aquanus deformity. So many patients with cavus also have clawing of the great toe. Because the EHL functions as an accessory dorsiflexion to the ankle, which places the first metatarsophalangeal joint hyperextension. This can be combated by Jones procedure where you surgically transfer the extensor hallus as long as to the base of the first metatarsal, which creates an active dorsiflexor and relieves the stress on the first metatarsophalangeal joint. And then what you do is you can perform a fusion on the first IP joint in order to prevent a floppy toe. So postoperative outcomes are good. It's important to note that patients will walk with a bit of a slower gait velocity, although they have a normal swing and stance phase and patients with arthritis or neurologic causes tend to have a little bit more pain and impairment postoperatively. So in summary, cavus foot can happen from both neurologic and non-neuromuscular causes. It's very complex. When you see a patient who has a cavus foot deformity and they present to you for the associated sequela, it's important to recognize that they have a high arched foot and discuss whether or not that should be treated with the treatment of the sequela. And this is just an overall diagram and a flow chart that shows how to address this. So if you see somebody with a high arch foot, you need to determine whether or not it's flexible. You can do that with a Coleman block test. If it is flexible, it is forefoot driven and that's where you do a metatarsal osteotomy with a peroneus transfer and then a possible calcaneal osteotomy. If it is not flexible, it is either arthritis or it is hind foot driven in which you need to do a calcaneal osteotomy and then a peroneus longus transfer plus or minus a metatarsal osteotomy. So I went a little bit over and sorry for the, sorry for going a little bit over on time. Thank you, Mark. That was a great overview of a very complex topic. There's a lot of information there and thank you for that. The next up will be Amanda Kiefer. Amanda is from Reno, Nevada. She's a nurse practitioner who works for a very busy orthopedic group where they have multiple orthopedic foot and ankle surgeons. And she's gonna speak to us this evening about workup of the flat foot. Amanda. All right, so can you guys see my screen? Nope. Okay, so yeah, I'm Amanda. I work in Reno, Nevada. I've been a nurse practitioner for about five years and I've been in orthopedics that entire time specializing in foot and ankle. And today I'm gonna be talking to you about the flat foot deformity. So it's basically gonna be pretty much the opposite of everything you've just heard. I have no disclosures for this talk. So for the flat foot deformity, we're gonna start off with the anatomy. The posterior tibial tendon is thought to be the most important tendon when you're looking at your flat foot deformity. It attaches the posterior tibialis muscle to the tuberosity of the navicular. You can see that here in this slide, it comes down right in through here and it touches right in here. That posterior tibial tendon is responsible for supporting the arch. It plantar flexes the foot and inverts the heel during normal gait. And there is an area where that posterior tibial tendon comes down around the medial mal and this is kind of the watershed area where the blood supply is not quite as good as anywhere else in the tendon. So if you're gonna have an injury, it's most likely gonna be right there in that area. Other ligaments that are involved, the spring ligament is the most commonly involved ligament. It attaches here from the calcaneus to the navicular here, also helps support the arch. And then the deltoid ligament, which attaches to that medial mal, that you're not gonna really see get involved until later on in the process of the deformity, but it is important to know. So pathophysiology of the flat foot, basically it used to be called just posterior tibial tendon dysfunction. They stopped calling it that because then they started to bring in the spring ligament and its involvement in this. But with the posterior tibial tendon, it's usually a degenerative process due to repetitive motion and movement without the proper support. This repetitive motion, it leads to dysfunction of the tendon and it allows that hind foot to be pulled into valgus and abduction of the forefoot. Other factors that can play a role into causing the dysfunction of this tendon is obesity and age. Most of your patients are going to be above their 50s and have a little bit of weight on them. Other factors that can lead to that are accessory navicular, which can cause a lot of strain on that tendon where it inserts into the navicular. If they have asymptomatic flexible flat foot, which they've had for a long time, over time that's just gonna cause tear on that tendon. And then if they're neuropathic and they have a Charcot process where the midfoot collapses. And then also, sorry, hind foot valgus will cause a lot of strain on that tendon. There's also consideration of acute injuries. This is less common. It can be blunt trauma directly over the tendon or if they've had multiple steroid injections into the tendon that can cause progressive weakening of the tendon. And also if they have like a Lisfranc injury where they have collapse of that midfoot. So next we're gonna talk about evaluation of the patient. So you always wanna start by having the patient standing in front of you and facing you. And you want them to be putting as much weight on both feet. A lot of times they'll not be putting their full weight on the affected foot because it's painful for them. So you wanna try to encourage them to be normal weight bearing. And you're just gonna evaluate that arch of the foot and you'll see if it's collapsing. A lot of times you'll see some medial swelling right along that posterior tibial tendon. You're gonna definitely wanna look over that medial mal area. And you may see some swelling over the lateral side of the ankle where there's the impingement between the fibula and the talus, right, the fibula and the calcaneus. And then you're gonna have the patient face away from you still standing and weight bearing. This is where you're gonna evaluate for that hind foot valgus. So in this picture, you can see on the right side that they have pretty normal alignment of their heel. And then here on the left, as you come down, you see that their heel drifts into valgus. And then you're also gonna see what's called the too many toes sign. And that's due to the abduction of the forefoot. So you can see these extra toes here. And then you're gonna wanna have the patient do a heel raise. I always have them do bilateral heel raise because a lot of times it's painful for them. You know, have them hang onto the bed and you're just gonna look and see if those heels invert and you're trying to see if they have a flexible or a rigid deformity. And then a lot of times they're not able to do it on the affected side because of that dysfunction of the tendon. And then I'll have them sit down and look at range of motion of the foot and ankle. You wanna evaluate the subtalar range of motion, looking for rigid deformity, as well as the ankle range of motion. You wanna perform that same SilverSkull test where you're looking at the difference in dorsiflexion between the knee in extension versus inflection. A lot of times patients with the flat foot deformity will have a pretty tight gastroc. And that test will help you evaluate that. And then you wanna have the patient invert their foot and resist you pushing against them to evaluate the strength of that posterior tubule tendon. And obviously palpate the tendon itself for where their pain is. And then you wanna palpate it on that lateral side of the ankle, looking for impingement. This is some x-rays. You always wanna do a weight-bearing x-ray. I always seem to have patients that are upset that they have to get new x-rays since they've had them in the ER or something where it's non-weight-bearing. And to explain them how important it is, because you really wanna take a look at that Mary's angle. And that's best evaluated on this lateral view with weight-bearing in a normal alignment that talus is gonna point down to the first metatarsal head. And then in a flat foot deformity, you'll see in this picture, the talus is pointing towards the ground. So you have a decrease in the Mary's angle. And then in this picture over here, you're looking for uncovering of the tailor head. You can see that there's more visible tailor head here than in a normal foot alignment. And then you'll have this kind of splaying out at the metatarsals, because that arch has collapsed on them. Most of the time, you do not need to get an MRI or a CT at this point in your evaluation, unless you're worried that they have ruptured that posterior tibial tendon or had some kind of acute injury where you're looking at the Lisfranc as well. And then you'll, there's four stages of the flat foot deformity. In the first stage, it's really just posterior tibial tendon involvement only. That tendon still functions. So when you have them do the heel rise, that heel is gonna invert. They're basically just having pain and swelling. And possibly an injury to the tendon. And then in stage two, you'll actually start to see that collapsing of the arch when they're weight bearing. They'll have dysfunction of the tendon where the heel will not invert, but their hind foot is still in normal alignment. So when they are facing away from me, you won't see it in valgus. Stage three has everything in stage two, except for that hind foot is rigid. So you're not gonna be able to move the hind foot and it will be in a valgus position. And then in stage four, you'll have the collapsed arch, dysfunction of the tendon, rigid hind foot, and then you'll start to get some asymmetry of the tibial tailor joint. You're gonna see a tailored tilt on your weight bearing ankle x-rays. And that's when you know that that deltoid is involved. Treatment for this, obviously you always wanna try non-operative first. If I have a patient coming in who is just in 10 out of 10 pain, had an injury, a lot of times I will place them in a boot to allow it to rest. I try not to do it for too long because I don't wanna make, like affect their flexibility because they're generally already tight in the calf muscle. But I do like them to wear it just to allow that pain to kind of resolve and the swelling to go down. And then I'll do a scheduled anti-inflammatory, like to do two weeks scheduled. In our clinic, we use Mobic generally, you know, and as long as the patient can take it and tolerate it, it's really helpful with that. And then really recommending physical therapy, working on strengthening up that posterior tibial tendon and working on their gait. A lot of times they have instability in the ankle because they're collapsed in the arch. And so the physical therapist will work on stretching out that calf and working on that heel to toe range of motion with them and trying to pull their foot back into normal alignment. Also foot orthotics are really important. We're really lucky at my clinic, we have a pedorthist who works directly with us. And a lot of times if he's not with the patient, he'll see him that day, which is great. Because I think, you know, the patient, if they have opportunity to go home, and they have to make an appointment, a lot of times, you know, they just won't do it. So he's great with that. And with that orthotic, you know, you're really trying to support that medial arch and bring their heel into better alignment if possible, which I'm sure we're gonna learn a lot more about later. And then discussion of weight loss. This was really hard for me when I first started. I'm a little more comfortable with it now. Just explain to them how important it is to just really try to get that weight off to stop straining that tendon, especially early in the deformity. Operative, obviously a last resort. I'm pretty lucky, I work with a surgeon and I get to do surgery with him once a week. So I will talk to my patient about what I think that he will recommend, but I always tell them, you know, it may change. I will get an MRI usually just to evaluate that posterior tibial tendon as well as the spring ligament and the deltoid. If they do have instability in the joint or that tailor tilt and I'm worried about arthritic change or cystic change in the subtailor or the tibia tailor, I'll get a CT as well. And then I refer them to the surgeon. And I do always explain to them, you know, if the patient is really not wanting to try any non-operative treatment first, so I say, you know, no matter what, you're gonna have to have an orthotic. You're gonna have to go to physical therapy whether you have surgery or not. And most people do really well with non-operative treatment, at least in early stages. And it does kind of help them be more compliant. And then I didn't really go out too much into the operative management because I don't do surgery. And so these are my references and that's my talk. Thank you, Amanda. That was really a great talk. And there was many, many, many important things that you brought up in evaluation of these patients in the office. So thank you. Next up is Dr. Neville. Dr. Neville is a professor of physical therapy at SUNY Upstate and is a really valued member of the education committee. He's also a past president of FASIG, which is the foot and ankle special interest group. And we've really enjoyed working with Dr. Neville and other people in this group over the last couple of years. So Dr. Neville is gonna speak to us about physical therapy aspects of treating deformity. All right, great. Thanks. Really my pleasure to be here tonight. This is always just a wonderful group to work with. As Dr. Zalt mentioned, I'm a past president of the foot and ankle six. I've been with the foot and ankle group in the Academy of Orthopedics for physical therapy for some time. But, you know, and I think five years now working with AOFAS as that partnership. So really a pleasure and great to spend a little time here tonight. I think I've targeted this talk correctly knowing that we had some great introduction of the surgical side and the, you know, for both flat foot and the pes cavus foot. And so hopefully I'm gonna address and target just this physical therapy component. A few disclosures, but nothing related to this talk. And again, so my role here, I'm gonna focus on physical therapy management. And I really even focus that further. Again, I know we have a nice talk coming up on orthotics and bracing. And so I'm gonna really focus this on exercising and in really manual therapy. It's a little hard to do that. These are complex. I think both for pes planus and cavus, pretty complex conditions. And so, you know, hard to leave out components of the treatment, but I'm gonna do my best here. Flat foot deformity, we've, you know, I think again, fairly complex condition. Amanda did a great job sort of talking about some of that complexity. I feel like every three to five years here or so, we get a new name for it as we continue to learn a little bit more about it. Our latest one is progressive collapsing flat foot deformity. Myerson's group's done a great job expanding on sort of our understanding of how we can characterize these. So I'll do my best, although I'm pretty comfortable talking about the four stages as Amanda mentioned too for PTTV. So, but I think this does just underscore just kind of how complex the problem is. But despite the changes in names, I think we really have, sorry for the images popping in and out there. Sorry, let me go back. I think we still have the same pathophysiology we're really talking about. And I think key to this is really recognizing whether it's a flexible or rigid deformity. And then, but then also recognizing the pathophysiology of tendinopathy is still critical. And then foot ligament damage, which again, Amanda covered already. So really looking at spring ligament, plantar fascia, origins of pain that also come from those. And I would say, I frequently see patients that I think present with more of a pain along the posterior tibial tendon, maybe an active tenosynovitis that's a component of it in the acute kind of stage. But then that tends to resolve and then a sort of lasting tendinopathy with pain along the course of the posterior tib tendon. And then this may continue down into the foot. I think a lot of times that is more ligament related, spring ligament attenuation, plantar fascia, and then even patients that present along later stages of the condition with lateral foot pain. We see abutment of the soft tissues in the fibula and the fibula on the lateral side that then becomes a source of pain. I shouldn't leave out that I, you know, for sure address those concerns. I think from a physical therapy standpoint, maybe modality use, soft tissue work and things like that, that can address the sources of pain along the plantar surface of the pain of the foot, as well as the lateral ankle. But again, most of my discussion here today for time's sake and also to fit within the other topics we have, I'm going to focus on the exercise component. We have about four clinical trials that have been done. I've been involved in one of them over the past, you know, set of years here, so almost 10 years. And so, and now we even have some systematic reviews that have come out. So really nice to see those. You know, some of these, Dr. Kulig's group out at USC, Dr. Houck and Dr. Jiang, I think have four of the clinical trials that really addressed exercise as an active component. And in the early stages of these clinical trials, this was at a time when we were really looking at eccentric versus concentric too for tendinopathy. This was common in the Achilles literature and it sort of bled into, I think the posterior tib literature. There is a now newer clinical systematic review that's also been done, which addresses this a little more globally. And I'll talk a little bit more about that. This Hoang systematic review really talks about active treatment versus passive treatment. I think that's a nice way of characterizing it actually. And the reason for that is that, although in the early days we really did talk about eccentric versus concentric exercise, I think we now know the literature is pretty conclusive that there's not really a difference, right? That the concept of eccentric versus concentric is probably not what's critical. What's critical is really about loading the tendon. And so it's either about total load or the speed in which that loading occurs that really is what's causing the outcomes we're seeing. As well as remodeling of the tendon or what we think is remodeling or organization of the fibers within the tendon and addressing the tendinopathy. So I just want to make that point that I think we still see a lot of discussion about eccentric versus concentric in the posterior tib literature. But I really think that's a really older concept and really what we're talking about is loading. And I would say clinically I address most of the exercise I think about with posterior tib tendinopathy from a loading standpoint. And so I'm going to spend a little time here just talking about these exercises. You know, I'm not sure how many PTs here are on the call, but you know, for sure many, you know, we go back to this on the recorded videos too, but hopefully this is a helpful just kind of introduction to some of the exercises we think about to address flat foot deformity. And this is really about posterior tib loading. So here you see, you know, pretty simple exercise using a band. This is the right, you know, left foot crossed over the right, but the right is being loaded with the posterior tib. So that inversion of the right limb there loading the tibialis posterior. And critical to this, and we have data supporting that it's really resisted forefoot adduction. That's the isolated. It isolates and attempts to really load the posterior tib the most. And so you see the band sort of, so, you know, positioned here along the forefoot with really resisted forefoot adduction as the key. You know, exercises that sort of continue from these, and I'm going to show you a progression here, kind of just trying to invert and bring your feet together. This is a good range of motion exercise really, but also kind of isolates and gets people using their tibialis posterior. Again, most of these exercises, I'm going to address it as, you know, Amanda did a great job sort of outlining that. I think of most of these patients as sort of stage two, you know, flexible flat foot deformities. They have, you know, they have use of the tibialis posterior, but it's limited and they have some range of motion within the joints of the foot to accommodate some of these exercises. So at least that's what's in the back of my head for the addressing most of these exercises. You know, starting heel rises. I think heel rises are a critical exercise that uses the posterior tib again, and really loads it a lot more. Again, like we see the band exercise up above is good, very isolated to the tibialis posterior. However, really once we get weight bearing, the loads go way, way up. So really the goal is to get into doing heel rises. So starting in a seated position like this with bilateral heel rises, you know, moving to standing, and then obviously eventually into single limb heel rises. Again, we know this, you know, single leg heel rises are, and double limb heel rises, I think Amanda mentioned it, is one of the diagnostic or assessment tests. But I would also say we use it, you know, aggressively in strengthening and in treatment. Interestingly, these are patients that really struggled to do it initially. And I would say you can actually be fairly aggressive with it. I'm amazed how I think I've gotten more aggressive in really encouraging patients to work on heel rise and work on really activating the tibialis posterior. And although initially there's some hesitancy for that, I think patients have initially present with a little bit of soreness, but honestly that tends to resolve fairly quickly. And in some ways I think we're under loading many of the patients in terms of what we really see at the tendon. You know, again, if we lean on the Achilles literature, the loading of the tendon is really critical, and this loading is actually fairly high. If we're really gonna get remodeling of the tibialis posterior and addressing this problem, the loads have to be fairly high and fairly frequent. So then you see even toe walking, and then, you know, this last one's actually more addressing like a balance exercise, but also good to look at, you know, multi-plane dynamic control of the ankle, whether that be single leg balance or other balance kind of exercises. So I would say this is a pretty standard progression. I kind of, and I wouldn't say it progresses from, you know, where I started to doing heel rises, and then you don't do the other exercises, probably continuing to do some of these, bringing your feet together like this, the seated heel rises, where you can really invert the hind foot and activate that tibialis posterior in a load-reduced position is also still really key. And that continues throughout the treatment, even after they're able to do, you know, maybe even single leg heel rises. And so then the goals are a little different too. That really helps to maintain range of motion at some of the joints, as well as that selective activation of the tibialis posterior. You know, if we look at the results of those systematic reviews, again, it's nice to have two of those out now that have reviewed a set of clinical trials on exercise. The first one did show positive effects with, and again, at the time, this was really talking about eccentric strengthening as being beneficial. And again, these are all, all of these clinical trials do pair exercise with typically orthosis or orthotics of some fashion. And then the second systematic review is also a nice addition. Again, here we're talking about these AI, which is active interventions versus passive interventions. And really this article covered a greater number of clinical trials. These included the ones in the previous systematic review, but then also additional ones. And really those additional ones are really more passive, right? So it's the use of just orthotics or passive stretching and orthotics. And really what the conclusions are from this one is that, you know, both of these do help with reducing pain. I think maintaining, you know, I would echo that clinically, I think maintaining range of motion, addressing some of the, again, what I mentioned earlier, the tenosynovitis and things like that. These can be passive interventions that are beneficial, but I think the addition of really active tendon loading exercises does further improve those outcomes. I threw this in, there is a bit of attention, and I would say I include this. It is a bit of a challenge in some of our posterior tib patients, just, you know, these are a little bit, you know, middle-aged to older individuals tend to be overweight, tend to have flatter feet, you know, obviously that they're being seen for, but then they don't use that foot in really active ways or they haven't in the past. And so doing, so IFM is intrinsic foot muscle training. These typically, this typically includes an exercise called a short foot, where you're attempting to raise the medial longitudinal arch while contracting, bringing the metatarsal heads towards the heel. This is an exercise that if you practice it, you can actually actively do this and pretty, you know, people who do it well, it's actually a pretty impressive exercise. You know, my typical patient I see with posterior tib tendinopathy certainly struggles with this, but it's something I definitely include. And some of that is because we have biomechanical data to suggest that it not only can help with strengthening the foot and the muscles within the foot, our intrinsics, but also have an effect on longitudinal arch. So our actual foot posture. A quick side note, I mean, patients that I see early on, I've really addressed most of these exercises to like stage two posterior tib tendinopathy, but I, you know, the early stages where maybe they don't even have much foot collapse, really just pain along the course of the posterior tib tendon you know, more manual therapy, stretching of the tibialis posterior, addressing trigger points, things like that can be beneficial. Here's just a quick picture of foam rolling or essentially soft tissue work within the posterior compartment muscles. You know, the soleus, tibialis posterior all can be beneficial. But then to get back to, you know, sort of our typical stage two collapsed flat foot deformity, I'm gonna leave some of the bracing for our next talk, but I did wanna use this slide just to demonstrate ankle power. So this is a graph of ankle power. So generating push off with our ankle during walking. And so this is the end of the walking, the stance phase where you push off using your ankle. And what we know is that, you know, using orthotics, this graph really is what's demonstrating using different types of solid ankle orthotics, we decrease that ankle power, but what I wanted to use this slide to sort of articulate tonight is just that actually the blue line, which is not using an orthotic at all, we also see actually a decrease in power generation compared to normal. So what we can take away from that is that, you know, flat foot deformity, stage two posterior tip subjects, they have a reduced ankle capacity already. And so the consequence of that is that it actually transfers more power and more need to the hip. And so we see this change in people walking is that they tend to engage a bit of a hip strategy because they lack the ankle power. And so then we even have data to really suggest that not only do they have ankle weakness, but they also have hip muscle performance changes. And so exercises that really engage the lower body kinetic chain are also important. I really like using a kneeling kind of exercise. So this half kneeling exercise really isolates the hip and forces people to really stabilize the hip. This is an exercise that, you know, perhaps is surprising to some, but I would say if you put the vast majority of patients in the typical demographic of stage two posterior tip tendinopathy, again, these tend to be predominantly women. In this position, it's actually a fairly difficult position to maintain, especially when, you know, here in this picture sort of showing moving a weight or, you know, rotating the trunk in a dynamic way really forces the hip to stabilize the trunk and the lower limb on the trunk. And key to this also is it takes the foot out of it. So if it is fairly painful, if they're unable to do some of the other exercises with the foot and ankle in the acute, you know, sort of exacerbated stages, this is a good exercise that we sort of add in to address some of the hip weakness. And then there's a, there's a range of exercises we could sort of add to this. These are typical lunges and squats and things like that. Okay. So I think I'm staying on time here. So moving to pes cavus, we actually have a bit less data to support our work on pes cavus, but Dr. Yacobana started there and really good introduction to what I'm going to say is we're going to, I'm going to address this all from the standpoint of flexible and adult idiopathic. So I'm going to sort of take out, you know, again, lots of potential causes for pes cavus, the neuropathic related ones, Charcot-Marie-Tooth, our stroke patients, our CP kids. Again, I treat a fair bit of all of those, but, but really addressing the exercises here that I'm going to talk about on the next few slides to what is the, the more flexible pes cavus foot in the, in the adult that it's really not as a result of any other, you know, neurological insult or things like that. Again, I'm going to focus on exercise and more manual therapy, knowing that we have some additional talks on orthotics and gracing coming up. So, so in this condition, you know, for sure, and this makes sense, this is a much more rigid foot. We're going to spend a lot more time on stretching. So, you know, key plantar fascia, Achilles, and, and really I like, you know, the exercise, you know, this sort of figure of an exercise here on the right, looking at really isolating the plantar fascia. So dorsiflexion of first MTP, you know, dorsiflexion of the ankle, really loading that plantar fascia. You can even add some manual resistance into the, the base of the heel or along the mid, the mi, the neo-longitudinal arch to continue to stretch that plantar fascia. Patients can take this home though. They can continue to do it with someone else doing it, or there's a range of exercises we can kind of you know, also add that, that continue to stretch the plantar fascia, but also key to this is going to be the Achilles. It's usually also pretty tight and limits overall ankle dorsiflexion, you know, a standing you know, a very standard typical wall stretch. It can be used here, but I would also say like stairs become key here. And in lots of times it's maybe not a full step, but even just up and down off a book or a set of books or some, some lower landing if there's some just, you know, two, four inch and then up to six inch or a standard seven inch stair for progression as we start to get increasing ankle dorsiflexion. And key to this is, you know, where is that range of motion coming from? For sure, some patients, you know, sort of the opposite of this pes cavus deformity, do they start to collapse through the metatarsals? So is it more in the forefoot? Do they start to get some of that range of motion through the medial longitudinal arch or through the midfoot or are they really remain, you know, do they remain having a really, a fairly rigid foot and getting the range of motion through the ankle? And, and really, I think it's more noting where that's coming from and maintaining this alignment in the frontal plane, as we think about increasing that ankle dorsiflexion and stretching the Achilles. Hindfoot inversion, eversion is also critical. You know, it's fairly limited for the most part in these patients and, and addressing it with a host of just active as well as maybe passive stretching is, is, is, is helpful. So another, you know, half kneeling kind of stretch, I think it is really good for ankle stretching. We'll see for strengthening in this group, I tend to not use this half kneel one as much because it's less focused on the hip. But, but now we're really talking about this front leg and, and using the front leg for the ankle stretching. There's a host of, of mobilizations that I think are, you'd likely see pretty actively used across any patient you refer over to physical therapy. These are talocrural or midfoot mobilizations that just start to try and increase the range of motion of those joints. You know, a midfoot twisting kind of mobilization tries to just unwind the foot from its, its cavus kind of position with the, with the varus heel and, and plantar flexed first metatarsal that we spoke of already. Mobilizations to really focus on the first TMT can be helpful, as well as just even sort of this plantar glide kind of mobilization that kind of just takes the foot away from that cavus position. I also have a last picture here of a sort of assisted dorsiflexion. This is referred to as a mulligan technique, but it's really, really trying to assist some increased dorsiflexion while stretching. Strengthening is still a component of, of the, the therapeutic management for these patients. Really focused more on balanced muscle control at the foot and ankle. I think this was addressed already just a little bit, but, but really looking at where does the, you know, do you have muscle balance for both inversion and eversion as we look at, you know, the posterior tib, peroneus longus, as well as the other muscles that sort of control just our frontal plane control of the ankle. You know, here are fairly dynamic exercise, but I think what we're really getting at here is just really looking at that frontal plane kind of control at the ankle. And, and again, moving up the chain to other joints is, is maybe warranted and reasonable in many of these patients. There is a one systematic review that, that has been completed looking at pes cavus. It actually combined static stretchings, the stretching I've already commented on here. So Achilles and plantar fascia stretching along with the east end to the plantar fascia. So this is really to the bottom of the foot. I'm these, this is a fairly rigorous trial and review of the, the, the trials on this, but the results I would say are pretty impressive and maybe too impressive. I would say I hesitate slightly to believe that. So what it's really showing is a reduction in the media longitudinal arch height and an additional radiographic measures that as you can see from the shaded bars to the non-shaded bars, these are differences over a six week period of completing these stretching exercises. So pretty impressive. It is fairly rigorous, but I would like to see it again in another trial to really know that it's, it's working that well. Overall, you know, I take away, you know, when I, when I see flat foot patients in the clinic especially if I think of the standards for stage two posterior tip tendinopathy I actually get fairly aggressive with exercise. I'm really trying to load that posterior tip tendon. I think initially it takes a quite, quite a bit to get people familiar with that, being able to do it again. It's actually a tendon they really haven't used much given the flat foot deformity and the progression of that dysfunction. But once they're able to do it and start moving to a double, double limb heel rises onto single limb heel rises, they actually tolerate it quite well. Lots of times I think the acute inflammation or I think is mostly attributed to tenosynovitis and can be, can be fairly acute, but is, is fairly short lasting in that once you address the swelling around the tendon, they tolerate the tendon loading fairly well. And again, no, no real preference for concentric or eccentric. It's really about tendon loading. And we add hip strengthening into that with some known deficits and hip strength in, in those patients. For the cavus foot, really more focused on muscle balance and then lots of stretching, right? Mobilizations and, and, and stretching techniques to try and increase the range of motion in these joints that we know are limited and the soft tissues around them. Thank you very much. Thanks, Chris. That was, that was a really great talk. I'm going to, I'm going to send more of my post-tubule tendon patients to, to therapy. That was, that was impressive. All right. So next up is, is Robert Lynn. Robert Lynn is a colleague of Dr. Gainey's who, from Hartford. He has served as the chief orthotist at Connecticut Children's Medical Center where I was a resident in the, in the late 1990s. And I, I knew that he was also established and ran a very large O&P school that was through the Hangar Clinics. And I know that program is really impressive and they have 24 graduates each year. He has many, many articles and has been on many national committees. We're really happy to have him here to talk to us today about orthotics and bracing for deformity. Thank you. Thanks for the intro and Lauren, thanks for the invite to be here. She still gets me into these things. As Dr. Zell said, by way of introduction, I do teach a, it's a 60 contact hour orthotic management of the foot and ankle over the academic semester. So I'm being tasked tonight to, to pretty much summarize that in 15 minutes. So I'm going to speak really, really fast, but I'm going to try to go over some of the things over the, my, the course of my 42 year career, the first 25 word in pediatrics. And as you might imagine, you know, the ideology is different. The club feet, the CMT patients, the congenital flat feet, et cetera. And then now the last 17 years I've focused more on sports, adult and geriatrics. So I've seen what a lot of either negligence, poor compliance, poor medical care can actually, their outcomes can be when in the latter stages of life. So it's, it's really the experience wheel has come full circle, if you will. Next slide, please. Okay. I have no personal or financial interest or conflicts. Next. So as, as the previous speaker so eloquently stated, one of the problems with the ankle foot complex, it is clearly the most complex joint that any of us will deal with. I do a lot of spinal work. I work with a lot of the hip replacement guys, shoulder replacement guys, and you know, the, by far the most impactful and most complex joint that I would ever consider managing is the, is the ankle foot complex. As we all know very well, it has multiple articulations, multiple triplanar movements, and it has many functions. You know, it doesn't just work as a bone socket or a hinge joint. I like to half kiddingly say it's the, the joint that allows you to return a kickoff. So if you think of for us football fans out there, what it takes to make those, those sharp cuts and dorsiflexion, plantar flexion, inversion, eversion, as you're returning a kickoff in a football game, you couldn't do any of that without a, an intact and functioning ankle foot complex. So the biggest thing that we find in terms of challenges orthotically is we're asked very often to extrinsically stabilize and compromise that very efficient, particular multiarticular joint. So with that comes compromise and I'll go over some of those concepts and some of the things that we experience on a day-to-day basis. Next slide, please. So one of the goals really is to, to, as I said, stabilize, realign, and when we do that, there's going to be biomechanical implications, not only just to the ankle foot complex, but to the joints proximal to that. So we will very often see, you know, fixed calcaneal valgus result in lateral compartment knee pain. But if you consider that carefully, we can also very often, if it's a dynamic deformity, use the rigid ankle foot complex with posting. And I'll go a little bit into some of the design considerations that make orthotic systems very effective to actually affect medial and lateral compartment knee pain, even hip pain, lordotic angles in the lower spine, et cetera. So next slide, please. So when we, when we, I tell my residents and both orthotic residents and orthopedic residents, don't just think about what you're doing for that particular joint that you're managing. Dr. Yacobonas, I use that slide, the forest of the trees in all of my talks. I didn't put it in this one because we very much in orthotics, we get focused on prescription comes in, SMO, AFO, FO, and that's what we look at. And that does such a disservice to the patient. You know, you need to really look at the much bigger picture if you're going to have a successful outcome. So next. So how do we get patients? One of the things that I think is a misconception is that, you know, a patient has to have a medical referral to seek an orthotic consult. And that's not the case. I mean, part of that I think is the fact that I'm very kind of long in the tooth. I've been around for about 42 years in this area of practicing and many patients will come in for a consult now. And I very likely, gladly will evaluate, take a, you know, a real complex comprehensive history and physical, but in order to treat, as you know, an orthotist needs to have a referral from either a physician, MD or DO, nurse practitioner, a podiatrist, or a PA. We cannot take prescriptions from chiropractors. We cannot take prescriptions from you know, nurses or some of the other allied health professionals who may be extraordinarily well-qualified, but we cannot actually act on a patient's needs without that type of referral. So next please. One of the challenges I think we're getting in today's world is the, you know, we're in a everybody wants everything yesterday society. So the advent and the development of more, much more qualified and capable prefabricated orthotic systems has, I think, tilted the scales to the other direction where in some cases or many cases they're overused. And one of the things that we use in terms of our decision-making process is that if there are multi-planar involvement, so basically if it's not just the subtalar joint or coronal plane, it's the sagittal plane or transverse plane. If there's more than one plane involved, very almost immediately I will start to look at custom systems as opposed to anything prefabricated. If there's any type of dystonia, spasticity, ataxia, athetosis, you will not control that adequately with any of the prefabricated systems certainly that I'm familiar with. And again, I've been around for a long time and I've looked at and evaluated many of these very, very slick prefabricated systems. However, there is a place for prefabricated systems and really many of them, expediency is one of them, but the other is the carbon fiber systems can be very effective with a simple foot drop patient. You know, we get whether they're temporary or permanent. I will fit a lot of these for patients who have had total hip or knee arthroplasties with neurologic involvement, spinal fusions with neurologic involvement. It might be temporary, but while they're in-house, physical therapy needs something to start gait training. And so we can put something on that has really good uniplanar stabilization effects. And I carry multitude of sizes and designs. And so in that way that the advent of that has been extraordinarily complimentary to my practice. But again, anything that when you're really looking at complex foot problems with the complexity of the foot and ankle, I immediately construct to consider more custom systems. Next. Some examples of some prefabricated systems. And I have no bias towards any of them in particular. I use many of the different designs out there, but they're extremely thin. But if you look at the foot plate there, even though you can put a custom foot orthosis on top of it, which sometimes will crowd the foot in the shoe, it can be extremely effective for foot drop patients and some patients like that. Next slide, please. This is a ground reaction orthosis that's a very rigid posterior strut, which will actually give you a knee extension moment and stabilize against crotch gait for a patient with a compromised quadriceps. Next. Now, as we start to get into custom systems, but I want to talk a little bit about foot management relative to foot orthotics, functional foot orthotics. I'm not a huge fan of foot off the shelf, just because they're very generic fitting. And basically what they generally do is shock absorb, provide some compression with pressure sensitive materials, but they really do not have the intimate control of fit and design that's necessary with many of the complex conditions that were discussed by the previous speakers. When we graduate from a foot orthosis or make the decision to graduate from a foot orthosis to go higher, to say either a UCBL, SMO, or even ankle foot orthosis, basically we look at angulation. If you have up to approaching 10 degrees of calcaneal angulation, forefoot angulation in any of the planes, basically you need to have a higher lever arm control of the foot. So once we measure out something that approaches eight to 10 degrees, I will start to consider either grasping the calcaneus and going with either UCBL and SMO or going much higher than that. And that's, you know, there's not a lot of publication on that, but again, with my vast experience, we found that that's a pretty good indicator, that type of angular deformity, be it either fixed or dynamic. You see on the slide here, that's on the left is basically my version of the Arizona boot. I'm not a huge fan of the Arizona boot, not just from the standpoint that it's material construction. It's not so much the design or the folks at Arizona. In fact, the owner of the company is a good friend of mine, but I just, you know, even if you take a cast in the optimum ideal alignment, it's a static cast. You send it out to have the Arizona boot fabricated, comes back. Then if you have any impingement or any tolerance issues in the dynamic sense, because we're asking hopefully these folks to walk on this, there's very little I can do to modify or mitigate that pressure. Many often, very often we'll just either eat it, do it again, do it again. And it's really not the most efficient. The material I use is a thermoplastic wrap over a bioelastic wrap. So you'll see the black plastic, it gives it the structural integrity. You'll see this design here on the left has an open heel. What that does is at heel strike, it mitigates some of the abrupt dorsiflexion moment by helping mimic first rocker. And you can see there that I've augmented. I almost always use posting in my orthotic system, be it foot orthotics, SMOs, everything. I think posting is a underutilized concept. And if it's done correctly, can very, very much give you a biomechanical advantage. The system on the right is the same bioelastic wraparound, again, taken off of a cast of the extremity. It gives you me, but it's a UCBL type of foot control. And then the proximal section gives me a little proximal endpoint stabilization. So there's a lot of variations that you can use once you actually drill down to what the patient need is, what the functional deficit is, and what your actual orthotic goals are. And I'll talk a little bit about that next. Same thing you see here with, this is a pediatric AFO with an adjustable ankle joint. That is dynamic. The posterior strut section is like a leaf spring, but it's got the side, it's a polymer ankle joint. One of the things that I think to point out is a big mistake that I see in custom orthotics is the way overuse of the full toe plate. We, all the studies, gait studies, and many of the papers will indicate that if you take away metatarsal extension, it impacts stride length, push off, you know, many parameters of gait just by taking away MTP extension. And so, basically, what I try to do is, unless there's a compelling reason to have a full and stiff toe plate, we'll try to preserve the metatarsophalangeal joint. And we can do so and still maintain control of many of the foot pathologies that we deal with. Next slide, please. So one of the things that, you know, when we get referrals, we'll see, you know, get a referral, you know, this patient has a stroke. And, you know, it's, I like to get into dialogues with the referring referral sources. And I like to get into dialogues with their treating therapists. You know, what are the primary clinical challenges or manifestations of the diagnosis? As you know, obviously, as orthodists, we don't treat the stroke. We don't treat the cerebral palsy. We're treating the clinical manifestation. What is the muscle imbalance, the tone, all those things? How are they impacting function? And when we really drill down to that, then I try to prioritize the top two or three pathologies or conditions that I can try to control while still keeping in the back of my mind what motions I can still preserve. And that brings me to the next sort of biggest issue that I see in orthotic management is we over brace. Now, once you over brace, it's very difficult to see or ascertain what, how much less brace you can get. Right? Ankle stabilized, the patient's not going to fall. They don't feel pain, but then how much do you actually of the rockers through stance are you impacting on which then affects the efficiency, energy, the smoothness of gait, et cetera. So next slide, please. One of the, just, you know, there are a lot of people out there, believe it or not, orthotics is not as highly regulated as it should be. There's only 13 States in the union that require, that have licensure requirements. The way we get around that is that board certification is required in almost every state in order to get third party reimbursement. So unless you have an orthotist that wants to practice for free, they need to have some type of credential in order to be able to bill insurance. But, you know, the American board for certification which I've served on their board. I've served as your president is the sort of gold standard for anyone referring patient or referral source trying to find a qualified practitioner in orthotics. And I know a lot of other people do it. And again, there's varying degrees of outcomes out there. The good board certified orthotist will provide a very comprehensive exam of the patient. You know, we almost never get a referral with a full physical therapy report. That'd be wonderful. I think I can count on both hands how many times that's happened. So we will, in our training, we are qualified to do random muscle tests, range of motion. I do the silver skull tests for every patient. I do, you know, that where it's relevant Coleman block tests all those types of things. And then basically put together a treatment plan and then put together the best orthotic design that will preserve wanted motion and reduce unwanted motion. Next please. So the main goals, as we all know align support structures, prevent undesirable motion Lord allow normal anatomical motion. And I rocker my residents to death. How does it affect first rocker, second rocker, third rocker because as you can't, if you can't preserve those rockers you are going to negatively affect gate. Sometimes you have to but you have to make that compromise knowing and protect joint integrity and mitigate many of the degenerative changes. These are more for my adult and geriatric patients but we certainly applicable in the entire age spectrum. Next slide please. So you can see as we start to get into various different designs, you can get there. Again, I could spend weeks going over every brace design available but it more relates to what is the deficit? What are your goals and what materials and designs best meet those next. So in the end, as you know any type of ankle foot orthosis or a foot orthosis can be an adjunct to surgical corrections. Sometimes it can delay or preclude surgery we very often are augmenting physical therapy. I work a lot with the pain management clinic at the bone and joint Institute. And we have a lot of functional improvement in function as well as quality of life. Next slide please. I like to use Dr. Dini knows Jack Banta. He was the first surgeon in chief at Connecticut children's and he used to always drum into the residents heads. It's not about the incision. It's about the decision in the same way. I like to sort of paraphrase paraphrase in embracing vernacular. It's not about the device folks. It's about the advice. So if you can work and partner with a qualified orthotist that will have a really academic a good comprehensive discussion with you not every patient will require that but certainly the ones that Lauren sends me. Well, but basically, you know the complex patients will get the best outcomes. Next slide. Okay. Is there, can you, yes. Let's hit that first YouTube. Can you see it? No, I can't. Okay, this is the patient that has the most rigid bilateral ankle foot orthosis on the market. There are two absolutely rigid carbon struts with a ground reaction, full toe plate. He looks, seems to have a very, a reasonable gait. He's got his diagnosed, primary diagnosis is severe coronal plane degenerative arthritis. He basically walks on his navigators. So he seemed pretty satisfied with these. In fact, he went out to Phoenix, I mean, Seattle to get these fabricated. Okay, let's stop that one, let's go to the next. Let's go to the next YouTube, please. Okay, same patient. He's now walking in a right articulated sub-gas truck AFO. As you can see the hinge and the left, my version of the Arizona boot. His step lengths are symmetrical. They're actually a little bit longer. His balance is better. See how he translates through rockers? So when he was referred to me, instead of going back to Seattle, we can stop that now. He basically was asking for some strap changes and everything because, you know, I'm a local guy and could I do that? And I did a comprehensive eval on him. All of his lower extremity motor powers, dorsiflexors, plantar flexors, quads, everything, was within functional limits. So somebody in this learned group explained to me why we locked him up with solid, the most solid ground reaction carbon fiber AFOs with stiff full toe plates. The biggest advantage she said to me in terms of the new designs, so as we progressed on, was later after I provided my systems, he and his wife went on a cruise. And he brought both sets of braces, a cruise up the coastline to Alaska. And he said he could not walk in those rigid braces. Imagine being on a deck of a ship without the ability to balance. And he said he basically never took those rigid braces, AFOs out of the bag. And in fact, he had to use mine. He was so glad he had those back. But the takeaway point here is that, you know, we can over brace very easily. And it seemed to be a very successful outcome. He was very happy. His therapist was happy with the rigid carbon braces, but he's, all the parameters of gait have improved with the more functional design that clearly just addressed his coronal plane degenerative arthritis. So I think, you know, if you, the takeaway point here for the entire presentation is, you know, we can do very, a great deal of good with orthotic management, but we can do almost equally bad with orthotic management if it's not done optimally. So thank you for your time. Thank you. That was a wonderful talk. And it was really cool to see those videos. Elena, do we have some time for questions? We're getting towards 9.30. Sure. Yep, definitely. And attendees are welcome. If you want to turn on your camera, if you want to ask a question, feel free. Maybe I'll start off with a quick question either for Amanda or for Mark. You know, these days when we read our journal, there's all these articles about weight-bearing CT scans. And do you think that, first of all, do you have access to one? And do you think that it's necessary for the workup of patients with deformity because there's many articles about it? And if not, are there any other x-ray views that you routinely use in the office, such as a hind foot alignment view that you find helpful? So in my training, I had access to a weight-bearing CT. I do not currently in my practice. I think that, do I think it's necessary? I don't. I think that it makes, I think there are certain pathologies that it actually does help that are beyond the scope of this talk. Like, you know, syndesmotic instability, midfoot and less frank instability. But for assessing a hind foot alignment, I do think it provides some value. I think it's easier to read than a standard weight-bearing foot or, you know, ankle radiograph because you can go slice by slice. But I think that if you carefully analyze a weight-bearing radiograph, I don't know, maybe I'm wrong, maybe I'm missing things, but I don't know that the weight-bearing CT is entirely necessary or adds as much as many proponents would say it does. I think that there are definitely pathologies where it adds quite a bit, but I think a good weight-bearing lateral radiograph, in my opinion, provides a lot of value. And a lot of times you can see where the apex, the deformity is on that alone. Thank you. I agree, it's just such a topic in the literature these days. Amanda, does your group have access to a weight-bearing CT or are there any other x-ray views that you like to get in evaluation of your flat foot patients? Yeah, we don't have access to the weight-bearing CT and they haven't really heard much gripe from any of the surgeons about, like they wish that they had them at least for the flat foot deformity. I definitely would probably, I didn't show it in my slides, but definitely getting ankle x-rays and getting calc views to kind of look at that hind foot alignment, absolutely. But yeah, I don't think a weight-bearing CT is really necessary. And another question for Amanda and Robert, like a lot of my patients that come in, they, with a progressive collapsing flat foot, they do not want surgery and we often settle on braces. And the ones that I usually discuss are a solid AFO, which I'm sure Robert would not be a big fan of, some type of gauntlet like an Arizona brace or a Ritchie brace, which would have some motion. In your experience, Amanda and Robert, which has been the best for a middle-aged, slightly overweight patient with like a type two flat foot and how successful is it? Well, you know, that first of all, describes a great percentage of the population that we see. I, again, I would like to preserve sagittal plane motion if at all possible. So my first consideration would be if I can do a Ritchie type style brace. The problem with the term Ritchie is they're really a two medial, it's a medial and lateral struts with a circumferential strap. I find that to be inadequate. I do a version of the Ritchie where it's a solid back. So the two proximal and lateral, medial and lateral wings actually are attached to each other but it is free sagittal plane motion. The only reason I would go to, and I do very often go to the Arizona style sub gastroc solid gauntlet is if the collapse is so profound and it's not just in this, you know, if you started to look at the x-ray and there's a vertical talus orientation, but it's dynamic, you can swing it back in. As soon as you start to let the ankle articulate at the talocrural joint, you're going to lose that coronal plane control. So that's when I have to compromise and do the ankle boot, the gauntlet type thing, the custom one. Okay, thank you. Does the audience have any questions? Can I ask a question? Sure. So a lot of patients coming in, this is probably for Chris and Bob, but this idea of minimalist sneakers and barefoot running and especially for a kind of mild posterior tip, perhaps over-treating could almost weaken the tendon. You know, just because patients are coming in asking about it too, you know, what are your thoughts on, you know, zero, you know, the zero drop sneakers, all that sort of trendy stuff that's coming into light? I would put the zero drop in a different category than the minimalist, but the minimalist, I would say very gradual, right? So for our flat foot or early stage, you know, early posterior tip, it's not a bad idea. I mean, the literal, you know, we have data to suggest intrinsic muscle strengthening may occur. I mean, that's where the trend is coming from. I think we're also seeing lots of injuries from it. So, you know, especially in these patients that are ready are, you know, maybe have spring ligament attenuation, things like that. They just have to be really careful about it. So I think, you know, I would say, you know, minimalist shoes, they're great around the house. That'd be a place to start, right? Start strengthening their feet within a flat surfaced environment and support their feet when they go onto uneven surfaces. The zero drop is a different thing. The zero drop is really about, you know, to me it's about ankle range of motion. So if they have the dorsal deflection range of motion to manage a zero drop, then, you know, that's where our pes cavus patients usually have less of that. It can help with trying to stretch it, but it's also going to give them a fair bit of stress on that tendon. Yeah, I don't see too many shoes like that, fortunately. Yeah, I send you mine that can't fit into any shoes. That's right. Yes, another question I have for Bob is related to, you know, insurance. You know, I found that getting, I sometimes will send patients more for bracings. I find that that's actually easier to get covered than an orthotic. That's absolutely true. The insurance industry, for some reason, has taken the position that functional foot orthotics, unless you're diabetic, are very often frivolous and not warranted medically necessary. And I know where that came from. I think, you know, I do see many patients who have like a grocery bag full of failed functional foot orthotics. And, you know, and many of them have paid out of pocket full price for it. all of them. You know, speaking about just successful functional foot orthotics, one of my mantras is if you take an orthotic design and you push down on the apex of the elevated foot orthosis and you can't have any dynamic component to it, it most likely will fail. And there are many that come from, you know, other areas, not to speak poorly about the podiatry industry, but I will see so many that are made out of nylon plastics, like roller door, nyloplex, and literally they're as hard as the table that you're riding on. And it might be contoured nicely and accurately underneath your medial longitudinal arch, it might match your anatomy, but with that type of rigidity, if there's any type of real deflection or deformity, angulation, that force is not well tolerated. And you can, you can, so, you know, systems we use are go from anywhere from one millimeter to five millimeters thick of a thermoform material that has a very dynamic component to it. On top of it, we'll put a little pressure sensor material, but that will not forgive a inherently strict 100% rigid device. But again, you're, you're right. I mean, we, foot orthotics are not covered very often. Certainly not in the Medicare population. Medicare does not cover functional foot orthotics unless you have type 2 diabetes, period. There's not a Medicare policy out there that the CMS will not cover. We've tried to fight it on a national level. I've been in Washington doing depositions and they kind of listen and say, thank you very much, we're not covering. If you come back when you have diabetes, which is ludicrous, as though none of the deformities or the conditions or pathologies that you've discussed that might happen to a 66 year old, um, it's, it's not going to be covered. So once you go to, you can go to a custom SMO or an AFO, all the impediments are pretty much erased. They do have a five-year rule though, which means that if you've gotten, I don't know if anybody's familiar with this, but this is another one of our wonderful CMS regulations. If you've had managed or any type of orthotic management on an extremity within five years, they will not cover a replacement system. And they're not very discriminating as to what, and as an example, I had a patient who had a fibular fracture from an ankle sprain. They were in a walking, short pneumatic walking boot, non-displaced fracture. Three years later, she had a, literally a blowout stroke, spastic equinovarus. We went to submit for a custom, you know, solid ankle AFO with a lateral flange. And because she had very unstable ankle, Medicare denied it because you got a boot three years ago. Now, how in what world is a lateral fibular fracture for a normal person, the same as a spastic equinovarus for a post-CVA? But it was the left leg, so sorry, lady. They said, you can wait 18 months, we'll approve the AFO. So that's kind of what we're dealing with, with the CMS population, which is unfortunate, but, but, you know, functional foot orthotics, it's a challenge. I wish I had better news. Bob, I know we're late on time, but I feel like I have to add, it's, it's really great to hear your interest in maintaining range of motion and not over, you know, over controlling the joints. I think that's been my longstanding, you know, soapbox too, that I think we really need this ankle metatarsal motion to maintain sagittal plane power and movement for walking. I mean, I spend most of my day thinking about walking like that. So, you know, so blocking those joints, which is tends to be the kind of default for many of these devices is, I agree, over, overdone. All right. Well, it looks like that's going to wrap things up, correct? I think so. Thank you to all the speakers. They were great talks. And thank you for everybody for attending our webinar this evening.

video

foot and ankle patients

flat foot deformity

cavus foot deformity

treatment decisions

causes

treatment options

physical therapy exercises

strengthening foot muscles

custom orthotics

orthotic devices

sagittal plane motion

comprehensive assessments