What’s up with the Weil Osteotomy?

What’s up with the Weil Osteotomy? Not doing any surgery I was not up to speed with opinions about this. First there was this blog post condeming it. Then there was a point/counterpoint debate in Podiatry Today, followed by a poll on the Weil Osteotomy on Podiatry Arena.

Severs Disease

A tight calf muscle has often been mentioned as a factor in Sever's Disease or Calcaneal apophysitis in kids. When you examine a lot of these, the calf muscles feel tight. But how do we know that this has anything to do with the cause of this problem? ...we don't. There are 3 explanations:
1. The calf muscles are tight and they were a cause of the problem
2. The calf muscles are tight, but the tightness came on after the Sever's developed due to, perhaps, some gait alteration
3. The calf muscles are not tight, but appear tight on examination due to a splinting like action due to the pain.

Which of these is the answer? ...I have no idea.

For the latest see Podiatry Arena on Severs Disease; or this video on calcaneal apophysitis on PodChatLive.

If you have Severs disease then it all comes down to managing the loads via modficiation of the activity and perhaps using a cushioned heel pad.

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Medial Tibial Stress Syndrome

Medial tibial stress syndrome is something that has always bugged me because I do not know exactly what it is. There are many competing theories that are underpinned by some good research as to what the exact pathophysiology of the condition is. Some of the theories are not consistent with each other. One recent idea that has caught my attention is that medial tibial stress syndrome is bone stress reaction due to increased bending moments in the tibia. Some of the rationale behind that does make sense to me. There is some discussion on this at Podiatry Arena (see: Medial Tibial Stress Syndrome)

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Terminology of hallux rigidus and limitus

I do get a little frustrated at the confusion surrounding the terminology of these conditions. To me hallux rigidus means just that: i.e. the hallux is rigid (it does not move). Some people use ‘rigidus’ for a reduced range of motion and some use it as another name for osteoarthritis (which obviously most cases of structural hallux limitus have). Also the term hallux limitus is a tad confusing - is it a structural hallux limitus (which some like to call hallux rigidus) or is it a functional hallux limitus (which some do not think even exists). So this is what I call things:

Hallux rigidus = no motion at the joint
Structural hallux limitus = structurally reduced range of motion
Functional hallux limitus = functionally reduced range of motion

BUT, then again, they can all be reconceptualised as a change in dorsiflexion stiffness at the first MPJ, so let’s toss all the names out.

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The real need in plantar fasciitis treatment

Everyone has their favourite treatment for plantar fasciitis and each technique has its champions claiming that it is the best. How can they all be right?

At the end of the day, true plantar fasciitis is due to excessive load in the plantar fascia, so the only way to treat plantar fasciitis successfully in the long term is to reduce that load. I can think of only 2 (maybe 3) ways in which the load can be reduced in the plantar fascia. One is low dye strapping and the other is with certain foot orthotic design parameters. The potential third way is calf muscle stretching as there are some fibres from the Achilles tendon that pass through to the plantar fascia.

All the other modalities such as cortisone injections, shockwave therapy, cryosurgery, active release techniques, magic wands, crystals, deep tissue therapy, TOPAZ, trigger point therapy, nerve blocks etc , etc only help with the healing of the damaged tissue. Not of these can actually lower the load in the damaged tissue.

The long term management of plantar fasciitis is dependent on the load in the tissue being reduced, not depending on some pivotal magical cure that does not reduce the load.

See these for the latest on plantar fasciitis and low dye strapping, as well as this approach.

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The paradox of sinus tarsi syndrome

Sinus tarsi syndrome is somewhat paradoxical in that it can be caused by inversion, as in an ankle sprain damaging the structures in the sinus tarsi by stretching them; and it can also be caused by eversion, as in a pronated foot with high forces pushing the subtalar joint to end range of motion and causing compression forces at the bony end range of motion. The structures in the sinus tarsi and their role is very complex and poorly understood. A better understanding will better help direct therapeutic approaches. However, in both the pain is on the outside of the ankle joint. Generally, the inversion type responds well to physical therapy intervention and the eversion type responds well to foot orthotics.

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More on barefoot running

I have previously blogged about barefoot running and how bad research on barefoot running gets reported. Now we have a publication in Nature that has been widely reported in the media and touted by the barefoot running community. The interpretation and use of this research has been so bad, that the authors took the unusual step of posting this disclaimer on their website:

There are many discrepancies in the way the press has reported our paper “Foot strike patterns and collision forces in habitually barefoot versus shod runners” (Lieberman et al., Nature, 463: 531-565) .....Please note that we present no data on how people should run, whether shoes cause some injuries, or whether barefoot running causes other kinds of injuries.

Now we have an anti-barefoot running website that has been set up to critically analyse the claims made. It appears to have touched a raw nerve in the barefoot running community. They do not like it when they get criticised, but think it is acceptable for them to criticise others ... don't figure! Even a Fench running website is highlighting the barefoot running debate.

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