Subtalar Joint Neutral and Its Clinical Significance: Lecture Summary from the 10th Annual Schuster Memorial Seminar

The Title was: Some Fun With Subtalar Neutral

The Key Points:

1. Positioning the foot and leg around subtalar joint neutral means that the stresses are even from medial to lateral
2. Subtalar Joint Neutral is crucial in Repetitive Motion Activities
3. Being too far from Neutral when functioning can cause pronatory or supinatory problems
4. These problems can occur up the leg into the back, spine, and upper extremities
5. Subtalar Joint Neutral has primarily a weight bearing significance
6. Clinically it is observed from the alignment knee to foot or tibia to heel bisection (this is also called the TC or Achilles Angle)
7. Most patients do not stand or walk in Subtalar Neutral due to variations in Tibial Varus or Valgus
8. This variation gets more exaggerated  when the varus or valgus starts in the knee (genu varum or genu valgum)
9. Most podiatrists obtain stability in their patients by heel verticality 
10. Clinically it is important to know when this heel verticality is not close to subtalar neutral (on the pronated or supinated side) due to symptoms produced or not improved

 

Here subtalar neutal and heel verticality are together in this stable foot

 

Here the left foot demonstates how subtalar joint pronation away from neutral setting up the left foot for pronatory symptoms from the foot up the lower extremity change. The initial goal of treatment here will be heel verticality to make significant positive change. If the patient is not responding to treatment, then the heel will be placed in more varus positioning closer to subtalar neutral. I tend to add a Kirby Skive to my orginal RX to obtain this improved varus correction.

 

Here the right foot is supinated away from both heel verticality and subtalar joint neutral. The goal of lateral support to bring these two positions into better alignment (more vertical heel and more in subtalar joint neutral) are placed in the RX. 

 

Here Subtalar Joint Neutral would position the foot very supinated to the ground. Dr Merton Root taught to position this foot type 2 degrees from the maximally pronated position. Dr Kevin Kirby designed the Maximum Pronation Test to ascertain whether the patient was maximally pronated. 

 

Here the Subtalar Joint Neutral Position is 13 degrees everted to the ground due to the high Genu Valgum present. The right foot is therefore functioning 6 degrees in a subtalar joint supinated position and the left foot 3 degrees in a subtalar joint pronated position. Ideally, your initial RX should be to stabilize the foot with Root Balancing of Forefoot Deformities and a left 3 mm Kirby Medial Heel Skive. This helps get the midtarsal joint maximally pronated for incredible foot stability. Remeasuring of the RCSP with the new orthotic devices should show 13 degrees of RCSP bilateral. This will make the foot more stable. 

Can a Patient Walk Well and without Problems with Big Toe Joint Fusions for Hallux Rigidus

https://www.facebook.com/download/531737191640275/02_07_2017%20Gait%20Analysis%20of%20Foot%20Compensation%20After%20Arthrodesis%20of%20the%20First%20Metatarsophalangeal%20Joint.pdf?av=1568287145&eav=AfY8moMdRWZwme9PP23bk81Af93vGN1LoENbVVyR_LM05adSRvNRB_f8Ex6t6ZxQsjs&paipv=0&hash=AcoGJAvMX3oPGRywSfE&__cft__[0]=AZWVks2l-WYTD_dHpYlGF8p0otjFiDYKrVcnZMdtauES1JJfZDs8JEL8gwvjaZtsqMnrnuWaWP7Y9SVKu9m6sBfIsILpm-VnQbEq6gGutHwtTKv9tMA4BPFHWiTT2Ey2a32O4kqxJH38zRglc7QlmnXgzS31GyPE2lcrDMeaz9GkMQ&__tn__=H-R

Lecture at this year's Richard O Schuster DPM Memorial Lecture

The Photo is from my lecture at this year's Richard O Schuster DPM Memorial Biomechanics Seminar on Subtalar Joint Neutral Position and its clinical significance.

The Speakers from Left to Right: Jinsup Song DPM, PhD, Howard Dananberg DPM, James Losito DPM (program coordinator at Barry University in Florida), R. Daryl Phillips DPM, Richard Blake DPM, Jeff Cusack DPM, Joseph D'Amico DPM (seminar director), Russel Volpe DPM, R. Paul Jordan DPM, Paul Coffin DPM, Barbara Reseque DPM, and Samantha Landau DPM

Rehabilitation of Injuries: Magical 80% Rule

Injury Rehabilitation: The Magical 80% Rule

     80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no re-flares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

     But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden,or non weight bearing on crutches or a knee scooter
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity. 

     It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc., but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, acupuncture, etc., is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with re-flares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc., etc., etc. It is the fun part of rehabilitation. 

     I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought that goes into on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!

7 Signs That You Should Bring Your Kids In To A Podiatrist: Blog Post

https://www.performpodiatry.co.nz/signs-kids-foot-problems/

Morton's Neuroma Physical Examination Testing

https://youtu.be/_7qNgYNUrmw