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Calcaneal fracture and subtalar arthrodesis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ann PT, May 24, 2013.

  1. Ann PT

    Ann PT Active Member

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    Hi everybody,

    Background: I'm not a doctor or DPM and don't even play one on TV. I am a physical therapist who has worked in orthopedics for 26 years and have been making orthotics for 23 years. I have learned a tremendous amount on Podiatry Forum and hope that you can help me better understand my current patient. I plan on contacting the orthopedic surgeon again with my questions but usually just get one or two word answers by email and I'd like to know more. Anything anyone can offer is greatly appreciated.

    My patient is a 40 year old female who was rock climbing and fell fracturing her calcaneus almost two years ago. She was transferred to our hospital and diagnosed with a closed Sanders 2 fracture with significant depression of the posterior facet, heel shortening, and heel varus alignment. She had an ORIF where the surgeon believes he corrected the length and varus alignment. The lateral portion of the posterior facet was a free piece which ultimately was replaced with no articular step-offs. Lateral, Harris and Broden heel views indicated "the reduction, restoration of length and restoration of normal heel alignment was noted to be excellent.) Plate and screws were placed.

    The patient went on to develop subtalar arthritis and in November 2012 had removal of some hardware and a subtalar arthrodesis using cancellous autograft and screws.

    Now she has been referred to PT with pain at the lateral border of her heel, midfoot and lateral ankle. Like with other calcaneal fractures I have seen after ORIF she is quite supinated in a relaxed standing position. In NWB I can get her calcaneus vertical but in weightbearing it is very difficult. Her calcaneocuboid joint is very stiff and possible slightly subluxed. I have been able to improve the mobility slightly with joint mobilization but she still supinates when she stands. A temporary lateral wedge just gives a superior force instead of tipping her into some pronation. It seems her injuries/surgeries/healing etc. have shifted her axis of motion so far that as soon as she stands all the force from above and ground pushes her into a supinated position.

    I know there's probably many more details that would be helpful but can anyone tell me about calcaneal fractures and why they end up supinated after ORIF? (I've seen this in other patients as well who did not have the arthrodesis.) I know this is a very difficult fracture to manage but I don't understand why I have seen so many end up supinated after surgery. And if the restriction is due to the hardware and/or how the calcaneus was fixed (even though the surgeons always say the alignment was wonderful intraoperatively), now what can I do with orthotics, if anything, to unload the lateral border without creating a rotatory force at the site of the fusion or creating just a superiorly directed compressive force with a lateral wedge?

    Any thoughts for me or questions I might ask the surgeon are very much appreciated!

  2. Lab Guy

    Lab Guy Well-Known Member

    Hi Ann,

    Very good post.

    You might inform the surgeon that you have exhausted all of your physical therapy modalities but she still has pain due to her uncompensated rearfoot varus secondary to her injury and this has shifted her center of pressure laterally creating pain in her lateral lateral column.

    The patient may benefit from shock absorbing insoles and the Hoka One shoes are very good in absorbing shock with their extra thick EVA outsoles.

    You may suggest the patient to be reevaulated for possible further reconstructive surgery to fuse her STJ in a slightly everted position. She may also have arthritis of her calcaneal cuboid joint and may be best served with a triple arthodesis to eliminate the pain.

    It is inevitable that fractures of the calcaneus goes on to fusion. Fusion of the STJ in varus ends up causing the lateral column to being beat up from ground reactive forces from the lateral position of the center of pressure that will not shift medial due to no motion in the STJ. As you well know, lateral wedging only serves to increase the GRF as the joint is fused.

    As an aside, to help prevent fusion in varus, a K-wire or steinman pin acting as an arthroesis is driven through the floor of the sinus tarsi, the pin is then cut and bent. The STJ is held in the appropriate position ( slight valgus) with the knee on the frontal plane and the bent end of the pin is turned into the anterior surface of the lateral processs of the talus to prevent further plantarflexion of the talus on the calcaneus.

    The heel can now be everted while the screw is driven through the talus neck to the inferior posterior surface of the calcaneus without worry that the position of the STJ is going to change as the pin is preventing movement of the lateral process.

  3. Ann PT

    Ann PT Active Member

    Thanks Steven.

    Although I didn't see her in between the ORIF and the fusion, my impression from her is that her foot was supinated after the ORIF and before the fusion. I have seen this with other calcaneal ORIF procedures as well. Also, I don't think she was fused in varus because I can get her calcaneus vertical in NWB. I'm sure the surgeon would say she was not fused in varus. It's when all the forces of weightbearing come into play that her heel is in varus. The lateral wedge we tried (unsuccessfully) was from heel to toe to try to eliminate torque at the fused subtalar joint.

    Does any of this information give you any other thoughts?

  4. Lab Guy

    Lab Guy Well-Known Member

    Interesting and challenging case, Ann.

    I understand that you think her rearfoot ended up in varus after her ORIF. Even if it was, once the fracture has healed, the fusion should be performed with the STJ in slight valgus. My experience has been in rearfoot fusions for end stage PT dysfunction and I do not have experience in ORIF for calcaneal fractures.

    Still, if your patient's STJ is fused, then there should be no motion on inversion or eversion. If there is no motion then it would stand to reason in my mind that the heel should be in the same positon in open kinetic chain and closed kinetic chain.

    Thinking it through, If the patient had a severely plantarflexed first ray, then an external supination moment would occur due to the GRF causing the STJ to invert into varus. With the Forefoot completely unloaded off a step, the GRF acting medial to the STJ axis would be much less, thus decreasing the external supination moment and the heel would be verticle or in valgus.

    However, in the above scenerio, if the STJ was fused, the position of the heel would stay unchanged. Lets say a patient has end stage posterior tibial tendon function as well as rupture of the spring ligament and plantarfascia. The STJ would then be in a postion of maximal pronation and would be stopped only by the interosseous compression force from floor of the sinus tarsi pushing up against the lateral process of the talus.

    Yet, despite the loss of these important internal supination moment producing structures, if the STJ is fused in varus, the peroneals will not be able to exert an internal pronation moment at the STJ without motion available.

    That being said, I do not think there are external supination moments/forces causing the fused STJ in your patient going from a verticle position to a varus position. It would seem that the STJ was fused in varus or that the varus is coming possibly from the ankle/lower leg.

    Wish I could help you more and hopefully the other more experienced posters will provide their insight. Have a good weekend.

  5. efuller

    efuller MVP

    I see an inconsistency in your description of the case. The surgeon says that the STJ was fused and you say you are able to evert the calcaneus to vertical non weight bearing. If the talus was fused to the calcaneus you need to figure out where that motion is coming from. It could be motion of the talus relative to the tibia. It could be soft tissue motion over the calcaneus that makes it appear that the calcaneus is moving. When you attempt to move the "STJ" you can slightly plantarflex the ankle joint and palpate the anterior aspect of the trochlear surface of the talus. When you palpate there you can feel inversion or eversion of the talus relative to the tibia. If this is where your motion is coming from mobilization is probably not a good thing.

    I agree with most everything Steve said. You can't evert the STJ because the STJ is no more. The STJ can't be supinated. There is another inconsistency in the story and that is the x-ray that says there is normal alignment and what you are seeing when the patient is standing. So, why the pain? Was the cc joint damaged in the original injury or is this a case of fused in varus with lateral column overload, or both. In stance, can you run your fingers under the first or fifth met heads. If it's fused in varus there may be very little load under the first met head. Treatment for that would be to increase the load under the first met head with a varus wedge. Now, you need to look at the whole foot leg relationship. That varus wedge could be inverting the ankle or it could cause a varus torque at the knee.

    Good Luck,
  6. Ann PT

    Ann PT Active Member

    Thanks Steve and Eric for your responses.

    I understand that if the subtalar joint is fused then it should not move in weightbearing or NWB. Originally I thought I was feeling a little movement there but in looking at her again I think her talus is rotated ("inverted") and her calcaneus is following her talus. There is very little movement of her talus when trying to supinate/pronate her foot in prone. I have mobilized her first ray/medial column which is plantarflexed to try to improve the medial forefoot dorsiflexion and lower the medial longitudinal arch but I still feel like her talus won't plantarflex and adduct. Do you know if there is anything written about coronal plane motion/restriction at the ankle after a calcaneal fracture and/or subtalar fusion?

    As for the fusion itself, I have reread the operative note and there is no specific comment on the position of the calcaneus when fused. It states two guidewires were placed "in standard fashion" which were noted to be slightly lateral but acceptable. Two cannulated screws were placed with good compression across the posterior facet. Cancellous allograft was packed into the fusion site as well. The position of the screws was noted to be adequate under fluoroscopy.

    Although the patient feels like she can get more of the medial border of her foot down after a few sessions of mobilization, she still has a lot of pain inferior to her lateral malleolus along the lateral side of her calcaneus within just a few minutes of walking. Any other input you have is greatly appreciated. She is seeing the surgeon next week and I hope to get more information from him then but it is unlikely.

    Thank you!
  7. drsarbes

    drsarbes Well-Known Member

    May I ask if, besides the Sanders II, did she receive any other injuries from the fall?
    You also mention some hardware removed prior to the fusion; I assume she had ORIF of the original
    fracture...can you determine how the Os Calcis looked prior to fusion?

    I think it is easy (and probably correct) to suggest the fusion resulted in a varus, but there are other possibilities; i.e., the fracture caused an intrinsic varus of the os calcis, the fusion itself failed, concomitant occult injury to the ankle or lateral ligaments, damage to the peroneal muscles, etc....

    Last edited: May 30, 2013
  8. Ann PT

    Ann PT Active Member


    This is what I have access to...

    CT Scan 5/29/11
    There is an extensively comminuted fracture of the calcaneus, with
    fracture lines extending to the anterior process, calcaneocuboid
    joint, anterior and posterior subtalar joints, middle facet of the
    subtalar joint, and sinus tarsi. Fracture lines extend to the
    medial, lateral, plantar, and posterior surfaces of the calcaneus.
    No other acute displaced fracture is identified in the hindfoot.

    ORIF calcaneus fracture

    Xray 7/20/11
    The patient is status-post ORIF of a comminuted calcaneal fracture transfix by means off malleable plate and screw construct. Alignment
    is unchanged and near anatomic. Hardware is intact. There has been
    further callus formation, however, fracture lines remain visible.
    There is mild hallux valgus deformity with associated degenerative
    change of the first MTP joint.

    MRI 5/10/12
    Moderate osteoarthritis of the talonavicular joint.
    There is a bony irregularity along the talar dome suggestive of an osteochondral defect.

    CT Scan 9/2/12
    Again noted is the markedly comminuted fracture of the calcaneus that
    has resulted in considerable flattening of Boehler's angle. There is
    marked narrowing of the posterior aspect of the subtalar joint
    comment indicating posttraumatic arthritis. The alignment has been
    secured in position by means of a side plate and multiple screws.
    The fracture appears to be bridged by an endosteal callus

    Xray 9/24/12
    The mortise, tibiotalar joint and talar plateau all normal.
    Status post ORIF calcaneal fracture with re- approximation of
    Buhler's angle, no hardware related abnormalities. There is a hallux
    valgus and mild bunion. Skeletal architecture is intact. Osteopenia.

    Subtalar fusion

    Xray 2/12/13
    Calcaneus shows impacted, angulated fracture in late stages of
    healing status post internal fixation by malleable metal plate and
    screws. 2 screws cross the subtalar joint posteriorly. Degree of
    healing and bony bridging across the fusion site is difficult to
    assess. No acute fracture, dislocation. Ankle mortise is normally

    Xray 3/6/13
    The patient is status post open reduction and internal fixation of a calcaneus fracture in near anatomic alignment using a lateral plate
    and screw construct. There has also been fusion procedure across the
    subtalar joint using 2 partially threaded screws. Instrumentation is
    intact and unchanged in appearance and position. Calcaneus fracture
    lines are barely visible, if at all. There is at least partial fusion
    across the subtalar joint.
    There is no acute fracture or dislocation. The bones are osteopenic.
    Osteoarthritis of the first metatarsophalangeal and talonavicular
    joints is unchanged.

    The patient's perception is that her foot was inverted after the ORIF and became more inverted after the fusion.

    Any of that help?

  9. efuller

    efuller MVP

    Treat the foot and not the x-ray. In stance, does the weight bearing area of the heel sit medial to the leg. If this is the case then there is a varus torque on the talal-calcaneal fused together unit. This varus torque, if present could be causing ankle pain. Can you repoduce the ankle pain on exam?

    You describe a plantar flexed 1st ray. Often, when people are fused in varus and cannot easily get load on their medial forefoot, they will attempt to "reach" the ground by plantarflexing the first ray with their muscles. This not a permanent solution. The muscles will fatigue and not be able to support much load sub medial forefoot. In this situation there could be high lateral loads and there could be a valgus torque on the ankle and this could be causing the ankle pain.

    So, it appears that there is an allignment problem that is not going to be helped by standard physical therapy treatments. You could just try an ankle brace to try and counteract either varus or valgus moment at the ankle.

  10. Ann PT

    Ann PT Active Member

    Thanks for hanging in there with me Eric...

    I totally agree that I need to treat the foot and not the xray but I'm not a doctor and didn't know if there may be something in the reports to answer Steve's questions.

    When I see my patient in the morning I will take a picture of her foot in standing and share it with you on the forum. What I see is a foot that definitely has a varus torque although less than when she started PT because I believe mobilization of her cuboid and medial column have helped get her medial foot down on the ground (her 1st met head was mostly off the ground when we started). My question is: where is the varus torque coming from and can I change it (with more mobilization) or compensate for it with an orthotic. It appears to me that in her truly relaxed stance, her calcaneus follows her talus (they're fused!) and she stands inverted because of the position of her talus. She can volitionally "pronate" her foot a few degrees but her true relaxed position certainly puts a varus torque on her ankle. If her subtalar joint is fused, then I assume this varus torque is coming from the position of her talus. Given her two surgeries and periods of immobilization after each, can I expect to alter the position of her talus with joint mobilization and decrease the varus torque? When a surgeon stabilizes a calcaneus fracture or fuses a subtalar joint, is it possible for the talus to be inverted even if the calcaneus is "neutral" resulting in an inverted relaxed standing position?

    I had the same thought about the plantarflexed first ray as you stated- that she had likely developed this in response to the chronic varus position of her foot. As a result, her medial arch was elevated even more than if the first ray wasn't plantarflexed. By decreasing the stiffness of the first ray and giving it a few degrees of motion into dorsiflexion, I believe this has helped to lower her medial arch. Her talus, however, seems to be what's driving the position of her foot and the varus torque.

    An ankle brace is a good suggestion but I just didn't have confidence that it would be enough to counteract the varus torque. Also I want to be sure I've done all I can with joint and soft tissue mobilization and neuromuscular retraining before suggesting a brace.

    Again thank you for your thoughts and input. On the off chance I can get the surgeon to respond next week, I want to be prepared with my thoughts and questions.

  11. Ann PT

    Ann PT Active Member

    Here's my patient's foot. One is in her relaxed stance position and one is with her trying to pronate her foot. Although the surgeon tells me her calcaneus was fused neutral, whether her talus is rotated or her calcaneus is really in varus, this is what she has ended up with. Now the question is...what to do about it...brace is an option but I'm sure she doesn't want to wear an ankle brace the rest of her life. Orthotics may be an option but temporary full length lateral wedging didn't help and I'm concerned about bring the ground up to her medially because I don't want to increase the supination force. Any more thoughts?

    Thank you for letting me think this through on Podiatry-Arena and for all the feedback!


    Attached Files:

  12. Lab Guy

    Lab Guy Well-Known Member

    Nice photos Ann and your patient is fortunate to have you as her physical therapist.

    Hopefully, Steve and Eric will provide their valuable input.

    The Dwyer closing wedge osteotomy may be a viable procedure that has a good chance to resolve the problem. I have always had success with this procedure on my patients for uncompensated rearfoot varus deformities.

    A Dwyer osteotomy has its base lateral behind the posterior facet and the apex is distal to the plantar medial tubericle. This procedure can help to unload the lateral column while bringing the first ray down to the ground. At the same time, I would probably recommend removing the osteochondral fragment from the talar dome and drill the subchondral bone as that may be an issue down the road.

    I thought the rearfoot would be in a greater varus position than the photo. I see very little post-op swelling and incision is well healed on lateral side. A Dwyer might be a good option to consider to correct the alignment.

    Best of luck to you and keep up your excellent work.

  13. Ann:

    Interesting case. From your photos, the patient's rearfoot was fused in slight varus position causing an excessive lateral overload of the midfoot and forefoot. I don't know of any physical therapy that will help get the medial forefoot to receive its share of the forefoot load and trying to introduce a varus forefoot extension into any orthosis may cause a feeling of lateral instability in the patient, making problems worse, but you may want to at least give it a try to see if it helsp the lateral column symptoms.

    Seeing surgical complications such as this is why podiatrists and orthopedic surgeons are always taught in regards to their rearfoot fusions: "Do not err in varus!"

    Regardless of what your surgeon has told you or written in his op report, the surgeon has left the patient with a slightly inverted calcaneus with a fused subtalar joint and chronic lateral forefoot overload as a result.

    Even though it is not your responsibility to suggest so, I believe this patient should seek a second opinion with an experienced podiatric surgeon or foot and ankle orthopedist to consider a lateral displacement osteotomy of the calcaneus to try and allow sufficient eversion moment to get the medial column weightbearing again. Also, this may require other surgical procedures to try and eliminate the chronic overload of the lateral column of the forefoot that is the likely cause of many of your patient's symptoms.

    Your current surgeon will probably deny that they did anything wrong. That is why I recommend second surgical opinions in such cases since, in my 28 years experience of seeing such surgical problems, I have found that many surgeons are virtually incapable of ever admitting that they made either the wrong surgical procedure choice or did the correct procedure with poor technique.
  14. drsarbes

    drsarbes Well-Known Member

    Well, first of all, your patient had a severe injury. The description does not sound like a Sanders II fracture to me. The photos you sent look very good, and if I were the surgeon trying to fuse a post comminuted fracture of the os calcis, I'd be happy with this. Bones don't always heal where you put them intraoperatively, especially with a "non virgin" heel.

    Secondly, we are all assuming, again, that her pain is biomechanical in nature. She may very well have a common peroneal injury or other soft tissue damage causing lateral foot/ankle pain.

    Third, although the ankle mortice was described as normal, at one point an osteochondral lesion was reported. This may be an osteochondral fracture

    Fourth, she has osteoarthric changes to the Talo navicular as well as the 1st MTPJ which, IF her pain is biomechanical, may account for the increased pressure on the lateral column.

    fifth, and I think most important......she did not have a triple arthrodesis, she had a subtalar fusion. Her initial injury included an intraarticular calcaneal cuboid fragment. She has documented arthritis in the talonavicular. If the surgeon did make an error (and I'm not saying he did) I would say he chose the wrong procedure...i.e., STJ vs TRIPLE.

    Good luck

    Last edited: May 31, 2013
  15. Ann PT

    Ann PT Active Member

    Thanks for the compliment and the advice regarding further surgical procedures. Given that I'm not a surgeon, I can't make suggestions regarding surgery but your input is appreciated for my own education.

    You have summarized well the ultimate picture. Whereever it's coming from and however it got there, her foot and ankle are in a varus position and loading the lateral side. She had a complex calcaneal fracture followed by a fusion and I don't think anyone is trying to place blame or looking for her surgeon to admit error, but we are looking for him to see where the foot is and help offer solutions. She and I talked today about getting a second opinion and she was already planning on doing so.

    I have no objective findings to suspect a soft tissue injury or nerve injury that would still be giving her pain 6 months after her fusion. I agree that the DJD at her talonavicular joint can be contributing to the posture of her foot and will ask the surgeon about the osteochondral defect.

    Again, thank you everybody for taking the time to share your thoughts.

  16. Like Steve said, an isolated subtalar joint fusion does not work well in these types of patients if the maximally pronated position of the STJ presurgically does not allow the medial column to become fully loaded by ground reaction force postoperatively. That is why we are all taught to "not fuse the foot in varus!"

    The results of these STJ arthrodesis procedures really don't depend on the frontal calcaneal position to the ground after the arthrodesis, as many have suggested in this thread. Rather, the results of these procedures more depend on whether the medial and lateral metatarsals rays have the ability, postoperatively, to become fully loaded by ground reaction force during weightbearing activities. Erring in valgus will allow the medial column to bear weight and accommodate to the ground while the Achilles tendon tension force will tend to cause lateral column loading. However, erring in varus will prevent the medial column from bearing full weight (and sometimes the first metatarsal head just hangs off the ground since the rearfoot has been fused in such an inverted fashion), causing all the forefoot loading to be borne by the lateral metatarsal rays, and lateral column symptoms will then become often times worse than the pain the patient had in the STJ preoperatively.

    I've seen quite a few of these patients over the years from other surgeons and about 50% of these patients are looking for malpractice lawyers after they have been fused into varus. These are not happy people.
  17. efuller

    efuller MVP

    It appears that in the relaxed view you can see what appears to be the first met sitting up in the air. You could try the run your fingers under the metatarsal test in stance. If you can easily run your fingers under there then she has definitely been fused in varus. It doesn't matter where the calcaneal bisection is, if the first ray isn't passively on the ground and loaded then you are going to have lateral overload problems. So, if the heel bisection doesn't matter, where the load is does matter. If the load is all under the lateral forefoot, in that picture, the lateral forefoot appears lateral to the leg. I can't tell for sure because it depends somewhat on where the knee is relative to the center of pressure of the foot. If she has some genu varum then she could have the center of pressure of the foot medial to the center of pressure of the knee and then there would be a varus moment on the entire lower leg.

    So, looking at just the foot and ankle picture it appears that the center of pressure of the foot is lateral to the ankle and if this were true you would have a valgus moment at the ankle. As Kevin suggested you could try a varus forefoot wedge. This could improve the lateral forefoot overload, but increase the problems of the whole leg. Try wedges of various thickness and see what is comfortable.

    Regarding the Dwyer calcaneal osteotomy. Yes, this will make the heel bisection better, but no it won't address the lateral column overload. The deformity is in between the top of the talus and the anterior aspect of the calcaneus. The Dwyer is located in the posterior part of the calcaneus and would not change what you want to change which is to decrease the lateral forefoot load (assuming that is what the problem is.)

  18. Eric is right here that a lateral displacement osteotomy of the posterior calcaneus, such as a Dwyer osteotomy, would not increase the eversion range of motion of the forefoot. However, the Dwyer osteotomy would decrease the rearfoot supination moment from ground reaction force acting on the plantar calcaneus and from Achilles tendon force acting on the posterior calcaneus. These mechanical effects may relieve some of the ground reaction force plantar to the lateral column during gait.

    An additional thought is one of the following surgical procedures to reduce the GRF plantar to the lateral column:

    1. A dorsiflexion wedge osteotomy of the cuboid to dorsiflex the 4th and 5th metatarsals
    2. Dorsiflexion osteotomies of all the lateral metatarsal rays to get the medial metatarsal rays more plantigrade
    3. A lateral closing wedge osteotomy at the talocalcaneal joint fusion site to evert the lateral column further
    4. A naviculo-cuneform fusion to plantarflex the medial column.

    Here is what Roger Mann, MD, says about this patient:


    Like I said before, never err in varus in these rearfoot arthrodesis procedures..they are a surgical nightmare to repair!
  19. Ann PT

    Ann PT Active Member


    Couple follow-up questions...

    1. You said "The results of these STJ arthrodesis procedures really don't depend on the frontal calcaneal position to the ground after the arthrodesis, as many have suggested in this thread. Rather, the results of these procedures more depend on whether the medial and lateral metatarsals rays have the ability, postoperatively, to become fully loaded by ground reaction force during weightbearing activities." Doesn't the ability of the medial metatarsals to be fully loaded by ground reaction force depend on the frontal calcaneal position?

    2. If she was in varus after her fracture, couldn't this have been corrected when the fusion was done?


    I have been able to mobilize her foot enough to get her first met head on the ground but I don't think this will last in the long term. Her talus appears inverted creating a forefoot varus which she obviously can not compensate for with a fused subtalar joint. I can try forefoot varus wedging...

  20. drsarbes

    drsarbes Well-Known Member

    Again, I think you are missing the point here. The Talo navicular and the Calcaneal Cuboid need to be fused to get this patient plantigrade. Period. A STJ fusion has already been done here. It isn't working.

  21. Ann PT

    Ann PT Active Member


    I am not a surgeon and therefore can not perform surgery or suggest it to her current surgeon. I can only think about the mechanics of the foot and ankle in front of me and address the comments on mechanics made in other posts. Discussing the mechanics of the foot and ankle in the context of this patient is an opportunity to learn more about mechanics. Right now, the patient doesn't want more surgery (even though it has not yet been suggested by her surgeon). I'm simply trying to help her in whatever conservative way I can and learn something about foot and ankle mechanics in the process.

    Thank you for your thoughts...

  22. drsarbes

    drsarbes Well-Known Member

    I understand. The previous post I made did look a little "terse".....
    I did not intend it to be.
    Hopefully your patient will find relief with your efforts.
    Good luck
  23. efuller

    efuller MVP

    The ability of all the rays to bear weight is loosely related to the frontal plane position of the calcaneus. However, you can have extremes of forefoot to rearfoot relationship that will make the correlation invalid. You can have an everted calcaneus and an extreme forefoot vaurs and the medial forefoot might not be able to bear weight. You can also have a forefoot valgus with an inverted calcaneus and have significant medial forefoot weight bearing.

    Also, the correlation will be a lot better when there is a STJ with motion.

    It's hard to know without seeing the foot pre injury or pre fusion. If there was a high degree of forefoot varus before the fusion then if the STJ was fused in its maximally everted position then the forefoot could still be in varus. However, if it was fused in a more inverted the varus could have been created. She did have a calcaneal fracture and that really srcews things up. So, it's hard to know if the forefoot varus could have been corrected for by the STJ fusion.

    So, when you mobilize the foot to get the first ray down, is there anyting keeping it there? In normal weight bearing, the classic study by Basmajian showed that, no muscle activitiy is needed to hold the arch up. The plantar ligaments hold the arch up. However, for the ligaments to hold the arch up the ray needs to maximally dorsiflexed. When the ray is plantar flexed the plantar ligaments are loose and any upward force from the ground will dorsiflex the ray. The only thing that can keep the ray down is muscular action. In the everted picture, she is probably really working her peroneus longus. It would be very tiring to use the peroneus longus to hold the first ray down all day long.

    I know that we all want to believe that our treatments work. What evidence is there that manipulation permanently changes the range of motion. If it does change range of motion does it do it in the face of fused joints? At which joints are you getting the motion? First ray? Ankle? The STJ is not an option.

  24. Ann, yes the more the calcaneus everts then the greater will be the medial metatarsal GRF. My point is that the surgeon should not use the calcaneal bisection as the absolute indicator of where to fuse the STJ since A) there is a wide range of inter-examiner error in determining calcaneal bisections and B) there is a wide range of frontal plantar forefoot to rearfoot relationships from one individual to another. It is better that the surgeon looked at the plane of the metatarsal heads to the ground as to where the calcaneus should be fused at the STJ than looking at the arbitrary calcaneal bisection, which, by itself, has little to do with the frontal plane relationship of the metatarsal heads to the ground. I suspect the surgeon of your patient never considered the forefoot to ground relationship when they did your patient's STJ fusion, they only looked at the calcaneus to ground relationship.

    A preexisting varus alignment could have been compensated for during the fusion of the STJ but it would be difficult to do so if the STJ, when maximally pronated, still left the forefoot in a varus attitude to the ground. As Steve said, reduction of varus deformity could be easily accomplished by doing a triple arthrodesis. However, in the triple arthrodesis, where the midtarsal joints are fused also, there is greater likelihood of development of midfoot DJD in the future.

    Hope this helps.:drinks
  25. Dananberg

    Dananberg Active Member


    Have you evaluated the relative strength of her posterior tibial to peroneals? My guess is 1) the peroneals are grossly inhibited (hence the dorsiflexed 1st ray position in the pic) and she is therefore chronically inverted. 2) Her limb has to have shortened to some extent due to the injury, and now needs a heel lift.

    Since it sounds like you practice some foot manipulation, try manipulating her ankle, fibula head (posterior to anterior) first, then TN joint (ant to post). This will often restore facilitation to the peroneals and will help with recovery.

    The other important factor is that she is likely more swollen that you would think. As you start to treat her, check heel contact with the shell of the device. If you get this orthotic right, she will improve and the orthotic will no longer fit in about 3 weeks or so. I used heat moldable type orthotics to get through this phase of care, and then casted for something more permanent once the patient maintained shell contact compliance for 4-6 weeks. Makes a big difference.

  26. Ann PT

    Ann PT Active Member

    Thank you all for taking the time to discuss this patient. Unfortunately, in my 26 years as a physical therapist, I have never worked with an orthopedist or DPM who was willing to talk about biomechanics. Since my entire focus as a PT is in restoring normal biomechanics as best I can, or in the case of the foot making an orthotic if needed, having this forum to learn from and ask questions is extremely valuable and one of the few ways I have to ask questions and actually get an answer!

    In the case of my patient, I totally understand the concept of a forefoot varus creating the varus position of her foot. I guess I used different words in my earlier posts when I referred to her talus being inverted but effectively I was describing a forefoot varus. I think Kevin’s point about what line to use (calcaneal bisection or plane of met heads) to decide about where to fuse the subtalar joint is excellent. I would love to know the answer to that about this patient but probably never will. Thank you, Kevin, for clarifying your point.

    Eric…as a PT I look at this patient as having 5 injuries: the calcaneal fracture, the ORIF, post-op immobilization, subtalar varus surgery, and another period of post-op immobilization. When this patient comes to me, I don’t know which restrictions are soft tissue that can possibly change and which are fixed due to the surgery. Generally a surgeon will always tell me the surgery, hardware, etc. has nothing to do with post-op restrictions and that it’s always soft tissue. Therefore, with this patient, I started at the calcaneocuboid joint and first tarsometatarsal joint to attempt to increase pronation and medial arch flattening via first ray dorsiflexion. I did not mobilize the talonavicular joint due to DJD. I made a few attempts at mobilizing the talus, primarily anterior/posterior due to the subtalar fusion, in hopes that if any of the forefoot varus was related to soft tissue restriction, I might be able to change that. We also worked on soft tissue mobilization of her gastroc to gain length and decrease tension. I do believe her forefoot is closer to the ground than when we started but not enough to alter her symptoms. I agree that if there is a bony problem (calcaneal varus or fixed forefoot varus) then whatever soft tissue changes I may have made will not likely last, but without any input from the surgeon, I felt I had to try.

    And finally to Howard, I do not do any manipulations but I do perform endrange mobilizations (Kaltenborn Gr. III-IV). I don’t want to mobilize her talonavicular joint due to DJD and I have mobilized her ankle. I think if anything, her peroneus longus is overactive trying to plantarflex the first ray and get it to the ground. As Eric said, if her bony structure places her in varus, her peroneus longus would fatigue and not be able to effectively compensate.

    We have tried various forms of wedging medially and laterally with no success. I don’t think there is anything more I can do for this patient and she will be returning to see the surgeon next week. I will email him my thoughts but probably will not get a response. The patient is already looking into getting further opinions regarding surgery. Today she mentioned someone in Vail, Colorado but couldn’t remember his name…

    Again, thank you all for your time and input. We’ll see what the surgeon says next week!


    P.S. I attached a few more views of her foot in case anyone is interested!

    Attached Files:

  27. Ann:

    Excellent clinical photos. It is obvious to me that the right foot appears "more supinated" than the left foot when viewed from anteriorly. To me, unless the patient's feet were this asymmetrical to start with, with a slightly lateral STJ axis on the right and a slightly medial STJ axis on the left, this indicates that the fusion was not done with the subtalar joint maximally pronated, but rather was done with the subtalar joint closer to neutral position.

    From what I can see, I believe this is the error of the surgeon...probably spending too much time intra-operatively trying to get the calcaneus "vertical" and not enough time thinking about the possibility that fusing the STJ so that the forefoot is in varus relationship to the ground would produce unequal dorsiflexion loading forces between the medial and lateral columns of the forefoot postoperatively. The result of this error?....chronic lateral column pain for this poor patient and the need for a more technically difficult surgery than the STJ arthrodesis. This is not a foot anyone would want to walk on.

    Moral of the story for those following along? Have foot surgery done by a foot surgeon that respects biomechanical principles, and doesn't think that "doing biomechanics" just means making orthotics!
  28. efuller

    efuller MVP

    The cosmetic result is actually quite good. Many calcaneal fractures result in an ugly foot. However, from the description of the symptoms the fusion was a functional failure. The surgery for the fusion could ave been very difficult because the previous fracture would have altered the anatomy and available range of motion. This may not have been a surgery where you put a giant screw through the talar neck down into calcaneus because there may not have been the range of motion to get the forefoot to the ground before before the fusion. If this were the case, there would have to have been some wedging of the joint surface to change the frontal plane position of the calcaneus. Not easy. That said, if it were my foot, and I had to go through the surgery, I'd want all of my metatarsal heads to bear equal weight. I'd want that even if meant taking out bone that would result in shortening. I wouldn't wish a calcaneal fracture on anyone.

  29. Dananberg

    Dananberg Active Member


    You wrote in response to my comments. "And finally to Howard, I do not do any manipulations but I do perform endrange mobilizations (Kaltenborn Gr. III-IV). I don’t want to mobilize her talonavicular joint due to DJD and I have mobilized her ankle. I think if anything, her peroneus longus is overactive trying to plantarflex the first ray and get it to the ground. As Eric said, if her bony structure places her in varus, her peroneus longus would fatigue and not be able to effectively compensate."

    I will take it that you have NOT evaluated her relative strength between posterior tibial and peroneals, and you are assuming that they are hyperactive. If you check these, you will see that the peroneals are terribly inhibited, and arthrogenic inhibition is common after injuries such as this.

    Also, look at toes 3-5, and how contracted they are on the R. Try at least mobilizing the proximal fibula (post to ant). The fibula must translate cranially and laterally for the ankle to have dorsiflexion ROM.* It should give her ankle considerably more ROM, but more importantly, will facilitate the peroneals. I have seen this type of post traumatic foot on numerous occasions....all the orthotics in the world won't work if there is an underlying muscular imbalance. That said, don't forget the heel lift. Really helps manage part of the inversion issue.


    * Dananberg, HJ, Shearstone, J, Guiliano, M “Manipulation Method for the Treatment of Ankle Equinus, “ Journal of the American Podiatric Medical Association, 90:8 September, 2000 pp 385-389
  30. Ann PT

    Ann PT Active Member

    Here's the update...my patient is seeing her surgeon this afternoon. I sent him a long email ahead of time with my concerns about the varus position of the calcaneus and the forefoot varus. He was kind enough to speak to me for 30 seconds on the phone this morning. He said his goal was to fuse her subtalar joint in a couple degrees of valgus but that it's probably in a couple degrees of varus. He did say when asked that he looks to get the calcaneus vertical as opposed to aligning it with the forefoot when he did the fusion. He thought she should be able to compensate through her 4th and 5th TMT joints for the varus. He didn't want to talk about the forefoot. He thinks any varus in the forefoot is a result of the calcaneal varus and "will be fine." His suggestion now is to do a calcaneal osteotomy. Even with that, I'm still concerned about the forefoot varus and not convinced it won't be a problem post-op, still sending her to her lateral border. Any thoughts?
  31. Ann:

    If the calcaneal osteotomy does not evert and/or dorsiflex the anterior articulating surface of the calcaneus, then a calcaneal osteotomy will not dorsiflex the lateral metatarsal heads.

    You may want to suggest to the patient to find a surgeon that understands the importance of the plane of the forefoot to the ground rather than one that is just worried about the alignment of the calcaneus to the ground. That type of surgical ignorance is what got this patient into the mess she is in now, in my opinion.

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