The Equinus Expert

Flatfoot reconstruction isn’t LCL vs fusion—it’s deformity selection. STF works in severe cases, but removes compensation. If hindfoot or forefoot alignment is incomplete, the ankle becomes the next deformity. Correct the system, not just the segment. #FootAnkle #PCFD #Flatfoot

Failed TAR + bone loss is limb salvage. Not about the implant. About approach: Define the defect Stage it Restore structure Respect biology + mechanics Miss one and it fails. Where do these cases break down for you?

Foot/ankle tendon lacerations are easy to underestimate. This review reinforces missed injuries can lead to weakness, deformity, gait dysfunction, and more complex delayed reconstruction. Strongest support for acute repair: EHL, TA, TP, Achilles. Small wound, big mechanical issue

This is what advocating for podiatric medicine looks like from the inside. No hallway too long, no office too far. Grateful to be leading this charge alongside CEO Meghan McClelland and our incredible APMA team. #APMAonTheHill #APMAAdvocates #FixPriorAuth

MIS bunion surgery doesn’t cause transfer metatarsalgia because of shortening. It happens when you dorsally elevate the met head. Sagittal plane control > everything. This is a technique issue, not a procedure issue.

Diabetes optimization before foot & ankle surgery is not just “medical clearance.” HbA1c, BMI, neuropathy, vascular disease, and medication class all influence healing and infection risk. In one study, each 1% increase in HbA1c increased infection risk 1.59×.

Bone-block Lapidus (Lapicotton) is gaining popularity for severe forefoot supinatus. But new data shows: • 33% tomographic nonunion ~10 months • 42% nonunion at 2 years Are we correcting deformity… or creating a biologic fusion problem at the first TMT?

Does 1st MPJ arthrodesis limit sport? Depends who you study. One paper shows lower sports FAOS vs Lapidus/Lisfranc. Another study of elite athletes shows 75% return to preinjury sport & 100% satisfaction. Fusion changes biomechanics—but athletes can still perform.

Midfoot arthrodesis union depends on more than hardware. Compression screws alone had the highest nonunion rates in this study. Successful fusion requires stable fixation, bone graft, and anatomic alignment.

Heel pain isn’t just plantar fasciitis. ~98% of heel fat pad deformation occurs in the deep macrochamber. Pain patients bottom out earlier and recoil less. Add equinus → higher impact loading into a compromised shock absorber. Heel pain is both compressive and traction-driven.

Flatfoot is common. PCFD is not. Arch collapse does not create pain. Peritalar instability does. Sinus tarsi collapse and middle facet uncoverage mark the difference. Radiographs underestimate it. WBCT reveals it. Flat is a shape. Instability is the disease. #PCFD #FootAndAnkle

Obesity does not appear to worsen PROMs or complications after 1st MTP fusion in several cohorts But do not generalize fusion data to bunion osteotomies Different operation. Different failure modes Technique matters Webb Foot Ankle Spec 2022 Chen FAI 2015 Milczarek Int Orth 2017

MIS HAV correction does NOT worsen flatfoot. I use SERI, address equinus with gastroc recession when indicated, and follow with a functional orthotic to support long term mechanics. The issue is not distal MIS. The issue is untreated equinus. Mizher FAI 2024 Michalski FAO 2022

Most surgeons understand HI is a distal deformity Historically the issue has been that open IP fusion felt fussy, so many deformities were simply ignored MIS changes the workflow Burr prep + headless screw makes IP arthrodesis simpler, reproducible, and aligned with modern FF Sx

Forefoot striking does not remove load. It moves it. This study showed: • 2.4x Achilles injury risk in NRFS runners • Higher MTS injuries The missing variable is often equinus. If DF is limited, strike changes amplify Achilles demand. Biomechanics is load redistribution.

MIS arthrodesis slurry debate. I prep with standard MIS technique, 20 sec burr intervals, bleeding subchondral bone. I do not irrigate or remove the paste. Cartilage debris is a prep problem. Bone dominant slurry behaves like local autograft. Wheeler FAI 2009 only clinical signal

Non union is rarely a screw problem. It is a biology and environment problem. Radiographs first. Biology second. Patient factors third. Construct last. Fix the right variable.

Sound on 🥴 hardware removals can be like a hit to the groin

Part 2 — Painful Peripheral Neuropathy. When oral meds plateau: • Think local (capsaicin, lidocaine) • Medical foods = adjunctive metabolic support • Escalate thoughtfully to neuromodulation Less polypharmacy. More sequencing.

Idiopathic peripheral neuropathy isn’t a Dx you start with — it’s one you earn. Before escalating meds: • Confirm the phenotype • R/O plasma cell & metabolic causes • Think structural vs systemic • Protect function, not just pain scores Dx 1st Medications 2nd Function always.