Praising The Importance Of ‘Heretics’ In Challenging Podiatric Dogma

Stephen Barrett DPM FACFAS

I love heretics. Give them to me small or large, morphous or amorphous, solo or in packs. I just love them, even when I disagree with them vehemently.

Why? I will tell you why. It is because they stir the pot. When the pot gets stirred, interesting things bubble to the top and this causes some type of reaction. Do I always agree with these heretics? No. More importantly, does science agree with them? Many times, science eventually agrees with heretics. It is funny to see how the once vilified heretic suddenly (“suddenly” in heretic time is usually a decade at least) becomes the hero after time and additional research.

The “heretic” initially has to suffer the public outcry, the organized disbelief of the knowledgeable “elders” and the vitriolic spittle aimed at them personally, not necessarily at their idea. These erudite folks are always aghast in the beginning when they are cloaked in the heavy threads of ignorance but over time they usually slip away into the ether, or jump on the bandwagon, disingenuously claiming they have been there with the “heretic” conceptually all along.

In 2005, Robin Warren, MD, and Barry Marshall, MD, two Australian physicians, received the Nobel Prize in Physiology and Medicine for their discovery in 1982 that it was really an infection of the gut by H. pylori bacteria that caused peptic ulcers.1 At the time of their discovery, they were heretics, branded as outcasts by those in conventional medicine who were certain in their belief that peptic ulcers were caused by stress and lifestyle. Surely, no bacterium could live in the toxic neighborhood of those caustic acidic gastric juices, those same chemical constituents constituting the skeptics’ spittle. It only took 23 years for these heretics to become heralded. Suddenly, they weren’t crazy.

We all know a heretic is a person who holds an opinion that is contrary to public belief or opinion. I would proffer that without heretics, there would be little advancement or improvement in technology in any discipline (specifically in our specialty), and thus no improved patient outcomes.

Dogma is a mysterious and underlying dark matter force that is always there. Dogma is pulling and fighting to try and hold on to the most outdated and disproven belief of the populous, or whatever body controls that protected small universe as the “sacrosanct truths.” We never quantify or acknowledge dogma until the disbeliever has an epiphany of his or her own. This “epiphany” is usually a bludgeoning of the skeptic with mounds of reproducible, independently generated replication of the heretic’s original science. Heretics can be the true superheroes who fight these “dogma masters” and their powerful and usually outdated, ignorant disciples without malice. Heretics are emboldened by discovery, truth and bundles of solid research backing them up.

We have been really lucky to have some real heretics in our profession and I hope we realize that some absolutely great advancements have occurred because of their work. Lives have been greatly impacted for the better because these “heretics” had the brilliance and stones not to follow convention or be bullied by it. These heretics had the tenacity to diverge from the pathway of the “entirely convinced mainstream.” With just enough deviation to give us something new and real but safe, their discoveries improve patient outcomes, without them ending up like General Custer at Little Big Horn.

There is this undeniable force of nature that aids the “heretic” and it is called time. Time allows for ideas to mature, stirring the pot of science to catch up with previously perceived radical ideas, and for the “mainstream” to either get on board with a body of work and recognize it for what it is or just disappear into a land of quiet denial, which is sometimes euphemistically called retirement. Those who choose the latter route and do not retire many times end up sitting in their over-staffed, under-utilized offices wondering why “that damn new guy is doing so well when he isn’t even on all the plans.”

A Closer Look At Two Recent Studies

Now let me get to the point of this soliloquy. There have been two important studies recently published in the Journal of Foot and Ankle Surgery that have largely gone unnoticed.2,3 That is a shame as they are really important, well done, solid pieces of research. I sometimes wonder why certain written “wonders” (such as barefoot running and onychomycosis) get our profession so excited. These topics are important and interesting in themselves, but really not meriting the discussion of what is contained in these two articles.

These two studies should merit discussion for one reason alone. You can help your patients with a very minimally invasive surgical technique for a very common problem: tarsal tunnel syndrome. Now for clarification, I am not saying that one does not need to address nerve compression primarily but the surgeon must recognize what is really causing the compression. All cases are different and we need to evaluate them from this standpoint.

Both 2011 studies deal with what happens in the tarsal tunnels with hyperpronation and, more importantly, what happens with the nerve when you do something to correct that pathomechanical situation. The first study is “The Effect of HyProCure Sinus Tarsi Stent on Tarsal Tunnel and Porta Pedis Pressures” by Graham, Jawrani, and Goel.2 The second study is “Effect of Extra-Osseous TaloTarsal Stabilization on Posterior Tibial Nerve Strain in Hyperpronating Feet: A Cadaveric Evaluation,” also by Dr. Graham and his team.3

Tarsal tunnel syndrome is still totally unrecognized by some, even in our own profession. “It rarely exists,” say some of the uninformed skeptics (hard to imagine that) and many others in other specialties suffer the same plight (the real plight is suffered by their patients who have heard they have nothing wrong with them.) While many in our fraternity recognize the condition, some simply do not treat tarsal tunnel syndrome effectively or mistreat patients with some modalities (usually steroid injections) to avoid surgery.

Giving a steroid injection into the tarsal tunnel is about as smart as igniting your Lucky Strike in the TNT factory but yet that is what many practitioners will do. Why? It is because they are afraid to really operate on the tarsal tunnel and they simply do not understand the peripheral nerve physiology of what is happening on the medial ankle and specifically the porta pedis.

By now, I hope that you have just woke up with your heavy coconut impinging every soft tissue of your forearm with the uncomfortable pins and needles of neurapraxia in your fingers. Now you will get the meaning of exogenous nerve entrapment, and this is what Dr. Graham is demonstrating in his exciting and compelling research showing how hyperpronation contributes to an exogenous nerve entrapment. Remember that equinus does the same thing in the forefoot.4 This is a Type I Sunderland peripheral nerve injury and unless you are Rip Van Winkle, it is usually quickly reversible. However, it gives you the idea that nerves can and are impinged by something other than venous engorgement, tight anatomical tunnels, fascial bands and soft tissue masses to mention a few.

Several authors have shown how important the position of the foot is when dealing with the tunnels of the medial and lateral plantar nerves.5 Rosson, Dellon and their colleagues have shown this both in the cadaver and in live surgery.6 They measured the increase in pressure with changes from a neutral position of the foot in the cadaver. In surgery, they showed how one can avoid these increases with proper tarsal tunnel decompression.

In Conclusion

We can glean a few important points from Dr. Graham’s articles.2-3

• Pronation during gait increases the pressure in the tarsal tunnel from 0 to 7 mm Hg in neutral position to 12 to 60 mmHg. This occurs with every step.

• Pressure at 20 to 30 mmHg impairs intraneural blood flow.

• Pronation increases the strain/tension of the posterior tibial nerve.

• An 8 percent strain obstructs venular flow and 15 percent causes complete arterial occlusion (remember, nerves need blood like college football junkies need the elimination of the BCS).

• A 6 percent strain decreases the amplitude of the action potential and a 12 percent strain produced a complete block of the nerve and had minimal recovery.

• By reducing the pronation via blocking the talotarsal dislocation with his HyproCure implant, Graham and colleagues were able to demonstrate a 43 percent reduction in posterior tibial nerve strain and a 34 percent reduction in pressure.2

Now this is some really good stuff because all of us have those patients who are so over-pronated, we know that we will not be able to have success without some mechanical stabilization in addition to our neurolysis. Conversely, there are some whom I now implant first, thanks to my fellow heretics’ work, and then wait to see what happens with their symptoms. Then I decompress if necessary.

I want to thank Dr. Graham for all his dedication and outstanding work, and also for making it onto my all-time heretic (read: hero) list. That is the highest compliment I could pay to Dr. Graham.

Financial disclosure: I have no financial relationship to GraMedica, the manufacturer of the HyproCure Implant, and no financial relationship to anything discussed in this blog, except that I am angling for becoming the curator of the Heretics International Museum.

1. Marshall B (ed.). The Discovery of Helicobacter pylori in Perth, Western Australia. Blackwell, Oxford, 2002.
2. Graham ME, Jawrani NT, Goel VK. The effect of HyProCure sinus tarsi stent on tarsal tunnel compartment pressures in hyperpronating feet. J Foot Ankle Surg. 2011; 50(1):44-49.
3. Graham ME, Jawrani NT, Goel VK. Effect of extra-osseous talotarsal stabilization on posterior tibial nerve strain in hyperpronating feet: a cadaveric evaluation. J Foot Ankle Surg. 2011; 50(6):672-675.
4. Barrett SL, Jarvis J. Consideration of equinus in forefoot nerve entrapments--treatment via endoscopic gastrocnemius recession (egr): a clinical case example. Submitted to Journal of the American Podiatric Medical Association, 2005.
5. Barker AR, Rosson GD, Dellon AL. Pressure changes in the medial and lateral plantar and tarsal tunnels related to ankle position: a cadaver study. Foot Ankle Int. 2007; 28(2):250-254.
6. Rosson GD, Larson AR, Williams EH, Dellon AL. Tibial nerve decompression in patients with tarsal tunnel syndrome: pressures in the tarsal, medial plantar, and lateral plantar tunnels. Plast Reconstr Surg. 2009; 124(4):1202-1210.

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