Sarah E. Haller, DPM, FACFAS
Fellowship Trained Foot + Ankle Surgeon
Essex Union Podiatry
o: 732.388.2375
f: 732.388.2377
We all know the Lapidus procedure addresses sagittal and frontal plane instability at the first tarsometatarsal (TMT) joint, but it doesn't automatically restore postoperative gait mechanics. One pattern I see frequently is increased lateral column loading/supination during the transition phase back to walking.
Preoperatively, many of these patients have first ray hypermobility contributing to sagittal plane collapse, which is the primary rationale for fusing the TMT-1 joint. Once the fusion is complete, that compensatory flexibility is gone, and many patients respond by shifting their weight laterally.
This compensation can be driven by several factors: guarding around the fusion site, proprioceptive adaptation, and peroneal or posterior tibial muscle imbalance that develops after weeks of altered gait during non-weight-bearing and protected weight-bearing. After performing this procedure for years, I've seen this pattern enough to know that if it isn't addressed early, it often becomes the patient's new normal.
Common consequences include fifth metatarsal overload, lateral ankle instability, and altered mechanics that can affect the entire posterior chain.
PowerStep® recently introduced a new Supination Insole focusing on the postoperative gait changes we need to correct. This new orthotic insert combines lateral forefoot and rearfoot posting to resist excessive roll-off, medial column support that minimizes pressure over the fusion site, and a firmer shell that provides initial control while transitioning to a more accommodative feel as patient tolerance improves.
It's important to view this as a bridge intervention rather than a permanent prescription. Prolonged use beyond the gait retraining period can simply replace one compensation with another. Appropriate timing is what makes this intervention most effective.
Suggested postoperative progression:
- Weeks 0–6: Non-weight-bearing or protected weight-bearing with the primary goal of protecting the fusion.
- Weeks 6–10: Weight-bearing in a walking boot. This is typically when the supination pattern begins to emerge.
- Weeks 10–14: Transition to supportive lace-up footwear. If radiographs confirm fusion and swelling is well controlled, this is when I typically introduce the insole.
- Months 3–6: This is the most important rehabilitation window where the insole helps support a return to activity while gait mechanics continue to normalize.
I also will use this new supination insole as a primary longer-term care for patients with a cavus foot or those with pre-existing lateral ankle instability.
The Supination insole has a multitude of applications in everyday practice! I’m so happy that PowerStep is evolving with patient care!