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Marlena Jbara, M.D.

Dr. Marlena Jbara is a pioneering figure in Musculoskeletal Radiology, blending her expertise as an academic radiologist with her passion for healing through imaging interpretation. With over two decades of experience, she's dedicated to educating physicians globally. Dr. Jbara is the visionary behind RadPodSquad, an innovative platform fostering collaboration among foot and ankle professionals. Through dynamic virtual meetings and evidence-based case discussions, RadPodSquad empowers healers to enhance their imaging skills and address patient needs effectively. Join the Squad and elevate your practice with us.

 

 

 

Dr. Barrett 00:05

My guest today is Dr. Marlena Jbara, who is a board-certified musculoskeletal radiologist and I think you'll find today's discussion very fascinating. She has developed a platform called rad pod squad, which is a educational platform for anyone who's interested in lower extremity pathology and corresponding radiological imaging. What I find so interesting in Dr. Jbara has expertise is that she has a very deep understanding of biomechanics and is able to put together her biomechanical knowledge with her knowledge as far as interpretation of different studies, MRIs, plain film radiographs etc, which gives the recipient of that imaging report a little bit more insight and she understands how complex the foot and ankle really are when it comes to pathology and appropriate imaging and more importantly interpretation. So please enjoy this conversation I have with Dr. Marlena Jbara. All right, I'm here with Dr. Marlena Jbara, and she is a musculoskeletal radiologist who has a great focus in Podiatric Medicine and, and pathology. Before we get started and get down to the weeds with what you're doing, tell us a little bit about your background and how you got to this point, because I think it's a really interesting story.

 

Dr. Jbara 02:35

Thank you so much. And thank you for bringing me on the show. It's been it was an honor to receive this invitation. And I can't say enough with how wonderful it is to collaborate and that I think that is what really got me into medicine. I am a board-certified American radiologist with a subspecialty expertise in bone and joint radiology, and furthermore, foot and ankle. And I was trained by an amazing radiologist called, his name is Dr. Javier Beltran. And he was from Europe. And he always impressed on me the importance of locomotion and walking, and understanding how to read images in motion. And that was different from everything that we were doing. I was originally trained in Brooklyn, but at downstate, and we learned like all radiologists how to find the anatomy, we went to the anatomy labs, and we learned how to interpret images. And it wasn't until I got to my fellowship with Dr. Beltran, where he began to impress on me the importance of understanding how we walk. How you throw a ball, how do you move? And how can we look at imaging through that lens. So, lo and behold, just like all of American medicine, we get out there and we learn how to interpret images. And we're just learning how to read the images and understanding what it means to have a turf toe and things like you know, the clinical part. But for the most part, radiologists are behind the scenes looking at images, and somewhat removed from that, that patient experience. So, I became interested in bringing that together.

 

Dr. Barrett 04:09

One of the things that I think radiologists have a very distinct disadvantage is they oftentimes don't have the ability to actually see the patient than palpate where it hurts and, you know, so they're, you know, just by the nature of the way that the specialty is, it's sometimes like having a little bit of a blindfold on because you don't get this. I think that that says a lot with what you're saying as far as integrating the biomechanics into what you're looking at. Because let's face it, these are dynamic structures. They're not static structures. And that type of understanding is going to give you the ability to help everybody else in your interpretation. So, I think it's great.

 

Dr. Jbara  04:54

Thank you, and that grown up early in my career when we were learning, one of the most important adjuncts to my training under Javier Beltran was ultrasound. And that's where radiologists first gets that opportunity to actually interact with the patient and also interact with a team. So we began early on looking at in the foot, especially we began looking at plantar, just the plantar fascia, looking at touching the fascia in the ultrasound suite with the probe. And I became very interested in how important it was to actually touch the patient put that together to understand the common complaints over time. And then furthermore, who are radiologist, it is not the way that we tend to sit behind a screen reading images, doing ultrasound takes that active events towards the patient and sort of you're acting almost alongside a podiatrist. In fact, I used to think we should have clinic where we have a radiologist next to the podiatrist, the podiatrist does their initial consultation and then we can corroborate that on an ultrasound. These are systems across the world by the way they do that in in in London and England, I've seen that where that happens, but as a mainstay of radiology has not initially gone towards that patient unless you were in ultrasound.

 

Dr. Barrett 06:15

Right? Right. So, we've got a lot of great stuff to dive into today and talk about your platform. And the fact that you know, this knowledge base that you have, you are sharing it with these practitioners, which I think is fantastic. You want to tell us a little bit about your platform so that they kind of get an idea of what they can get into and that lets specifically go into the forefoot and talk about plantar plate because I think there's so much that we could talk about with you probably do 10 episodes but let's just focus on forefoot plantar plate after today. So, tell everybody about rad pod squad?

 

Dr. Jbara  06:55

So in my career, I'm an experienced academic radiologist, I spent a number of years in New York. And I began to see as a radiologist early in the 20 years of like 2000 to 2010 that the amputation rate was through the roof. And I was sitting in a room reading MRI after MRI wondering, you know, are we making any difference? Because it seemed that the amputations would just continue, there was nothing we could do. I looked at the guidelines from the American College of Radiology. And they suggest that you get an early MRI, when you see a patient who potentially has osteomyelitis. And I began first, honestly, with a bit of a bias. I said, What Why are we not doing better here? Like what's wrong with us? And I decided to start with a research project that had me studying about 500 patients who have diabetes who already had an amputation and whether or not they got an early MRI, did it make a difference was MRI a game changer. And I didn't find that the end of my research that it changed the amputation rate, but it decreased the death rate. And that's in diabetic foot and ankle you can take a look at that. And I surmise that the reason why we were decreasing the death rate was because now we were talking to one another, the surgeon was talking to the radiologist, that we're all collaborating together. But I always had this idea that one of the things that was occurring in medicine was I wasn't seeing the podiatrist enough. I wasn't interacting with them. I didn't see where we interface I went to Grand Rounds, and I gave Grand Rounds. But I didn't always see the podiatrist in the loop. And it dawned on me, I need to know who they are because how will I ever know the clinical really well? Or how do I even know where ulcer is? Now for those of you who may not realize by now that having a foot ulcer is the predisposition to having osteomyelitis, and that it may cause you to have amputations which may cause you to have years of your life removed. So, it's a very important strategy. And I began to wonder on one to make a collaboration directly from radiology to podiatry. And I began and I created a 24-hour lecture series that was commended by the American Academy of Podiatric graduate medical education. And all the residents in Northwell have 14 different hospitals had the ability to come to my course, check out my lectures interact with me. And let's see, we saw through polling that they did much better and we brought in new systems we even were able to create a system where we had official text-based photo language where we could the radiologists could see the ulcer when they're reading the case. So, we developed all that with you know with wonderful results. But to take it up a notch. What I wanted to do was to really talk globally to the problem that we have in diabetic foot but just in front of ankle imaging in general, we do a lot of imaging and imaging is one of the most important reasons for patients come into the system, for Foot and Ankle issues. And we want to do our best so that we really can understand how we're going to treat the patient. But if we only have one side of it as a radiologist, just having the pictures, we don't always appreciate the tremendous clinical features like in forefoot you mentioned, a podiatrist can see very quickly that say that the second toe is starting to cross towards the first toe, as in a case of a classic plantar plate tear, but a radiologist was never trained up through that area. So, it may not be obvious that we should be looking for that very quickly if we want to make that diagnosis. Right.

 

Dr. Barrett 10:46

Right. Right. Well, and I think because of our specialty again, you know, peripheral nerve, and we ended up seeing a lot of folks that have had failed Morton's neurectomies and different types of devastation surgically induced from the standpoint of attacking the forefoot, but with all of these different things where I think they were able to have a little bit more appreciation of what you're pointing out, like, increased like say they have a long second, third and fourth metatarsal, and they have an equinus component, they're pretty much doomed to a high pressure them that in that forefoot. And there's not many radiologists that I know what that will say like you will look at the cortical sclerosis in the second metatarsal. That's a very objective finding because of a biomechanical event that's going on in this particular patient. So, it gives you a little bit more understanding of, you know, everything that's going on. And that and that type of just that that verbiage in one of your reports is going to change maybe the way that podiatrist or foot and ankle orthopedic surgeon so maybe look at that, and could totally change the care that is rendered and the treatment path that they go down. So I think that's an important thing. So, they can go and we'll get more into this at the end where they can go in and join your community and everything. But we wanted to talk about planter plates specifically.

 

Dr. Jbara 12:27

Absolutely. I'll take you through. And I can already introduce you to the community by seeing some of what I've got going on here. So not the invitation to get rid of that. So, when we talk about what I'm trying to do is basically it's a fellowship that many radiologists I already trained radiologists across the globe. And what I'm looking at specifically is to create a foot and ankle fellowship program which I've called Rad Pod Squad. And there's a whole community where you get to know other physicians and we discuss cases as they come up in my classroom is where you get to have quite a bit of content. There's, you know, tons of lectures on every aspect of Podiatric radiology, and it's geared that we're all learning the same way like what we all need to know what the radiologist, what the podiatrist what we all need to know to get to treat our patients well, specifically and for often imaging I have had, you know, for years, I was talking about something called psuedoneuroma.. And I was called into the office and asked, what are you talking about?  And we've known a lot about forefoot imaging and the different problems with nerves out there, but it's been slow to change the medical establishments' ideas, so I created this Rad Pod Squad to enlighten them to bring out some of the features of what we've been studying and bringing all the important players into the same room. In order for us to impact forefoot disease. We need the podiatrist we need the surgeon we need the radiologist we need the whole foot care team to understand and what we're understanding it like in an example like for have a plantar plate. I basically have videos that can take you through that. But just for the sake of time, just looking at a static lecture and this has been videotaped. We're looking at the plantar plate. As we know the plate is responsible for the metatarsal purchase from the heel strike to the early into the late flat foot phase to the toe off. We're using those toes to really toe off and when they go bad, right we can were out of place and it can pop up and become a crossover. What we're talking about in the biomechanics, what you were alluding to is being able to interpret your X rays, being able to see hammertoe deformities and translate that to the doctor who is not looking at the X ray who we can start to understand how we can grade and do better work with understanding where our patients are at and I use this X ray as they tell us a lot about our biomechanics. But as you have mentioned if we have an elongation of the second toe, or even if we have the plantar plate for the first off at the sesamoids, on our different line. And all of these features of cortical stress and deformities and splaying are not things that you see in a typical X ray, but you want them to be, because they really make the difference of where you're going to stratify your patient now, and I'm an artist on the side. So you'll often see things like, my pictures of what all of the anatomy of this are, in studying the plantar plate, I think it's important for a radiologist to have all that background to understand all that clinical and for the podiatrist, to understand what they can expect from a good report, we put together protocols that really help us to see the plate now this is what you can see on MRI. And I think once a podiatrist understands what they're seeing on MRI, it becomes important part of their surgical experience. If you're going to take these regions, you want to understand what you're cutting what you're doing. And in the past, we would just lovely dissect out into the dorsal space, we would take out what looked like an X shaped nerve, and we would put it in the can and that would be the end of that. Now we clearly know that there's a lot more involved anatomy than meets the eye. And that may be a large part of why these plates don't always do well long term of why a nerve procedure may not do well. And really, it's even more complicated than just learning about what's there. It's learning about how the hind foot is loading the forefoot, as we've mentioned. So, at Rad Pod Squad we routinely got this is content that's available to anyone any day. But the real benefit in the community is really asking questions like today. Today a student was asking me about a plantar plate. This is a student showing me an MRI. Now, one of the things is I trained people from all over the world and all over the world, they do things differently. So, this is a very wide field of view, it's happened fast field of view just to see the plate, but you can see the great toe. Essentially, we're looking at the specimen. This is a fat suppressed image. But we're looking at the great toe when you see in the sesamoid some of these ligaments. While we're looking at the nerves themselves, we can see if we look at the metatarsal is in the short axis. I know that you don't know that. And if you want to know more, you're going to join Rad Pod Squad.com. But we'll be looking at these reasons the why the metatarsal 's are looking this way. And one thing I pointed out to the student that this physician was that even though the doctor was interested in a plantar plate tear, take a look at the hind foot, take a look at the edema that's around the Posterior Tibial Tendon and appreciate the fact that this patient actually has some form of pes cavus They have not actually thought but and we can see that a lot of non-weight bearing just from just from looking at or trying to guesstimate where we think is the talar vector in comparing that to the first metatarsal vector that have normal Mearie's line. So very important to load and understand the hind foot before you go and take out a neuroma in the forefoot because this cavus if someone does some sparing procedures here, they're going to have less and less fourth metatarsal purchase to accomplish their phase of gait. So there's a lot of complicated stuff as you stuff I could I could add 10 hours to our time together. But I wanted to just share that it's very complicated, and I think in community is where we can really, really bring this together. And that's why I encourage people to join the Rad Pod Squad to discuss cases and to have this is a great example as well. This was a student the other night. Hi Marlena, can you give me advice on measuring hindfoot valgus Saltzman view. If I have a referring foot surgeon who asked for them. And he's admitting none of his colleagues understand what calcaneal line to use. So now we're getting to it, you know what people don't know. And I'm able to share with them where this literature came from how to measure on how to talk to their physician, so that would make a difference and help the physician to understand how to balance that hind foot alignment view. I'm going to stop for a second. I think you had a question or a comment.

 

Dr. Barrett 19:07

Well, no, I think I think that you know, when we talk about forefoot but you have to appreciate the global nature of what's affecting that forefoot and you have to look proximately do they have an equinus of some type gastroc, gastrocnemius, or gastrosoleal equinus and is that cause and then overload on the on the forefoot? Have they been given a bunch of steroid injections that really do nothing's from a standpoint of improvement of the outcome for the patient, but yet it will erode the plantar plate. So, maybe their quote and neuroma-like pain gets improved, but then they come in with a hammer toe. So, there's a lot of things that are going on that you pointed out but you have to look at these not just from that little specific area of tissue, but what's happening proximally with that patient from a biomechanical standpoint that's causing that, that tire, so to speak to wear out. I use the car analogy an awful lot, because people understand it. And it's like, if you have a tire that keeps wearing out on the passenger front side of the car, well, it's probably not the material of the tire the tire itself, it's probably the it's the alignment. So why would you just continue putting a new tire on this thing? And not try to get it back into alignment? I think that's what you're saying here?

 

Dr. Jbara 20:31

Yes, I don't think it's much more complicated than meets the eye, which is where I think each group purports to have the answer or the best way to look at it. And in fact, it's a fallacy because no one group alone, whether you're a podiatrist, or a radiologist, or any anyone in the field, together, we need to understand all of the biomechanics in order to understand what the imaging is showing us. But classically, this is very complicated. There are multiple features when you think about the foot and ankle 28 bones, over 30 ligaments, a lifetime of blisters, right? I mean, there's no end to the complexity. When I tell my students, you know, I'm going to teach you, you know, there's a medial column and a lateral column, they look up to the sky, because he's a radiologist who are great, extremely brilliant, by me trying to tell me that I don't know this. But the point is that, just like you said, it may not be obvious, but when we're doing something like a hallux valgus repair, but we have not fully understood both the hindfoot alignment. What are the forefoot alignment or understood? Does the patient have the confounding issues? Or are they at risk, that's a really risky thing to just change the hallux positioning without going through all have it. And we're beginning to see those failures in diabetes like for patients who early on clad by mechanical failures, once you get diabetes, now you're on a locomotive train to a wall. And you really want to understand we've done some studies to understand the full line and ahead of time, but this is where in rap hotspot, we basically will take you through some you need to get into the angles, you need to sort of see what you don't know. So, there's wonderful tutorials of how we take these X rays. Now, I'm not training someone how to take an x ray, I'm going to train you in interpretation, but having excellent technique is essential. So, and I tell my students, we don't know everything. I don't know everything. So, having a flexibility with not accusing someone or asking questions. You want to come and ask your questions. You want to not be afraid that you're the only one who's not doing it. Right. We want to get to the right position. It took a lot of people naysayers telling me oh, my Marlena here just hallucinating. You know, what are you talking about? I'm like, you know, but no, it really seems to make sense that a lot of people with hallux valgus seem to need it. You know, they already have a pes planus. I don't know, there's something to it, we do need that compensation. So, I'm not sure what's the right answer. But in the future with AI, it will be very possible that we can marry something like a gait analysis to a mobile MRI and understand exactly the changes that occurred through the phases. And there'll be lots of information that a computer so we want to understand how to guide that. No, I think that's what Rad Pod Squad is about.

 

Dr. Barrett 23:24

That's great, because now if you look at an x ray of a patient that doesn't have a significant amount of osseous deformity, you really don't have an idea of necessarily what's going on with that plantar plate,  if it's early, and that's where dynamic ultrasound can be so valuable because you can take and you can stress and see if they have a positive Lachman sign and you can see that that plantar plate just open up and I had so many MRIs that have come back and they said, you know, there's no issue with the plantar plate but you can take the patient's foot and dorsiflex or dorsally sublux the proximal phalangeal base on the metatarsal head and I might be a six millimeter gap, but there's no way that the MRI is going to pick that up because it's a static MRI. And you know, when the foots in a resting position that that plantar plate isn't being stressed so a lot of times it floats under the radar. I don't know how you feel about it.

 

Dr. Jbara 24:24

I do and I in Rad Pod Squad you know this whole section. I don't want to take it to the volume of it. But what I wanted to show you is that when I show a trained and create a podiatric system in hospitals that help people to understand how to use ultrasound as an adjunct or by even have podiatrists that graduate and come back and one training on how to bring that to their office by not necessarily I think that there has to be a lot of training to understand that but having the podiatrist who knows the patient who knows how to stress this Lachman maneuver has been trained clinically, you can really see here I'm just demonstrating a Moulders' maneuver. And there's more to it. But basically, you can see this hypo echoic nerve that's going to plunge out of the space. As we go up and down with our Mulders sign. This, again, is looking at one aspect of the total issue. So, when I think about ultrasound, let's think about it as problem solving. And what I want to do is they always really prefer to have some baseline, high quality MRI, ankle, and foot, and then we use ultrasound, just understand where to put our injections, what we're looking at how dynamic it is, and I agree with you, it can give us like, I have ultrasounds as well on the on the course than help us about Lachman's maneuver. I think these are essential parts of your training, once training to understand how we're going to impact these diseases and how we can talk about them. I think that, you know, we're all looking at the same thing from like, from different parts of the steering wheel, but putting it all together, I think you need a map, you need good X ray evaluation, you need to be a student understanding the biomechanical disadvantages that occur by being able to predict the biomechanics. And then we want to talk about which the podiatrist is in perfect position; how do we treat it? Do we do surgery? Do we do offloading? You know, I think prevention is going to be a key player in the future. And being able to predict the best offloading is going you know, that this is all available imaging is going to move into AI. And we're gonna be able to put it all together. But for the podiatrist who really wants to get a head start and where we're going in the next decade. I think this is where it's at understanding dynamic imaging and marrying that to your clinical practice. And even bringing your patients into the picture, showing them the picture, it can be an amazing visual thinking strategy, I believe you if you show me something on the picture, like show me where this

 

Dr. Barrett 27:00

It's amazing how good patients are in understanding their ultrasound imaging. They don't need to be a radiologist to see that gap in the tendon or to see that subluxation of the base of the Phalanx on that the head of the metatarsal, they get it and they can, you know, I think and I think that really imparts a lot of very important information to the patient that actually helps them in their treatment course because once a patient really gets a grasp of what's going on. It's easier for them to say, Okay, I'm going to buy into this, I'm gonna do everything that I possibly can to get this condition better or improved. But if they don't understand it as this, this nebulous thing, like just take this pill, the compliance isn't going to be as good as if you really educate them and get them on board with you. So, it's amazing how especially with a larger structure like plantar fascia, it's very easy for them to see it degenerative area and the fascia itself on ultrasound. I mean, that's and then you can show them on the contralateral side, this is what it looks like on the flip that doesn't hurt, you know, and that really is very powerful for that it empowers them with knowledge of their own physiology.

 

Dr. Jbara 29:55

I agree with you and I you know I have other interests that look to how we can increase patient engagement. And a lot of doctors, they, you know, we're tired, we were burned out, we have a lot of things on our mind. And it can be hard at the end of the day to take more time with each patient and to explain it. But I think you can effectively find strategies to explain it. And you can even Empower members of your team to help with the patient to explain what and why this is important. And I think that when we ask what people get concerned about their own health, they're in a great position to impact their own health. And absolutely using the image to explain just like a gastroenterologist, when they do a colonoscopy, you get little pictures that show you the polyp that they remove. At the same rate. Exactly. Now, anybody can show you anything. So, I don't want to use it as as a technique to just get one get someone to get something. But I really think that understand, I think many people can appreciate the picture that they can see what you're trying to do. This is too thick, we want to get a thinner, we weren't going to try these maneuvers. But I need you to wear your boots, or I need you to do those stretching exercises that you want to enroll people as the team, you're not going to be able to handle any doctor. And it's unfortunate, because podiatrists, get some of the sickest patients such as patients with diabetes, the seventh leading cause of death. And the diabetic foot is in the billions of dollars as to what it costs to manage it. So, we are in the trenches, that we have to find strategies that help our patients get better, but also help us feel when doing something that makes a difference for us to do this over time. And that's why I think building a community with using radiology for a million reasons, not just the excellence in the imaging or the excellence in the care, but the community in the collaboration, you have backup, we can talk about what we see. And what we're going to do before we get to a point where, you know, things are failing, many of the surgeries predictably can fail. If we don't, please strategize the best patient selection. But it may not be obvious to you that just looking at an x ray or an ultrasound is not enough, no matter what you think it's not enough, you need to understand how the hips are even loading down. So I think we need to work in teams where I could podiatrist is going to have a good physiatrist a radiologist, they can talk to an ultrasound, you know, somewhere in their world because for the dynamics, and from there, they're choosing who they're going to operate on how they're going to do conservative procedures like injections, where we are and what we're doing, and it's going to people are gonna get better around us, which is going to make everyone happy, you know, not only emotionally, economically, globally for our health, it makes a difference.

 

Dr. Barrett 33:06

So now here's the scenario that we see as tertiary nerve specialists, we get all of the crazy stuff that has happened down the line, and they've seen multiple practitioners and one of the things that we see more commonly now and there's this, there's this divide of philosophy in basically in orthopedics as well as podiatry about if you have somebody with an arthritic condition or the first metatarsal phalangeal joint, there is the group that wants to do a total joint implant and then there's the other group that wants to fuse this first MPJ. And we rarely see people that have serious complications one year two years, three years post implant arthroplasty. But we see a fair amount of people who have developed less of metatarsal pathology because they have the first MPJ fused. And as you may, you alluded to earlier, this is a very dynamic big load bearing joint. And if you take that motion away, at some point down the line, we're going to end up paying for it and its just kind of interesting out and up and seem any sequela from fusions of the 1st MPJ but we see a lot of it.

 

Dr. Jbara 34:31

Yes, I just this morning one of the one of the radiologists from the group brought a case, they did a chevron procedure, and the patient has first MTP pain and we were looking at the case together. The case was complex in that the metatarsal head, the chevron procedure, the metatarsal head had an osteochondral defect and went on to have osteonecrosis and edema. I can show it to you if you like and the chevron screws one of them was actually perforating to the sesamoidal complex. What happened first, did the chevron fail? Did the head already have an osteochondral defect? What exactly is the chicken or the egg just in that one Chevron procedure. At this point, it's clear that the patient than usual state of affairs in this case would be fused that joint to decide to fuse it, or to replace it. What I explained to the doctor on the second plate, we already have early crossover. So, doing something right now, thinking of the long stream, the person was 34. So, this is a 34-year-old who is presenting this way. And this means that for a long part of their life, they could be at risk if they get diabetes, if they can have a lot of issues. So, this is not a small thing. And I see that there's, there's complications, I think it behooves all of us to understand our preoperative strategy, without a doubt, to understand that it's going to take whatever operation that you're going to proceed with, you want to protect those lesser metatarsals either through rigid orthotics that have already built in correction. This is not my area of expertise. But I've spent enough time in podiatry that I can tend to see what the orthotic might need just from looking at the static image. But it's going to take those pressure sensitive areas. But without a doubt, to do a chevron or to do any of these proper procedures, you gain a hind foot workup. I think it should consist no less than a gait analysis of the hind foot and forefoot MRI just to understand your baseline where your how much cartilage you're beginning with. But then understanding what's the post op plan, it's not just to get the hallux valgus and then walk. And you're going to need to know your orthotic specialist like your best friend, it's going to be essential that you understand when you're pregnant, even if a woman gets pregnant, that changes on the stress over foot, the changes in the hit, those are dynamic things you need to be this is an endpoint just like you're getting a blood pressure check. You're checking your balance biomechanics all the time, so that you're recognizing where it's drifting. The good news is that we don't, it doesn't happen overnight, like you mentioned a year, two years, there's time, there's time to work it out. And there's time to work it up properly. And I think if you get better patient selection and understand your offloading, you're gonna see that your forefoot procedures do better and lasts longer. You know, when I when I have forefoot problems and one thing I learned when I was young that I went to a sneaker store, and the woman said, you know, you're having trouble in the front of your foot, but maybe you should get a sneaker that you sit deeper into the back of your foot. And this has been years before I understood about biomechanics. And I think about her now how lucky are her clients, people that came into her store that she helped offload that she was already recognizing in the sneaker industry, just how people are, that's what we need to do, we need to really take heed and notice that and we say we do. But weight bearing X rays, they're not really properly obtained, or gait analysis or asking people need to be part of this. Just like I want them to have like, you know, just like they know their medicines, they write them down, they bring their sneakers and they have them in a box if they know they can show someone what their biomechanics are doing. This is essential, there's no way around it as a radiologist, you know, we are at we see all of the insides, but you need the outside as well. But as a radiologist, I've also learned that you can make those relationships just by asking the podiatrist or starting to do ultrasound. I've trained physicians, you know, throughout my career, and the complaint that they say is mostly is that there's no time for this. There's plenty of time when you're in the lawyer's office dealing with all of the masses, there's plenty of time to get disillusioned about it. I know that it takes time. But what I'm trying to do is to find the inspiration and motivation. I love what I do, because I keep learning about it. And I'm learning from all of you. So, well. I think there is a place for this, you know, and I'm glad that you asked. Well,

 

Dr. Barrett  39:24

I think you made some really important points and one of the things is like let's say they do have a very degenerative first metatarsal phalangeal joint and the surgeon does a fusion and that patient does very well. But they do very well maybe for the first six months to the first year but they had a long second metatarsal and they didn't address that. So now a year down the line. They come in with either a second interspace neuropathy. I hate to use the word "Morton's Neuroma" that's a whole different discussion itself because it's a nerve entrapment and it's not an aroma until you cut it out. But that, you know, I'll never I'll never get that message through I then, you know, bitching about this for 30 plus years. But long story short, many times with these procedures, you're kicking the can down the road. And they may feel like, Man, my patients are, you know, I'm doing a lot of these fusions. They're doing awesome, because they don't show up until a year, two years later, or then they show up someplace else. And it's like, well, this is a whole new problem. Well, the answer is no, it's not a whole new problem. It was a problem there that was waiting to happen, that you just didn't take the time to either acknowledge or you are ignorant to its presence at the onset. So I think there's a lot of merit to what you say is that you have to look at these things globally. Because we're not we're not very successful, when we just treat a symptom without understanding why that symptom is occurring in the first place? So, my hat's off to you for that. What about inter metatarsal Bursa? I wanted to talk about that, because I I have some suspicions about that. But I'd like to hear your input on it.

 

Dr. Jbara 41:16

Sure. And in terms of the intermetatarsal bursa, that's basically a space that exists next to the neurovascular bundle.

 

Dr. Barrett 41:24

Is that inferior or superior to the deep transverse intermetatarsal ligament, correct? And the neurovascular bundle is inferior to the deep transverse intermetatarsal ligament.

 

Dr. Jbara 41:36

So, the deep transverse intermetatarsal ligament is a band that goes along the plantar aspects of the metatarsal head and it would be good for me to share my screen and show you pictures of that.

 

Dr. Barrett 41:50

Because my it's my understanding that the TIML is really a confluent structure with the planet plate.

 

Dr. Jbara 42:01

So, the so let me just get to the classroom and I'm just going to go I have a lot of my videos are videotaped but we have let me just open up plantar plate and I'm just going to look to the normal anatomy. So, we first want to qualify what we're talking about with you asked me originally about the deep transverse intermetatarsal metatarsal ligament and what you can see what's going on here. This is a great anatomic drawing. This is basically m one, this is the lesser metatarsal is m two, M three, and M four. Taking you through my--I call this the penguins. These are my penguins. What we have we looked at the site I made the second bigger but that doesn't make it the just taking a look what we have are your going to be your tendons that reinforce the capsule the proper and accessory collateral ligament. This is the region of the plantar plate. This is your flexor tendons, your digitorum longus and brevis. You can see there's a band that goes underneath the metatarsal heads it does not come out to the proximal phalangeal level. So, at the level of the metatarsal bands. This is a reinforcing structure to help the accessory collateral ligament support the plantar plate, what lives here this right here is your Bursa. It's superior, it's deep. It depending on what you're looking at, if I'm looking at the plantar, right you have to qualify everything you say I'm looking at the plantar surface of the foot. What you can see is that I have a neurovascular bundle here and I have a nerve vascular bundle here I'm we're at the metatarsal level, but this is your intermetatarsal bursa region. Technically, pseudoneuromas in general are fibrous changes surrounding a nerve, if that's if it's said to be in the midline. And that we have a neural enlargement that's coming through this region, the neurovascular bundle is actually there on both sides. But what happens is if it's in the midline, it can be large in the middle and you've dumbbell shape. We'll call that a traditional Morton's neuroma. If it's hanging on closer to this, if the neuroma is hanging on one of the sides of the capsule, that's a pseudo neuroma. And that's a term we give to recognize the fact that the neuroma or the fibrosis the perineural fibrosis that used to be called neuromas are basically a part of the plantar capsular problem. And so we used to just treat neuromas until we realized it's not the neuromas fault. It's the metatarsalgia just likely coming from the plate but you to speak to your question regarding the anatomy, the bursa is a potential space. This is actually the gross anatomy just looking at the plantar plate itself. On the plantar plate is a fibrocartilaginous structure that I've indicated here by that low band that when I could talk about this forever, but what you're seeing here is a deep transverse intermetatarsal ligament. It's the fan at the level of the metatarsal heads that will connect one metatarsal head to another But, you could see it a little bit better here.

 

Dr. Barrett 45:03

So, I guess my question is: Yeah. So, Marlena, my question is, is that the bursa is superior above the deep TIML, the neurovascular bundle is below the deep TIML. And my question is, when you see some of these radiology reports, they'll say, a large bursa in the third interspace. Okay. And then when I see that I want to look and see where this is on the image itself. And my question is, is that really dealing with the with the pathology so much, because it's really kind of if you think about it, it's in the neighborhood kind of on top of where our stuff is going on with a Morton's entrapment. And then my other question is that, if we have a partial plantar plate tear, obviously, there'll be some extrusion of joint fluid. And is that sometimes picked up as an intermetatarsal bursa, or are they always distinctly separate? I don't know if I asked that question very well.

 

Dr. Jbara 46:21

What I wanted to do, as you're asking him what it would be helpful to see an actual image that will help us to talk about what I hear what you're saying, one of the things I hear you saying is you get something from a report, and it's not really the issue, they see an intermetatarsal Bursa. So what right is that? That's my question generator, one of one of the things all together, I think, that we need to get clear on is, what are the pain generators? And I don't think that that's a simple question. I think that we can talk about the psuedoneuroma. We can talk about the plantar plate issue, we could talk about the intermetatarsal bursitis. But there's pain, and then there's dysfunction. And pain may not be the worst part of this. Removing the pain may be a treatment strategy that we employ. But what have we changed? The marching dysfunction that's going on about like what you said about the tire, that just changing the tire? It's not the material of the tire. That's wrong. So, I think, when radiologists one of the problems is that we don't know, I think that a lot of people don't when you're trained. You don't know, you think, you know, we think we know what causes pain, we think if we see a fracture with edema that's the pain. But there are things we don't know. And one of the things I've don't know is about what is the significance of inter metatarsal bursitis. Because it's not there by itself. But sometimes there's a few problems, your imaging may not be showing a plantar plate, this exam came from another country. And you can see that it does not have the resolution that I need to see some of the features to be so specific about where it gets. So here I'm looking at it, I'll just zoom this up. It's not the greatest example on Earth, but we're looking at, you know, the plantar plate, and I really can't even discern, I know that this is the region of my collateral. This is my accessory. This is my flexor tendons, but I don't see anything inside of them. It can be that you just the radiologist didn't even realize that the resolution isn't there to see all the structures. And so when I see some intermetatarsal bursitis here, is that all that is or is that actually a neuroma?

 

Dr. Barrett 48:37

And I would ask you, or I would say it would be very difficult for me to believe that is part of the neuroma, which I hate to use that word, but let's call it the nerve entrapment. Because anatomically, it's in a distinct area from where the neurovascular bundle is running. So that's where that's where I'm having some confusion that the other thing that's that we did way back probably early 2000s Is that when we suspected a plantar plate rupture, we would inject the joint with Omnipaque and you would see this, if the plantar plate is ruptured, you just see this big Rorschach blot where the Omnipaque would extrude into, you know, the adjacent tissues. And then interestingly enough, we're wanting to follow that up what happened with you just did a metatarsal osteotomy without any addressing of the plantar plate. And we had a handful of patients where at three months post stop, we injected with the Omnipaque again, they had this nice little crescent moon that the radiopaque dye didn't go anywhere. So, its kind of confirmed that that that plantar plate had healed by eliminating of that pressure. I thought that was kind of an interesting thing. But in a couple of cases I can remember you could see that dye actually extrude up into the interspace where these bursae are. And I was thinking, Well, is there some fluid coming out of this MPJ that is somehow extruding up into the interspace? And is that maybe the bursa that we're seeing? You know, and I don't know. I mean, I'm just asking you for your experience on that?

 

Dr. Jbara 50:20

Well, one thing I can tell you is that I don't think they're exactly an isolation. And just because they don't knit live as close as you think they do. I think in dynamic walking, a lot of these relationships change depending on how much crossover how much flexibility you have in the forefoot, and what it is, what your tissues are, how close these metatarsal heads are together. There's a lot of features. There's a lot of variation. But when I'm looking at a patient, what I'm trying to determine is really do you have a real plantar plate tear a gap? If you don't have a plantar plate tear, I want to understand where the degeneration is. I'm not as super concerned about the fluid per se, as I am looking at the structures to understand how I can grade them biomechanically. So, I can let someone know we're wearing out here. This is where it's wearing out. Whether you there had a tear? Yes, we a lot of them have psuedoneuroma. In fact, almost every case I read that has forefoot pathology is going to have some amount of neural fibrosis around that. That's the natural course. But in terms of things being contiguous with one another, and defining an actual break and tear, you can do that with excellence on MRI, looking at a defect in the plantar plate. And there are many researchers that do that very well. Now, average radiology across the board, if you're not scanning, and you're not seeing these every day, it takes a special amount of training to read forefoot or ankle very well. We know that. Now. That's part of it. There's a desert, there's a mixture of questions you're asking here, but just because I have it. So, you're, you're when you talk ab out the deep TIML just to speak to that point, the deep TIML stops at the level of the interspace. So, you can have a nerve that can bigger and floppy and going up over its region. And that's where we begin to see that egg shaped or that X shaped nerve. And I don't have a great example in this case. But this right here is your interdigital nerve that quite hyperintense imaging you are seeing there. And what I can tell you is that it's more of a presence of what the plantar plates doing for this kid. And what I was explaining for this 34-year-old patient, what was more concerning to me was the amount of pressure that's going on her great toe see this pressure point. And there's also one under the fifth. One thing that we can help the doctor understand is that this patient needs offloading can look at how perhaps uncompensated, their Biomechanics is right now. And why is that and that's what I was explaining to the student if you as a radiologist are not paying attention to the hind foot don't recognize that the patient might have an extra articular coalition and that's what they have here that they keep on their in their uncompensated state.  What is the treatment at this point before anything tears would be to get this forefoot biomechanics aligned to the hind foot and use this information here to begin because one other thing I'm worried about in this young patient, if you look at the fat, and the muscles, there's a lot of marbilization of this fat and in that's what we get paid to do as a radiologist is to tell you this, you don't need to know that. I'm not here to train a podiatrist to replace me. I'm here to work with them so that the patient gets everything they need. And I would say most people wouldn't expect the 36-year-old female to have neuropathy. But I absolutely see that every day. If you're Hispanic or a person of color, you have early stages of neuropathy. That may be what's adding to this person's problem. So, let's just say 36. They're pretty healthy. Let's do procedure here. Let's you know, this patient presents with a neuroma or something, right and they begin to operate, not realizing all along This is the early stages of neuropathy, and collect global neuropathy. And we really need to deal with the whole person right now. So, there's a lot of there's a lot riding on a podiatrist and get the answers correct. And there's a lot of fallout when they don't and I don't think it's fair on either side. I don't think we're giving ourselves enough of a chance to learn the way we need to see all the modalities together to make a difference.

 

Dr. Barrett 51:38

Now, that's a very valid point. And, you know, I just sent a patient earlier this week that had been up that at Emory, Johns Hopkins had a definitive hereditary based neuropathic condition, but yet all of the symptoms were solely in the forefoot, bilateral, he had no symptoms virtually anywhere else. So now what you're not to say is okay, do we have a superimposed exogenous nerve compression, because of the abnormal biomechanics? And that's what's fire? Is that what's firing him up rather than this occult genetic neuropathy that is magically not affected anywhere else in this body? So, you have to put all this information together.

 

Dr. Jbara 54:47

Yeah, and there are many, there are many neural syndromes associated with flip syndromes. And that, you know, you realize this, because when I deal with surgeons who deal with the most difficult feet, cerebral palsy patients and congenital issues, they're always the spine surgeons as well, there's a relationship of understanding how elegant and, you know, important all of these structures are. And I have seen some of these idiopathic neuropathy is that, but the most important thing there again, is, even with all of that understanding where we are, what we have to do to balance it better, so that we're not driving it to get worse, you know, and it may be that eventually the whole point, but needs to fuse, because a lot of these patients have such terrible muscle tone, it's very floppy, and they're going to get all sorts of eventually, you know, amputation. So, I think it behooves us to understand more and more, not just for our everyday person walking around looking for a good pair of sneakers, but for all the reasons that, you know, diabetes is the seventh leading cause of death in America. I mean, there's no question that this understanding the foot is, is a cornerstone of getting some life longevity, some gone on that patient, because they you know, when you get a trans metatarsal amputation rate, you may look at mortalities that are elevated of 30 to 40%.

 

Dr. Barrett 56:52

It's not, it's incredible. I mean, if you look at the mortality after a BK amputation, there's maybe two or three diseases that are worse for a three to five, five-year survival rate. And you know, so it's a, it's a very big deal. Marlena, we have got to get people to your rad pod squad platform, because I think you have such an awesome platform and this stuff is really empowering. And I would encourage all of our listeners to really go and, and connect with you on this, I think what you're doing is fantastic. I want to bring you back and talk about imaging of the heel, because that's kind of an interesting thing, I think that would be really fun. But for this, this one, let's wrap it up with you tell the audience where they can go, how they can connect into this, this awesome forum.

 

Dr. Jbara 57:45

The quickest way is to just go to Radpodsquad.com.