The AOFAS Orthopod-Cast

CMT MasterClass Part 1

Guests: Dr. Glenn Pfeffer; Hosts: Pam Luke and Joe Park
Release Date: January 14, 2026

Main Theme & Purpose

This episode is the first of a two-part series focusing on Charcot Marie Tooth (CMT) disease, specifically examining its related foot deformities (notably cavovarus foot), and the clinical and surgical approaches for orthopedic surgeons treating these complex cases. Dr. Glenn Pfeffer, a recognized authority in CMT foot surgery, shares his expertise on best practices, typical patient presentations, surgical decision-making, and patient management nuances.

Key Discussion Points & Insights

Dr. Pfeffer's Journey into CMT Orthopedics

• Origin Story and Early Encounter

  • Dr. Pfeffer recounts his transition from hand surgery to foot and ankle orthopedics, prompted by a personal dislike for being on call for hand replants.
  • His experience with a young woman presenting severe foot deformities due to CMT marked the beginning of his journey into this subspecialty.
  • Notable Quote [03:00]:
    "She said, do you know what CMT is? And I lied. And I said, sure, yeah, of course... She showed me these gnarled, like live oak, twisted feet. And I realized she was barely walking. That was the beginning, really." — Dr. Glenn Pfeffer

• Growth of Practice and Patient Advocacy

  • He highlights the historic lack of awareness or consensus regarding CMT management in orthopedics.
  • Word-of-mouth and involvement with patient advocacy organizations expanded his experience and influence.
  • Use of Instagram to reach underserved populations (e.g., Arkansas), now boasting thousands of followers and millions of video views.

• Personal Philosophy

  • Dr. Pfeffer emphasizes finding personal passion and fulfillment in one's orthopedic career:
    • "When you love something, it'll tend to work out for you. You know, when you're working something on a Saturday afternoon or a Sunday afternoon, not getting paid for it and you love it, you know you're in the right place." [08:04]

CMT Examination and Patient Assessment

• Understanding the Patient's Perspective

  • Patients often adapt to chronic impairment, masking severity.
  • Importance of external input (family, friends) to help them identify the extent of their impairment.

• Barriers to Care

  • Many neurologists provide inadequate support or guidance for CMT-related foot issues.
    • "Neurologists are often, forgive me, but the biggest impediment to someone with crooked feet getting good care." [10:22]
  • Orthopedic surgeons are encouraged to proactively liaise with neurologists to offer surgical solutions.

• Muscle Strength Evaluation

  • Primary focus: Is a muscle strong enough to be transferred?
  • Around 20% of patients have flail lower extremities and do better with bracing solutions.
  • Feet categorized as "rigid" are rarely truly so; often correctable with sufficient effort unless severe joint degeneration is present [12:00].
  • Key exam findings:
    • Calf (Achilles) contractures are common but underdiagnosed.
    • Peroneus longus and brevis strength can be deceiving to assess, especially in kids compensating with toe extensors.
    • Differentiate true strength from compensatory movements (e.g., toe extensors mimicking tibialis anterior).

Surgical Algorithm and Pearls

• Soft Tissue vs. Fusion
  • Preference for soft tissue balancing and tendon transfers over fusions wherever possible [16:00].
  • Fusion (especially subtalar) indicated only if absolutely necessary for stability when motors are absent.
    • "I only do [subtalar fusion] for stability... You can't get the heel out of varus by fusing the subtalar joint. You have to do a calcaneal osteotomy." [16:58]
• Tendon Transfers and Specific Techniques
  • Peroneus longus to brevis transfer is standard for restoring eversion.
  • FHL transfer considered if peroneals are nonfunctional.
  • Caution with posterior tibial tendon releases: preserve if possible, only transfer or lengthen in specific circumstances.
• Adolescent and Pediatric Considerations
  • Adolescents (13–14+) are treated as adults; avoid simple soft tissue releases alone.
  • True pediatric patients (6–9 years) present unique challenges due to ongoing deformity evolution.
  • Overcorrection (into plano-valgus deformity) is a rare but recognized risk (about 5% prevalence).

The Posterior Tibial Tendon — Crucial Technical Advice

• Key Surgical Principle

  • Dissect the posterior tibial tendon to its cuneiform insertion in every case for proper transfer.
    • "The posterior Tibial tendon has to be dissected out to its insertion on the cuneiform. There's absolutely no possibility of doing the surgery correctly 100% time is impossible unless you do that." [19:33]
  • Advocates for lateral cuneiform as transfer site to optimize correction and eversion.

• Approach to Lengthening vs. Transferring

  • Adolescents/young adults (<25 years) may benefit from strategic Z-lengthening without full transfer if the posterior tib is not the primary deforming force.
  • After 25 or with longstanding deformity, the tendon is usually too contracted for simple lengthening; transfer required.

Miscellaneous Surgical Tips

• Avoid overaggressive release of subtalar ligaments to prevent overcorrection.
• Occasional need to manipulate the tibialis anterior if it is an inverting deforming force — direct transfer to the dorsum recommended rather than split transfers [23:40].
• "A tendon should do one thing, that's controversial." — Dr. Pfeffer [23:55]

Notable Quotes & Memorable Moments

• On Finding One's Calling:
  "Follow your passion. We spend 35 years being somebody else a little bit, don't we? ...It's hard sometimes for our personality to come out what we really love." — Dr. Pfeffer [08:04]

• Regarding Neurologists and Systemic Issues:
  "Neurologists are often… the biggest impediment to someone with crooked feet getting good care." — Dr. Pfeffer [10:22]

• On Surgical Dogma:
  "I was always sitting there listening to CMT talks, feeling so dumb because people would say you always have to transfer the posterior tibial tendon. And I'd be sitting here thinking, really?" — Dr. Pfeffer [22:31]

• Critical Surgical Pearl:
  "The posterior tibial tendon has to be dissected out to its insertion on the cuneiform. There's absolutely no possibility of doing the surgery correctly 100% time is impossible unless you do that." — Dr. Pfeffer [19:33]

Important Segment Timestamps

• Dr. Pfeffer’s Introduction and Early CMT Experience — 01:33–05:40
• Growth of Practice, Advocacy, and Instagram — 05:48–07:52
• Advice for Young Surgeons/Following Passion — 08:04–08:53
• Patient Assessment and Neurology Barriers — 09:25–12:00
• Examining and Correcting CMT Deformities — 12:00–19:04
• Posterior Tibial Tendon Techniques — 19:33–22:30
• Adolescents vs. Adults, Pearls and Pitfalls — 23:02–23:55

Summary

This engaging episode offers a masterclass from Dr. Glenn Pfeffer—combining clinical wisdom, personal anecdotes, and practical surgical pearls on the nuanced evaluation and management of CMT-associated foot deformities. Emphasis is placed on the importance of understanding the patient perspective, the pitfalls of prevailing medical dogma, maximizing muscle function through tailored tendon transfers, and appreciating the technical subtleties required for optimal surgical outcomes. Dr. Pfeffer champions patient advocacy, multidisciplinary collaboration, and encourages surgeons to find and pursue their passion within orthopedics. Stay tuned for part two for further insights.