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Orthotic help

Discussion in 'Biomechanics, Sports and Foot orthoses' started by drsarbes, May 28, 2008.

  1. drsarbes

    drsarbes Well-Known Member


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    I have a 31 year old male runner with the following:

    High Peroneal and lateral knee pain.
    Complains of wearing his shoes out quickly on outside of heel.

    Findings:
    5 degree fore foot varus with slight adductus.
    less than 5 degree dorsiflexion with knee extended
    45 degrees STJ inversion, zero eversion
    Palpable accessory navicular
    Early heel lift.
    Muscle and neuro normal

    Suggestions on Orthotic type and posting?

    Thanks

    Steve
     
  2. efuller

    efuller MVP

    Some questions:

    Is there callus consistent with uncompensated /partially compensated varus? (Callus along lateral boarder of foot? sub 5ht met head?)
    Is there genu varum or valgum
    Is the knee pain reproduced with abduction or adduction of tibia on femur?
    Can I assume no pain with testing of Post tib and / or palpation of navicular from normal muscle exam?
    Where is the STJ axis? Results of supiantion resistance test?

    Some thoughts.
    A classic varus foot where there is difficulty getting the medial forefoot to the ground because of lack of range of motion usually does well with a forefoot varus wedge/extension under the met heads. Sometimes this foot type will use peroneals (does the 1st ray look plantar flexed?) or hallux flexors to increase weight bearing medially. (possible cause of high peroneal pain. Hallux hammertoe may result form long flexor activity.

    When there is frontal plane stress on the knee (genur varum or genu valgum) the stress will be resisted by compression on one side of the knee and tension on the other side of the knee.

    A genu varum will put a varus stress on the knee that could cause pain in lateral knee at the lateral collateral ligament. Don't add forefoot varus wedge.

    A genu valgum with an uncompensated varus will have increased compressive forces at the lateral aspect of the knee. Do add forefoot varus wedge.

    The peroneal pain could be caused by a laterally deviated STJ axis. No forefoot varus wedge

    The classic Root, Weed prescription writing instructions would be to neutral position cast balanced to vertical assuming RCSP was vertical. (with those measurements there is a high probability of RCSP being inverted, if the measurements are accurate.) I would bet that that prescription would be about as effective as an OTC device or worse. The Root, Weed prescription does not specifically address the pathology. (I also think that forefoot to reafoot measurement is not a consistently repeatable measurement.)

    Why does the person hurt in those locations?
    How do we make an orthosis to reduce stress on the injured structures?
    What are the injured structures?


    Cheers,

    Eric
     
  3. Mark_M

    Mark_M Active Member

    Are his shoes contributing to the problem? Id check his running shoes are appropriate and perhaps suggest a shoe with better lateral support eg Asics Nimbus.
     
  4. Dananberg

    Dananberg Active Member

    I would strongly suggest an evaluation of his peroneal strength. Patients who wear out the lateral side of the shoes, but demonstrate a pronated foot posture (ie, FF varus), often function with the peroneals markedly inhibited.

    Manipulation of the ankle starting with the fibula head can go a very long way to solving this type of problem. Orthotic correction alone is insufficient to resolve this problem. That said, however, using a device that is not posted in varus will have a better chance of success as varus posting will only increase the lateral shoe wear and thus perpetuate his symptoms.

    Howard
     
  5. drsarbes

    drsarbes Well-Known Member

    Thank you for all the responses.

    There is a slight genu varum, no first ray plantar flexion. Peroneals are normal. He has no callosities.
    He works construction during the day and wears the lateral - lateral posterior down. He is aware that as the boots wear his symptoms increase, but states he is already purchasing new boots every 3-4 months.

    My take is uncompensated (at least by the STJ) FF varus. His early heel lift and slight abductory twist allows some weight on the medial forefoot.

    Is there any thought as to different orthotic postings/construction for work and running?

    As a side note: He came to me with a bag full of previous orthotics: Some from Podiatrists, some from PT, some Chiropractic. I was very hesitant to cast him for yet another pair, however, hearing his history and experiences with previous practitioners, it does not appear as though any of them fully examined and evaluated him biomechanically.

    Steve
     
  6. efuller

    efuller MVP

    A good test for uncompensated varus is to have the patient stand and ask them to evert their feet. If they are out of range of motion they will not be able to lift their lateral forefoot off of the ground.

    This is a difficult one because what helps his foot may hurt his knee. Actually, was there a complaint about the foot other than shoe wear?

    You could add a forefoot varus wedge to one of his existing orthotics as a trial.

    You could also do what Howard said.
    Cheers,

    Eric
     
  7. David Smith

    David Smith Well-Known Member

    DrSarbes

    I would go with ankle mobs with attention to superior tib fib joint and massage of the medial and lateral knee joint line, then reassess. What is the hip RoM internal external rotation like? If he has restricted internal rotation it might be good to do stretching using strain and stretch technique of the external rotators and see if this increases internal RoM. Then reassess his gait.

    Cheers Dave
     
    Last edited: May 30, 2008
  8. drsarbes

    drsarbes Well-Known Member

    Hi Davis:
    He has limited external rotation, his internal is around 45 degrees.
    I've ordered an Orthotic posted 3 degrees 2 thru 5, rearfoot at vert. with a deep heel cup and lat clip. I thought I'd try this for his work boot and see how it goes.

    I'll let you know

    Steve
     
  9. Jeremy Long

    Jeremy Long Active Member

    I am in agreement with Mark. The vast majority of athletic shoes are wholly inadequate to properly assist with this foot type. The most thoughtful orthotic design will be useless unless the footwear in which it is housed reduces lateral compression. Even as good of a shoe as the Asics Gel Nimbus is, the CMEVA midsole will still likely prematurely compress in the lateral column, further accentuating this patient's symptoms.

    There are a few shoes which still use polyurethane midsoles with internal slip construction. The combination of these elements will both restrict the effects of excess heel inversion and enhance shock absorbancy far beyond the range of most shoes. The Saucony Shadow 6000 and older versions of the Nike Air Pegasus both meet these criteria. Avoid the current Pegasus, as this shoe has a softer durometer lateral heel plug, which may exacerbate symptoms. Another viable option is the Spira Volare III, as its combination of Wavespring technology and external TPU midsole reinforcement have been effective with many of my patients sharing similar dysfunction.
     
  10. LMadeley

    LMadeley Member

    Orthotic type:

    mid-foot device (around 80% arch fill) with a lateral clip (or lateral heel cup), heel post on lateral side only, use flexible polypropylene like 3mm. Can add cuboid notch or lat column elevation. Add at least 6mm heel lift. Start with rigorous post leg stretching. Consider adding forefoot lateral posting. However, if the ankle joint function is poor, beware of adding too much forefoot lat padding as it may create a pseudo equinus.
     
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