14 yr old female, numerous pains

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Hi there,
I have been treating a 14 year old female patient for the last 2 months.
She initially came to see me as she was complaining of generalised pain in her feet, pain in her shins, medial knee pain, some hip pain partcularly her right hip and also some lower back pain.
She is an avid netball player through the winter and plays squash and does all other Sports during school sport lessons. This is when her pain is particularly a problem and the pain in her shins has caused her to stop playing sport from time to time but only on a short term basis.
After a biomech assessment I discovered that B/F are overpronated and b/heels are in a varus position. She also has marked genu valgum and her r/leg is slightly longer in the femur than her l/leg.
I initially prescribed her with 3/4 length slimflex with 4degree medial rearfoot wedging and reviewed her in 2 weeks. After this time there was no foot, shin or knee pain. She was still having some discomfort in her hip and the back pain had stopped in the lower back and transferred to the left hand side of her back. I then added a slight heel raise to the left orthotic which after 2 weeks left the patient with no discomfort at all.
After a month of the patient having not seen me I asked her to come back in to review. Although the pain was no where near as bad as it had been it had slowly been returning to the feet and knees. After viewing the orthoses again there was substantial wear so I replaced the wedging to see if that made any difference again. I am seeing her again this weeks and wondered if anyone had any ideas as to what my next step could be if there have been no improvements in the last 2 weeks??

Many Thanks =)

 

Hi,

Check she is wearing her orthoses most of the time.
At her age a bit of pain may be less important than looking good for her friends.

If the orthoses are comfortable and are working why not have some custom devices made up for her? You'll have a little more choice on type and style, and most labs have outgrowth insurance so the parents don't need to keep shelling out for new orthoses every growth spurt.

I assume you've checked that there are no other upper body pains, and there is no familial history of RA. If not you need to write to the GP for more information. If there is any suspicion of Juvenile RA (or any other systemic disease) you should refer her to her GP with a detailed letter, and follow-up phone call as necessary.

Let us know how you get on.

 

Hi there davidh,

Many thanks for your help. I have taken it all into consideration. Fortunately, I saw the patient last night and have had success. No aches or pains so I am now going to source her some more robust orthotics as the slimflex are bedding down quickly with the amount of activity that she does. From this I am able to see that she does wear them an awful lot as the ones I use don't compress that quickly!!
I am definitely going to look into a company that does the custom orthotics so that her parents do not have to keep shelling out for new ones. Definitely a great tip =)

Thanks again

Sarah

 

Sounds good Sarah:drinks.

 

"She initially came to see me as she was complaining of generalised pain in her feet, pain in her shins, medial knee pain, some hip pain partcularly her right hip and also some lower back pain."

Look upstream. These are classic signs of gluteus medius and/or gluteus maximus dysfunction allowing excessive moments in the medial direction (adduction and internal rotation) that translate downstream to high loads to the medial foot. Plenty of research to support that. Orthotic intervention may be indicated, but may be more of a crutch than a solution to the causative biomechanical dysfunction.

 

BRUK:

Since when have foot orthoses ever shown to be, by scientific research, to be like "a crutch". If the pathology is caused by abnormal moments during gait and the foot orthosis can alter the magnitudes, temporal patterns and plantar locations of ground reaction forces on the foot so that the moments acting on the joints of the foot and lower extremities are normalized, how then is the foot orthosis like "a crutch".

Bruk, do you also view custom eyeglasses as "more of a crutch than a solution to their causative" visual dysfunction? Should we tell people to quit wearing their eyeglasses and contact lenses, but rather do daily eye exercises, since eyeglasses are "more of a crutch than a solution" for those individuals not having good visual acuity?

Have you been hanging out on the internet with Blaise DuBois and Nick Campitelli....is that where you get these ideas??

Since when has anyone with any knowledge of custom or over-the-counter foot orthoses ever considered them as a crutch? No one with good knowledge of the therapeutic potential and research behind foot orthoses would ever even think that foot orthoses are like "a crutch".:butcher:

 

I don't know that any research has been done to determine whether or not orthoses are crutch-like in their function. I don't really care, because I see it in my clinical practice every day, and so do many other clinicians that venture up the kinetic chain as far as need be to identify the root cause of a problem.

Substitute "crutch" for "foot orthosis" in this sentence and they have the same meaning: "the foot orthosis (crutches) can alter the magnitudes, temporal patterns and plantar locations of ground reaction forces on the foot ...."
Sure, I took a piece out of the original sentence to illustrate a point, but I would take issue with the assumption that "the moments acting on the joints of the foot and lower extremities are normalized." Likely they are at the foot, but they become progressively less influential in normalizing biomechanical moments the further up the kinetic chain one measures. I don't do published research, but utilize research methods and tools with many of my patients (insole pressure analysis, video analysis, and EMG analysis), and I've long ago stopped hoarding and memorizing research citations to support my methods. I do relish in reading and applying research though, which is why I come to Podiatry forum, despite the frequent and rapid degeneration of clinically professional discussions into personal attacks and sarcasm. I have not come across such unprofessional behavior in any other professional forums.



I have worn corrective lenses for 35 years, and if I could stop wearing them by doing eye exercises I would, but I don't know of any exercises that would correct my visual deficits, and none of the medical professionals that I've ever consulted with have ever indicated that this would be possible for me. But to answer your question; yes, eyeglasses are indeed a "crutch." They change how light enters the eye, but they don't change the flaw in the eye that creates the functional deficit.
Here is one definition of "crutch": anything that serves as a temporary and often inappropriate support, supplement, or substitute; prop. In the case cited at the beginning of this thread, if the abnormal forces on the foot are due to a biomechanical issue at the hip, then yes, indeed, orthoses would be a crutch, and possibly a dangerous one. If that young woman indeed has hip stability problems that lead to foot and lower leg issues, and her symptoms are placated enough by orthoses to the neglect of actually addressing her real causative problem, then she will continue to play sport, but with poor hip control, and put herself at serious risk for catastrophic damage, such as a non-contact ACL rupture.


If you'd like to debate how well orthotics affect, knee, hip, pelvic or lumbar biomechanics, I would invite you to have a discussion with Chris Powers. He does much of the research that I base some of my guiding principles on, and he is much more able to cite the specific articles that you need to qualify a thought or idea as having clinical validity.


I recognize Mr. DuBois and Campitelli only from Podiatry Arena, but often have to skip their threads due to the adolescent personal blather that encompasses their postings, and not necessarily generated by themselves. I don't hang out with anyone from here, because quite frankly I would not spend my personal time with people that demonstrate some of the sarcasm, arrogance and personal viciousness that I often see in this forum.

Your post to me could have been worded politely and professionally, but you chose sarcasm and a tone of vindictiveness. I'm not thinned skinned, and I appreciate a good debate, but I'm no pushover either. Do you behave the same way when engaging in face-to-face discussion? Do you speak to your patients, staff, peers and friends this way? I can assure you that if you behaved this way while speaking to me in person you would be left talking to an audience of one, yourself. Just because our avenue of communication here is on an internet forum, one is not granted free reign to conduct themselves poorly.

If you can't engage me on this forum with a modicum of professionalism, then I implore you to put me on your Ignore list.

 

By the way, I do provide orthotic services and devices as well, when appropriate.

 

Bruk:

Good reply.:drinks

Sorry, if I offended. I guess the crutch thing hit a raw nerve with me since it sounded just like the kind of negative propaganda being spread across the internet by all the barefoot/minimalist shoe fanatics (e.g. Blaise Dubois and Nick Campitelli).

Now let's get on with the discussion, Bruk. I don't think that any eye physician would view corrective lenses as "crutches". Maybe you view them this way. However, I, and most others, don't. In the same way, I don't view custom foot orthoses or over-the-counter (OTC) foot orthoses either as "crutches". I don't know of any experienced podiatric physicians either that would view custom or OTC foot orthoses as being "crutches". However, Bruk, if you want to think that they are "crutches", then that is your right.

So, Bruk, let me try to understand why you would call both eyeglasses and foot orthoses "crutches". Let's first look at the recognized definition of a "crutch":

Which of the following of these four definitions would also apply to foot orthoses and eyeglasses, Bruk? I am interested in how you somehow consider either foot orthoses or eyeglasses being related to any of these definitions?

What is your rationale for calling foot orthoses or eyeglasses a "crutch" since they certainly aren't "crutches" per the accepted definition of a "crutch"?

Am very interested in your reply since I have never had a health professional knowledgeable in foot orthosis therapy ever describe either OTC or custom foot orthoses as being "crutches".

By the way, Bruk, you don't happen to be a physiotherapist do you? They are the only health professionals that I know of who seem to be under the wrong impression that foot orthoses weaken the feet. What is your profession and your real name, if you don't mind.

 

I also have a problem with Bruck's initial post on this thread.

Bruck, I'll address you directly so that you can answer me directly if you choose to do so.
I believe that it is a common supposition that our feet were designed for hard and flat, which is what most of us support and ambulate on for most of the time.

Individual body geometry, and this goes all the way up the kinetic chain to the Temporomandibular joint, can vary widely, and some bodies are just not great on hard and flat surfaces.
The foot, being the interface between the body and the ground, is certainly a factor in this overall picture.

Exercises and streches at the hip and lower back will not make a massive, permanent improvement in a (hypothetical patient) female with a wide pelvis and an accentuated q-angle who may also have increased lower limb internal rotation due to her feet configuration, and the fact she walks around on hard and flat surfaces.
Of course, putting this hypothetical patient on different terrain, composed mostly of soft and undulating, may make a real improvement in symptoms without any medical intervention.

Foot orthoses which normalise lower limb internal/external rotation may help. Foot orthoses and exercises and stretches may help even further.

 

Here is someone else, named Kenneth Craig, who also believes, like Bruck, that foot orthoses are like crutches in his reply to a blog by Nick Campitelli:

http://www.podiatrytoday.com/blogged/defending-my-position-orthoses

Maybe Kenneth Craig and Bruck are one and the same?...they sure both like to think that foot orthoses are crutches...looks like they are reading from the same book, doesn't it??

 

I would agree that orthotics have much more effect at the foot than they do further up the kinetic chain.

You did walk, unexpectedly, into an old open wound/debate. Sorry about that. However, I would like you to defend some of your statements.

I think the eyeglass analogy to ortotics is still a good one. The orthotic "filters" ground reactive force, by changing the location of where the force is applied.

So, if the orthotics don't have much effect further up the chain, as you stated above, how are they going to negatively effect a hip stability problem? What is the mechanism by which this happens? How does a hip problem cause symptoms in the foot? How would an orthotic add to the risk of an ACL rupture?

For our current discussion, I don't really care about literature sites if you have a logical explanation of why you believe the things that you stated in the paragraph quoted directly above.

Eric

 

Good point, Eric. I hear that many physiotherapists use the logic that the foot orthoses aren't addressing the "root cause" and are a "crutch" since the "root cause" of the patient's problems are weak muscles proximally.

However, with all the studies that show that foot orthoses are helpful for proximal problems (e.g. medial tibial stress syndrome, patellofemoral syndrome and greater trochanteric bursitis, to name a few) then how do we know that those clinicians that promote only hip/core strengthening, and don't how to use custom foot orthoses properly, are, in fact, addressing the "root cause" of the problem?

In other words, the "root cause" of the patient's problems may be the abnormal plantar locations, temporal patterns and magnitudes of ground reaction force acting on the plantar foot? Maybe strengthening hip and core muscles or gait retraining are "a crutch" that are only a temporary fix for a structural or functional problem of the foot and lower extremity that more appropriately be fixed with a well-made pair of custom foot orthoses?

Moral of the story?.....clinicians that live in glass houses shouldn't be throwing stones....

 

You comments are 'right on'. I have often wondered if these individuals (i.e., Mr DuBois, Campitelli and others) behaved the same way with their patients as they do on this forum. If they do, how do they stay in practice?

Professor Rothbart

 

This forum, the Podiatry Arena, is not about selling products, patents, or ourselves, its about up-leveling our knowledge through sometimes heated discussions which serves to stimulate new ideas.

There are those people that cannot bear the heat of truth within the Arena and they run away. There are others that stay in the Arena even when they are dead wrong and have their own agenda ( ie, to make money from the public) and end up on the ignore list.

The top posters on Podiatry Arena are highly respected and have consistently offered their invaluable time for free providing their priceless insight, experience and passion into the field of biomechanics.

Kevin Kirby, the MVP, has posted 6,596 times and has been thanked 1,649 times and has been giving selflessly to the Arena since 2004. People here love Kevin because he will answer questions with textbook worthy posts which even includes diagrams.

All the top posters have busy practices and their fulfillment comes not from getting patents, selling products or being immensely rich, but helping to take the magic out of biomechanics so we can All get better outcomes.

I for one appreciate all that I have learned and I always make sure my grammar is good when I write a post :dizzy:

Steven