Adult toe-in and ITB trauma query

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Hi All

In a previous thread from Phil

From the thread Gait plates for toe in Oct 2005 - you wrote

I have asked him today in a PM --

Have you ever used this (roll bar) for an adult patient? I have one who suffers reoccurring GT bursitis and ITB pain because of a unilateral toe in gait on the same side. I'm reluctant to use a gait plate and so is she.

How would you position such a met roll bar? Is it similar to the gait plate angle in that they must toe out to progress over it, roughly parallel to the forward progression angle of the CoM.

Clinical Evaluation;
The Patient is female 71 years old but youthful and fit. The problem is left sided. She has a pronated RCSP about 7dgs. The Hip has 15dgs external rotation and 65 dgs internal rotation where the position of reference is with the knee straight ahead. I.E. left hip neutral is internally rotated. The foot is 5dgs extrenally rotated relative to the knee. Malleolar torsion is in normal range. This suggests internal femoral torsion.

Just before heel strike left leg she goes from a toe out foot placement angle to a toe in at heel strike followed by a fast internal rotation of the knee. This causes her to lead with the left hip during contra-lateral swing thru and ITB is tensioned excessively especially at late contra-lateral swing. This internal torsion of the left hip remains thru stance and does not unwind until toe off and then unwinds to an externally rotated position. Therefore the ITB is also tending to traverse across the GT causing pressure and frictional trauma at this site.

Does anyone use gait plates for adults or are there other methods that have worked better. Orthoses alone do not relieve the pain of this condition (although it is improved) she attends an Osteopath who treats the ITB / GT bursitis problem, which puts it right for a few weeks but the pain soon returns. She has the usual stretching exercises.

I feel if I can get her to a parallel or toe out foot placement position then this will resolve the problem.

Any suggestions?

Cheers Dave Smith

 

Hi Dave,

Only a guess without seeing this lady, of course, but I would look for this being a two part issue. One, the limb is likely short. This is why the osteopath helps only temporarily. Her pelvis rotates repetitively to accommodate the short limb, and a pelvic manipulation can temporraily reduce the tilt and dampen the symptoms. I would suggest you carefully evaluate her very shortly after her osteopath appointment. There is usually a much smaller underlying true LLD which causes a perpetuation of the asymmetry.

The other issue which is often involved in this gait process is ankle equinus caused by a fibula fixation. This can create a peroneal inhibition, and further perpetuates the adducted position during gait.

Accommodate her Functional hallux limitus with a c/o, get the LLD appropriately managed, then manipulate her ankle and I would imagine you could get a long term successful outcome.

Howard

 

Howard

Yes your not far wrong in your assumptions, this lady is very delicate in terms of orthosis balance, ie small changes in orthosis design cause large changes in symptoms. She has a low right hip about 10mm less than left. She has a tendency to an equinus right ankle, when the ankle is mobilised the hips become level, However when she has this symmetry it gives her left sided lumbar pain. She also required 4mm heel lifts to resolve anterior tib pain and mid lumbar pain. No heel lifts or more than 4mm heel lifts bilateral caused those symptoms to reoccur. The addition of a 6mm heel lift (instead of 4mm) to the left foot resolved left lumbar pain. Reading back thru her notes (including chiropody care, she has been coming to me since May 2003) Orthoses with 1st MPJ c/o similar to Vasyli Dananberg style
appear to give better results than when 3/4 length were fitted to accommodate low volume shoes. She has always had Red Vasyli (£85) renewed every 2 years and does not want to afford bespoke orthoses (£260) ( I've advised goto bespoke semi rigid orthoses and I think she might just have to dip into her purse this time).

I did not mention that at her last assessment I noticed a distinct reduction in the left hip external rotators. I was unsure whether this weakness was due to antalgic response or due to muscles being over worked or if there was some neurological problem. I referred her to GP who referred to physio with no real improvement and then she went on to an osteopath privately.

Thanks for your reply, grateful if you could pick the bones out of this one if you can.

Cheers Dave Smith

 

Howard and all

Fitted this lady with a lateral extension Poly carbon gait plate to the left foot and Vasyli Dananberg orthoses with 1st MPJ cut out and 4mm heel lifts. I added a 3dgs + 3mm lift combo high density medial rearfoot post to the plate. The result was an excellent change in the kinematics of the hip and knee. (PDF report attached) She also explained that walking was much more comfortable with the gait plate than without, which was surprising since I had expected and explained that she may need a breaking in routine to get used to it.

Regards Dave

 

Dave,

I for one (and I'm sure I'm not alone) enjoy your case studies and attached reports immensely. Please keep them coming!

Ian

 

Thanks for the encouragement Ian

:drinks