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Lateral stj axis medially rotated

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Nov 23, 2017.

  1. David Smith

    David Smith Well-Known Member


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    Hi

    Consider the case of a female presenting with lateral ankle pain diagnosed as sinus tarsi compression. she also reports inversion sprains occur quite often.

    She has very compliant joints especially the lateral column which is very compliant to dorsiflexion. Her STJ axis is very lateral at the heel but very medially rotated, projecting thru the posterior 1st MPJ.

    Foot posture is very pronated and supination resistance and jacks test are fairly heavy. in gait foot placement toe out and low gear push off - Pressure mapping shows CoPP progresses thru 3rd MPJ and she seems to avoid FncHL.

    Here's a link to treadmill walk video https://www.coachseye.com/v/269de6d5aac64b15833134dcc0e843a1

    My question is: to relieve compression of Sinus tarsi area requires increased supination moments applied by an orthosis, how ever the very lateral STJ axis at the rear foot leaves her susceptible to ankle inversion at heel strike. (NB She reports the ankle goes over if she hits an uneven spot at heel strike.) Therefore a medially posted device might cause inversion sprains but a laterally posted device might increase pronation moments and so increase ST compression. Medial forefoot posting only might be a solution but the lateral column is very compliant and so would suggest lateral posting would stabilise the foot more optimally.

    Any thought on how you would design the orthosis? Thanks in anticipation.
     
  2. efuller

    efuller MVP

    Interesting case. Just reading the text I would have thought to recheck the diagnosis to make sure it wasn't peroneal tendonitis. When my intial exam doesn't quite make sense, like this case, I always recheck my diagnosis. What happens when you test the peroneal muscles?
    However, after watching the video, it really looks like a foot that should have sinus tarsi pain. One thing to remember from Taliard's paper on sinus tarsi syndrome was that there is peroneal inhibition with sinus tarsi syndrome. (I disagree with Tailiard's reasoning for peroneal inhibition. I believe peroneal inhibition is pain avoidance because further peroneal contraction will increase compression forces in the sinus tarsi.) The peroneal inhibition that is seen is a likely cause of the lateral instability. If you make the sinus tarsi more comfortable, you can reduce the peroneal inhibition. Therefore I would treat the sinus tarsi pain with a rearfoot varus wedge effect in the orthosis. To be able to titrate the amount of varus wedge you could make the heel cup symetrical (vertical heel bisection) and then add a flat external rearfoot post and then and some cork to the post that you can grind in a varus angle. If there is too much varus angle (patient feels too unsteady) you can grind the cork so there is less of an angle.

    My foot has a medially deviated axis and does get supination when pushing on the heel. When I add too much varus wedge to the heel of my devices, I can feel the increased activity of the peroneal muscles at heel contact. However, some varus wedge feels better than no varus wedge. I did get sinus tarsi pain especially in a pair of early Nike Air shoes. The ones that had a hole in the side of the midsole so that you could see the air bag. I saw a fair number of people with sinus tarsi pain with those shoes.

    Eric
     
  3. David Smith

    David Smith Well-Known Member

    Ah Thanks Eric, I haven't read Taliard's paper but understand your view on peroneal inhibition, thanks for highlighting that. I do find the laterally translated-medially rotated stj axis foot a bit of a challenge sometimes and it can throw up apparent conflicts like this case. I fairly confident of the Dx sinus tarsi compression so I'm thinking that using a temp orthosis to test the medially posted rearfoot might be worth trying before going to bespoke. The only other scenario I was considering was that the peroneals could be firing for too long to increase pronation moments to resist the supination moments due to the lateral stj axis at rearfoot and compliant lateral column at forefoot, therefore lateral posting in forefoot with neutral rearfoot might switch off the peroneals. Cheers!
     
  4. Trevor Prior

    Trevor Prior Active Member

    Dave

    Interesting case - you can almost see the compression at the sinus tarsi. However, I think this is one case where you definitely have to look outside of the foot. Look how much her hips and pelvis are moving over what appears to be a foot with slightly less general motion and tight posterior muscles. As a result she she cannot compensate for the rotation generating proximally and has an early heel lift and abductory twist, both of which will not help the feeling of instability.

    Add onto that the BMI and the compression forces are somewhat greater.

    You have to reduce the compression but you will need to provide a heel lift as without it, you will reduce her ability to compensate further, and work on the posterior muscle inflexibility - not sure how successful you will be with exercises for the proximal function as there may need to be a reduction in BMI.
     
  5. Dieter Fellner

    Dieter Fellner Well-Known Member

    Good to see a video along with the narrative. My eyes are getting a little old but I think I see an abductory heel twist. Is there a soft tissue ankle equinus? Rearfoot eversion, forefoot abduction. I'd focus on that too since her chief complaint is sinus tarsi pain. Has she a history of ankle sprains? Might consider a MRI to r/o talar dome (and other articular) lesions. I can't reference a paper but recall increased peroneal activity - putting the foot into eversion, can be a pain avoidance reflex. If this is so, the sinus tarsi pain is a sequela.
     
  6. efuller

    efuller MVP

    I don't like the idea of the peroneals firing too long as the cause of the pronation in this case. Yes, with laterally deviated STJ axes you will see peroneal caused pronation. But those feet tend to have pronation range of motion available and tend to not get sinus tarsi syndrome. In the video, the foot looks like it is at end of range of motion in the direction of pronation. Your exam showed heavy supination resistance and heavy hubscher which are consistent with high pronation moment from the ground. Certainly, check the maximum eversion height before you add a valgus wedge to the forefoot. I realize you said this was a secondary possibility. It is a theoretical possibility, but an explanation that has very low probability.
     
  7. First of all, I wouldn't try to do a video gait analysis unless I could see the leg and ankle. The pants obscure so much vital information that gait examination using this video is not something I would recommend or even attempt. At least if you could have pulled the pants up so we could see the ankles, this would help some.

    I vote sinus tarsi syndrome due to her medially deviated STJ axis in the forefoot and her obvious obesity. If the STJ axis is slightly laterally located in the rearfoot but significantly medially deviated in the forefoot, then this will produce increased sinus tarsi compression forces since sinus tarsi compression forces are highest just before the instant of heel-off. If she weighed 40 pounds less, she would probably not have the sinus tarsi syndrome. Also, tell her to not walk barefoot or in low heeled shoes (i.e. zero heel drop) such as flip-flops since this will also increase sinus tarsi compression force.
     
  8. Dieter Fellner

    Dieter Fellner Well-Known Member

    I'd add, in the office, I regularly see 'sinus tarsi' syndrome. A shot of LA/cortisone with strapping can help with pain and provide diagnostic clues
     
  9. David Smith

    David Smith Well-Known Member

    Ah great, thanks for your thoughts and observations guys, very useful. Kevin, I agree it would have been better to have clearer visual on the ankle joint and lower shank and would normally do that. However when I took the video I was more interested in the hip and knee action and relative positions. I had already visualised the foot and ankle dynamic RoM action and wasn't anticipating posting the video at the time but this was the only one I had.
    No equinus ankle all RoM are large and compliant, quite a floppy foot. She does complain of right midfoot dorsal pain around the 3rd 4th 5th met cuneiform - cuboid joints. when walking - couldn't be elicited in clinic but I suspect lateral column compression. Yes she does have a lot of hip swing but hip RoMs are good but restricted in ext rotation (ie knee only goes to 5dgs past straight ahead but has 70dgs+ of internal rom and with hip joint in mid range the patella's are squinting so this is consistent with internal femoral torsion) This will add a longitudinal torsion in the leg that will tend to pronate the ankle joint complex but at contralateral end swing phase the standing foot will tend to experience a supination moment as the hip reaches it limit of external rotation. There is an external tibial torsion in compensation for the internal fem torsion which results in a toe out thru swing as the knee faces directly forward and the she adducts and places the foot straight ahead at foot contact. I think this preparation to abduct the foot at end propulsive phase and early preswing adds to the impression of an abductory twist. I think the straight ahead foot placement reduced pronation moments due to horizontal posteriorly directed GRF at foot strike, however this allows internal knee excursion and with knee flexion becomes a function valgus that requires strong action from the hip abductors to control. I think these actions and reactions are the reason for the excessive hip rotation thru the gait cycle and will as has been said increase sinus tarsi compression and lateral instability at different times throughout the stance phase.
    Just thinking out loud as I go along and take into consideration your comments :) So I think that, like Eric first said, this will require careful posting to address compression and yet avoid lateral instability over time thru the gait cycle. I think I have a better handle on the problem now thanks guys but any more input you might have would be really interesting to consider.

    Cheers Dave!!
     
  10. The comments that Eric made were good. I would have no problem using a 2 mm medial heel skive in this patient but would not over-invert the orthosis, choosing rather to prevent excessive medial arch collapse than to try and put her in neutral position with the orthosis. Remember, to get rid of sinus tarsi pain, you only need to move the lateral process of the talus away from the floor of the sinus tarsi of the calcaneus so they aren't hitting each other so hard with each step. You don't need to have the subtalar joint in neutral position. If she does have lateral ankle instability, make sure she stays out of soft-soled shoes since her body weight is so great, she may tend to lean these types of shoes excessively into a inverted position over time which I have often seen be the source of their lateral ankle instability. A good orthosis in a more firm lateral-soled shoe should greatly help this patient....along with a weight loss program.

    Cheers,

    Kevin
     
  11. Dieter Fellner

    Dieter Fellner Well-Known Member

    Colleagues,

    I have attached an article that might be of interest, tangentially. Since putting this into practice I have found this to be quite useful under various circumstances, and also the manipulation technique described therein.
    I assume she was checked for a LLD?
    By all accounts, she might be a good candidate for Hyprocure stabilization if mechanical therapy comes to naught. Don't shoot me (!), but this works very well, in the right hands (as the saying goes ....)
     

    Attached Files:

  12. I have seen Hyprocure implants cause sinus tarsi pain. In my medical community, if someone put a Hypocure implant into a patient that already had sinus tarsi syndrome, and the patient had worsening of their sinus tarsi pain, that patient would probably win their malpractice case against the Hypocure surgeon. In other words, there are much better ways of treating this obese female's pain than putting an implant into the sinus tarsi.

    Cheers,

    Kevin
     
  13. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin,

    I am aware this is your position based on your experience in your locality. How much personal experience do you have with this surgical option? i.e. how many have you inserted? My experience is based on personal exposure to a very many patients who have benefitted from Hyprocure, for managing this ailment. I cannot therefore agree, there are 'much better ways' of treating this type of pain.

    Moreover, if a patient cannot tolerate the device it is a very simply matter to have this removed. No harm, no foul. Tell me Kevin, which treatment do you know that is 100% reliable and fail-proof? If the patient in this example sustains an ankle sprain with an orthosis, would she not have a good legal case?

    Cheers!
     
  14. If the Hyprocure works so well for sinus tarsi syndrome as you say, Dieter, then you should publish your results in a journal. You are the first person I have ever heard using this device for sinus tarsi syndrome.

    Cheers,

    Kevin
     
  15. David Smith

    David Smith Well-Known Member

    Thanks for the
    Thanks for the paper dieter
     
  16. Dieter Fellner

    Dieter Fellner Well-Known Member

    The use of Hyprocure is already well documented by Dr. Graham and the technology is used world wide.

    I would be flattered to think so, but I gravely doubt that I am 'the first person' to do so, Kevin. Perhaps, like bunion surgery, there is a west and east coast divide in the approach to a patient. If so, I am sure you will continue to do what you deem to be right, and I will not be too critical of you for such a choice.

    However since you have no personal experience of Hyprocure I will take your advice with a pinch of salt, on this occasion.

    Thank you for your contribution.
     
  17. Trevor Prior

    Trevor Prior Active Member

    Dieter

    I trust you are well. I have done the training for this device but have to say I have steered clear of it as it does not quite stack up to me personally. We have few long term results and good evidence is required. Unfortunately, Dr Graham's research would not be sufficient as this would be deemed a conflict of interest.

    I am aware of colleagues who use this but, to my mind, it often has to be accompanied by adjunctive procedures as blocking the sinus tarsi is rarely enough alone.

    In the case Dave submitted - her primary problem is the sinus tarsi pain rather than a secondary problem due to TPD and the adult acquired flat foot for instance. In these instances correcting and balancing the foot as a whole, alters the forces across the foot and thus has the potential to reduce symptoms.

    I am assuming that when you operate on patients with this device, they generally have a greater pathology / more severe foot type?

    I think it is highly likely that, as much of her problem is load being placed on the foot and then the sinus tarsi that simply increasing the load / volume in this area would be doomed to failure.

    Can you confirm, would you operate on a patient such as this with just a compression syndrome and the BMI and do nothing else to obviate the excessive forces (i.e. adjunctive procedures)?

    To be clear I am asking if you would operate in this instance full stop and secondly, if you did, would you not do adjunctive procedures as required - i.e. NC fusion, gastroc recession etc.?

    Best wishes

    Trevor
     
  18. efuller

    efuller MVP

    When I was at CCPM, after we first got the EMED force platform, I measured a patient before and after a sta-peg arthroresis. After the procedure there were very high lateral forces consistent with a partially compensated varus. This is what the arthroresis does, it decreases the amount of STJ eversion available. The procedure created a partially compensated varus foot. There is a reason that the surgeons say thou shalt not varus.

    The maximum eversion height test should be something assessed pre-operatively and lack of eversion available should be a contra indication for the procedure. I would like to see the study seeing if lack of eversion available does predict failure of the procedure.
     
  19. Trevor Prior

    Trevor Prior Active Member

    That's why they often need an adjunctive procedure. Something to plantarflex the medial column and probably reduce the equinus component.
     
  20. David Smith

    David Smith Well-Known Member

    Update:
    29/1/17 review aspects of gait and bmechs.
    The weight bearing lateral foot is compliant enough to come off the ground fairly easily i.e. eversion height compatible with lateral post.. The pain in left ankle is defo sinus tarsi compression.

    Trial 5 conditions of orthoses and capture on Coach's eye,
    1) neutral posted rigid shell OTC, https://www.coachseye.com/v/f8ab5129bec247a28b185d6315bc73a9
    2) skive medial rearfoot https://www.coachseye.com/v/c7707eea70934bfd88afe9e2fa1aa1ec
    3)skive medial with 5dg medial rearfoot post and lateral post 4-5th https://www.coachseye.com/v/7749080f8f094f698e4e298253f7e041
    4) same as 2) but with medial rearfoot post removed https://www.coachseye.com/v/8208bc3a81ad4fbdb74c28889ab5f673
    5) barefoot.https://www.coachseye.com/v/746270e2b76d49a0ba8c44394a67fa89
    She reported that the 4th condition was most comfortable relief of the ankle left pain. None caused lateral instability, however there was what appeared to be an exaggerated f/foot abductory twist and early swing whip and the heel clips the right shank - did not notice this before so much but in the 5th video it was with barefoot and the twist was still there but muted compared to shod.

    I've gone for a flexible shell with minimal arch fill, 2dgs rearfot post in Firm EVA, 4mm medial heel skive, 2dgs f/foot lateral post 2-5th, 1st ray addition 2mm, 3mm heel raise. 6mm pitch same both feet.

    BTW this lady is only 60kg and 153cm tall but all her extra weight is around the hips. BMI25.6 so not so over weight.
     
  21. Dave:

    Thanks for the videos, very instructive. Definitely helped being able to see her ankles and legs in these videos. Hope she does well with her new orthoses!
     
  22. Petcu Daniel

    Petcu Daniel Well-Known Member

    I think it is about left foot, isn't it? I suppose there is a difference in the left's foot propulsion and right's foot one as it can be seen from plantar fascia tension (see attached capture from the movie). In an old thread Simon has uploaded two documents with the position of subtalar joint axis in dynamics in a low and high gear propulsion (https://podiatryarena.com/index.php?threads/bojsen-mollers-high-gear-low-gear.2023/ ). To be easy to be seen I put those images in the same attached document (hope this is Ok!). You said that her STJ axis is "very lateral at the heel but very medially rotated, projecting thru the posterior 1st MPJ" (I think in a static test) and has a low gear push off. In dynamics, according to the attached document, seems that this orientation of STJA correspond to a high gear propulsion. Can you attach the pressure mapping for both feet? I'm a little confused!
    Daniel
     

    Attached Files:

  23. David Smith

    David Smith Well-Known Member

    Here you go Daniel (Yes left foot) - video pressure mapping - https://www.coachseye.com/v/91253e9d1b3249ca8473e014472459a5 The attached PDF study area map identifies the integral curves for each masked area
    Schen M mask.PNG Schen M medio lateral.PNG
     

    Attached Files:

  24. Petcu Daniel

    Petcu Daniel Well-Known Member

    Looking at the movies I personally don't see any difference between conditions but probably I'm biased because I don't expect to see kinematic changes! But looking at the Kevin's example of an abductory twist case I think it is a difference in the toe clearance between those cases and I suppose this could be an explanation of the early swing whip movement from your case (hope I'm referring at the same sequence as you!). I don't know if an intervention (orthotics and shoes) could have an immediate effect as in the movies where the shoes and orthotics created a heel lift seems it is without an effect. What do you think?
    Reference:
    Daniel
     

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  25. David Smith

    David Smith Well-Known Member

    This is the lady on treadmill with new orthoses. https://www.coachseye.com/v/a0ac9ecdacd94c5685851be6fd956185- (cut and paste this if it doesn't go to video direct from link) She reports that she finds them comfortable and adding spring to her step.
    Still has the adducting heel whip in early swing. I put this down to internal femoral torsion and weak hip abductors allow the knee to adduct (internal rotation of femur with flexed knee) in stance and so as a compensation she actively externally rotates the hip in early swing to have a foot placement that allows the knee to be straight ahead. If instead she did not externally rotate and landed the foot with toe in then there would be more relative knee adduction and internal hip rotation which would restrict the following swing phase of the contralateral leg. Done some manual therapy to strengthen hip abductors and given strengthening for hip abductors and glutes.
     
  26. David Smith

    David Smith Well-Known Member

    Just as a follow up - this lady had great outcome of full pain relief for years. She returned today (6 years later) because the pain had returned the same as before. Turned out she had been to NHS for new orthoses (to save money) and was using them instead of the original orthotics we made because they were full length and didn't fit her newer shoes. I stripped down her old orthoses and refitted as shells only. We'll see in a few weeks if that was suscessful.
     
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