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15 year old with unilateral pes planus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markleigh, Apr 7, 2011.

  1. markleigh

    markleigh Active Member

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    I have a 15 yeard old male patient with unilateral (left side) pes planus. Big boy both in height & weight. Has been treated since approx. 4 years of age with various types of orthoses (always only left side treated). I've attached a picture of both his foot & the device.

    Main issue is:
    a) he cannot walk for more than 100 metres without getting considerable lateral foot/leg pain

    b) the device is causing blisters in the 1st met/cuneiform & nav/cuneiform region

    The device still fits well in length & width. Pain is located along the lateral fibular border/peroneus longus region (upper 1/3rd of fibular) & then from the lateral malleolusextending along the peroneus brevis to it's insertion at the styloid process. He has no restriction in any joints (talo-crural, STJ, MTJ, 1st MPJ) & reasonable flexibility with achilles/hamstrings. Muscles testing is slightly reduced through posterior tibial & peroneals with left being weaker than right by approx. 25%. In gait the foot is maximally pronated throughout. He cannot single heel raise on the left foot. The current orthosis APPEARS to support/control well.

    The mother also asks is this something that in the long term would be better treated surgically.

    How would you treat or address this? Would you adjust the device (my first choice was to renew the medial padding plus make some allowance for the medial prominences & add some extra rearfoot correction). Would you make a new orthosis & if so what sort i.e. would you use a similar device & do you find it is best for controlling this foot-type? What thoughts do you have regards surgical correction of this problem?

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  2. Hi Mark

    1st you need to workout if the lateral leg pain is comming from pain avoidance - ie the medial blisters and irratation.

    If so I would make him a new device ( I probably would do anyway as this ones not working and buying shoes must be a nightmare)

    Medial skive device but how much is hard for us to determine as we don't have the answer for my 1st question or what supination resistance is like.

    I would also use lots of arch fill (ie low arch height device) but then pad the device with poron/ppt for all the lumps and bumps and then cover is material that is low in friction.

    If new conservative care is of no help - surg consult but I would try a better device
  3. markleigh

    markleigh Active Member

    Hi Mike. Thanks for your response. These are things I have thought of. He has a very high supination resistance (10 tonne truck level ;). He has ceased wearing the orthosis over the last few weeks too let the blisters heal but had continued to have the lateral leg pain i.e. he still had pain with or without the orthosis. I was expecting if it was pain avoidance with the blisters causing issues then it might have been more likely to cause post. tib. type pain. So my thinking is the lateral leg pain is not avoidance related. My other concern was the type of orthosis with the extremely high medial/lateral flanges - he doesn't have much transverse plane deformity. Would a more typical orthosis design be appropriate/suitable? i.e. not the very high flanges - this would then reduce/prevent the blisters (I know it is difficult to make these calls without seeing the patient)? What about your thoughts on surgery? 15 year old - big boy & I think concern with long term pathology (from myself & his mother who asked about surgery).
  4. - Where is the pain in the lateral leg ? Diagnosis ?

    - I would never make a device that looks like that ( maybe cause I don´t work with kids much ) . I would like to think a medial skive ,low arch profile high lateral edge/flange would be the go, with the Poron and low friction top cover as described before. This may help with the blisters - time will tell.

    as for Surg. I´m not one to say what type of surgery but Arthroesis may be an option. What this does is create a new maximum pronation point so the STJ axis will have a new rotational equilibrium point when maximally pronated which may have benefit. Short and long term, but you maybe able to create a new Rotational equilibrium point in a similar manor if you can provide enough Orthotic reaction force medial to the STJ axis, but findout what the lateral leg pain is first.

    Kevin wrote a piece re STJ arthroeresis which you can find here Biomechanics of Subtalar Joint Arthroereisis

    We bashed it around here - Biomechanics of Hyprocure Arthroesis

    and here

    Biomechanical treatment post-op Hyprocure

    Hope that Helps
  5. markleigh

    markleigh Active Member

    Thanks again Mike. Diagnosis - peoneal tendinosis/peroneal muscle strain.
  6. efuller

    efuller MVP

    Is the lateral leg pain in the sinus tarsi? Is the pain made worse when he stands on something that attempts to evert the foot further. I had a patient that had a foot that looked like that and it hurt worse for him to stand in the bathtub because is sloped toward the center.

    I agree with the high degree of medial heel skive and low arch height device. You don't need the high medial flanges as you mention there is little transverse plane motion to resist. Although, with a lot of skive it is good to have a high heel cup.

    Hopefully, a better orthotic can get him some more distance before his ankle starts to hurt. I'd certainly try a different pair of orthotics before sending him to a surgeon. You also need to identify why he hurts. Is it eversion moments?


    There is no reason to rush to surgery.
  7. Well that throws a bit of a curve ball.........

    orthotic suggestion - without seeing the patient.

    Maybe medial skive ( but not as much as if the peroneal were not painful, if that makes sense) /high lateral edge/flange/ Low arch profile/ increased push under cuboid and styloid process of the 5th( very important no increase "push under the calc) - PPT/poron and top cover as before. - do you agree here ?

    Forefoot posting a hard one Varus will supinate the subtalar joint ( if the medial skive does the job on the STJ axis), but valgus with rev Mortons extension may reduce loads on Peroneals - longus especially and I assume dorsiflexion stiffness of the 1st MTP joint is high, so help with that - tricky tricky not sure ??

    Get physio help with the peroneals, start with lce/rest maybe try hiking or high top boots.

    Good luck tis a hard one. but a new device is worth the try and if not off for a surg consult.
  8. Boots n all

    Boots n all Well-Known Member

    Would love to see the wear pattern on his shoes sole, is it to the medial side?

    Despite the device, as good as it is, l feel that he would still be tipping into the medial side l also think the lateral leg pain maybe him trying to hold it up.

    The trick here is to have the shoe wide enough that the devices center, is center of the sole, and the center of this device sits well outside the boundary of most soles.

    If the sole is not wide enough a medial sole flare or even buttress might be the go?

    Trace the foot and device with a vertically held pen and compare that to the sole.
  9. Griff

    Griff Moderator

    Just to be different I would probably seek a surgical opinion at this stage. That presentation + inability to perform single leg heel lift = Posterior Tibial Tendon Dysfunction in my book. He is 15 years old - he's got a lot more miles left on these feet of his. Agree with the comments made regarding new orthoses however.

    Interesting conundrum here for those who subscribe to the tissue stress theory. Diagnosis of peroneal tendinopathy made usually = design orthoses to try to pronate the foot more. Is this good in a maximally pronated foot with PTTD? Doubt it.
  10. markleigh

    markleigh Active Member

    I'm the Podiatrist & I'm confused I guess by the symptoms & I'm thinking what am I missing. The peroneals are pronators of the foot. Why is the foot maximally pronated? The STJ axis is medially deviated. Peroneals & post. tib have good strength, no evidence of PTTD. Ive been reading through a lot of material including each of Kevins books & now i cant even understand why Eric & Mike suggest a lower medial arch for the new device? My brain has turned to mush :bang:
  11. Due to the history of arch irritation and the device will be more comfortable for the patient in this case.

    as for your other question

    one reason could be peroneal spasm, I just thought of that.

    another reason is found in this thread - where the PL is both a pronator and supinator of the STJ - How significant is the Peroneus longus as a Plantarflexor of the 1st Ray?

    but it is an interesting one.
  12. Griff

    Griff Moderator


    Obviously you have seen the patient and I haven't, (so I won't presume to be right!), but this is all the evidence I would need to have a high index of suspicion for a left sided PTTD.
  13. markleigh

    markleigh Active Member

    I guess I didn't consider PTTD as there was minimal weakness (equal in strength to peroneals on the left side) & no pain/edema etc in the tendon. I maybe feel foolish then to ask why he couldn't do a single heel raise on that side when his gastroc. and post. tib appeared to have good strength. I appreciate you guys helping me in this.
  14. footdoctor

    footdoctor Active Member

    Hi Mark

    Would there likely be peroneal overuse in a medially deviated foot? Not likely.Yes agree with pain avoidance theory from irritating med arch profile but as Mark says the symptoms remained when removing the devices.
    Fibular stress fracture? Has it been x-ray'd?
    Check the lower 1/3 of fibular border for peroneus brevis TP's and upper 1/3 of fibular border for Peroneus longus T/P's. Also, why only 1 device? Will this not create an functional leg length discrepency unless of course the unilateral max deviated left foot was creating one already? Strange one.....Need to think outside the box...

  15. Forces - ie the dorsiflexion forces acting on the ankle we too great for the triceps surea muscle group contraction to cause a change in kinematics of the ankle joint. Ie plantarflexion or toe raise.
  16. markleigh

    markleigh Active Member

    Thanks Scott. Will check for TrP's. I'm still not sure on how the symptoms fit with his foot function. I see him again early next week & everyone's comments have given me some further things to follow up on. Why only one device? The mother said that was what was always done as there was no concern with the opposite foot (he was seen by various OT's, Physios & Orthopaedic Surgeons over 10 + years at our local major children's hospital & they said they couldn't do anymore). I was certainly planning to place an orthosis on the right side.
  17. footdoctor

    footdoctor Active Member

    Just another though.... Do the devices significantly supinate the rearfoot? Are the peroneals fighting the devices?

    Going against the tissue stress model, why not add some valgus felt weding to the sock linen and see what happens short term? Unlikely to cause any great damage over a couple of days.

  18. footdoctor

    footdoctor Active Member

    *wedging* sorry
  19. Timm

    Timm Active Member

    I would be thinking sagittal plane facilitation for this patient if going to go for a new orthotic prescription. Inability to go on tiptoe, weaker peroneals and tib post, severely medially deviated STJ axis and subsequent extremes in resupination resistance and I'm guessing Jacks test(force to establish the Windlass) is also really high with probable delayed timing.
    I have had good success lately with similar presentations (although the feet didn't look quite so bad) with orthotic prescriptions that have Been aimed at helping 'ease' sagittal Plane progression as I feel the peroneals in some people are recruited to help with ankle plantarflexion despite their relatively small contribution to ankle plantarflexion moments compared to the primary plantarflexors. From your findings I wouldn't be too concerned at this stage with medial skives to a foot with peroneal pain. I think if thr orthotic prescription focuses
    on reducing the stress to the tib post, Achilles, plantar fascia etc you will find his peroneal symptoms would also improve.
    Orthotic prescription:
    - medial heel skive
    - few mm heel raise
    - lower arch profile
    - semi rigid shell - rigid shell will likely result in similar scenerio he is currently experiencig with blistering
    - met dome +/- cluffy wedge
    - forefoot valgus vs Varus wedging
  20. efuller

    efuller MVP

    The patient had blisters in the arch. Trying to push up on the arch with a higher arched device will repeat. It is really hard to believe that the foot in the picture has peroneal tendonitis. The lateral pain is consistent with severe sinus tarsi pain, which the foot in picture looks like it should have. You do have to take the suggestions with a grain of salt as we have not seen the patient. X-ray would be helpful. Perhaps a vertical talus.

  21. Mark:

    I have seen quite a fair number of feet like this over the years in this age group. First of all, when I see lateral leg/peroneal pain in a foot like this, I think of peroneal spasm and possible tarsal coalition. I know you said the STJ range of motion appears normal, but have you actually measured it?? If the boy has less than 20 total degrees of calcaneal inversion-eversion, then you should suspect tarsal coalition. This is the number of degrees that Dr. John Weed taught us to start looking for when considering tarsal coalition and in the 100s of patients I have diagnosed with this condition over the years, I have always found Dr. Weed's observation to hold true. Plain film x-rays are warranted initially and then CT scan next to rule out tarsal coalition.

    Secondly, I never use a medial flanged device (UCBL) like the one you have shown us for treating these individuals since these devices tend to create shoe fit problems. Rather I will use a 6 mm medial heel skive, 20 mm heel cup, 3-4 mm heel contact thickness with rigid and long rearfoot post on a 6 mm polypropylene shell. The orthosis shell is made extra wide to support as much of the medial midfoot as possible but still fit into the shoe. I will not try to overload the plantar aspect of the medial arch by making the medial arch of the orthosis too high, which may cause blisters and skin/bone irritation, but do want to support the medial arch as much as the foot will tolerate in order to transfer as much orthosis reaction force medially on the foot which will increase the external subtalar joint supination moment along with the medial heel skive in the orthosis. I also try to get these kids to wear high top shoes and boots with high durometer midsoles/soles as much as possible also since will further increase the external subtalar joint supination moments acting on the foot.

    Certainly, in an individual of this age, where the foot is probably close to being at skeletal maturity, the consideration should be given to reconstructive foot surgery. In this foot, with this much deformity, most foot surgeons wouldn't be using a subtalar joint arthroereisis procedure in isolated fashion to try to correct the deformity. Without looking at the x-rays, typical procedures which may be attempted would include a gastrocnemius recession with Evan's calcaneal osteotomy and possibly some form of medial column stabilization procedure. However, I would definitely give the diagnostic/orthosis/shoe suggestions I have outlined above a try before I referred to a surgical specialist for reconstructive foot surgery.

    Hope this helps.
  22. drsha

    drsha Banned

    Am I totally lost here?

    His other foot looks pretty "normal"?

    Don't we need an MRI to find out the integrity of his musculotendonous units?

    Is there a neurological component, accident history, what caused this foot to exist?

    Is the foot manually repairable?

    Do you want his mother to continue to ask her question for another 11 years?

    Are we seriously trying to marry this boy to that orthotic (or some extra padded version) for the rest of his life.

    I know...
    think pathology, not wellness.

    Dr Sha
  23. markleigh

    markleigh Active Member

    Too Dr Sha & others, I will be following up some thoughts/suggestions that have been made hopefully early next week when I see the patient.

    His right foot is normal.

    The foot shape/posture/position was not due to any accident & was present from at least 4 years of age (when the mother was concerned enough to seek medical advice) so i'm assuming it has been present since birth/weight bearing.

    The patient/mother want to do whatever is best both for short term comfort & long-term reduction of complications (whether that be orthoses or surgery).

    No I'm not trying to marry his foot to that orthotic. I am trying to find what is the best way to treat this patients pain & long term concerns. I was not ruling out the use of the old orthosis however & attempting to adjust it to make it comfortable & providing relief of his pain. I equally see that a new orthosis will probably be better but I wanted to "trial" some changes before making that final decision.

    I have greatly appreciated everyones thoughts & it has made me consider that I have not assessed his problem as clearly as I should have.
  24. Mark be good if you can keep us updated over the months.
  25. Kent

    Kent Active Member

    I agree with Kevin. I'd be treating this as a tarsal coalition until proven otherwise.

    Thinks horses, not zebras!

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