Advice for rigid pes planus

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Flat Footed 70 year old male patient. I would really appreciate advice concerning orthotics.

My patient has a rigid right flat foot and is experiencing medial tibial stress pain. His presentation is classic, ie abducted forefoot, prominent medial malleouls and rearfoot valgus. There is no callus. His left foot has very painful hd and callus at base of first metatarsal which I have treated.

My proble concerns orthotic prescription. What would you advise? In the meantime I have given him advice about footwear and shall be speaking to him soon about the next step.

Thank you for your help.

 

Re: Pes Planus

Hi Valerie,

Here some other threads on Medial Tibial Stress that you might want to take a look at.
Medial Tibial Stress threads

So right side only Medial tibial stress, with a rigid pes planus foot.

I´ve got some quick questions 1st. Is the whole foot rigid ie every joint?

Is there any dorsiflexion or plantarflexion avaliable at the talo-cural joint?

How is the patients balance ?

Does the pain follow the muscle and tendons distally and if so which muscles are painful or more painful than others?

I think we need a little more info to try and find the best treatment plan.

 

Re: Pes Planus

Pes planus is not a diagnosis, it's an acquired position, foot type or foot structure. It sounds like your patient may have adult acquired flatfoot/posterior tibial dysfunction. If so, the patient may need anything from a foot orthosis, to an AFO, to foot surgery, depending on the stage of the condition. Can the patient do a single foot heel raise? Here are links to Dr. Richie's fantastic lecture (see heel raise technique) and an article he wrote that may be helpful in evaluating your patient:

http://richiebrace.com/HANDOUT RICHIE ADULT ACQUIRED FF.pdf

http://www.podiatrytoday.com/article/2584

Respectfully,
Jeff

 

Re: Pes Planus

Hi Jeff
To be fair to Valerie she did in her Text say the problem is with Medial Tibial stress pain, but I agree the Pes planus heading is very misleading and to be truthful not a great term .

Hopefully Valerie will come back on and we can work her through some of the terms she´s using, patient detailed discription and give her some help with treatment plan.

 

Re: Pes Planus

Isn't medial tibial stress pain also called shin splints? This would be quite different than posterior tibial tendon pain associated with adult acquired flatfoot. If the patient has adult acquired flatfoot, then we would need to know more about the stage or severity to offer specific treatment advice. I hope Valerie sees my comments as an effort to provide some constructive feedback and not as criticism of her.

Respectfully,
Jeff

 

Thank you so much for responding. I am very happy to receive your advice. I am going to perform additional tests (muscle strength, standing on tiptoe, calcaneal stance etc) to assess the severity of the pes planus. Incidentally, why is that not the corect term? There wasn't a tag for that complaint either. The patient is feeling pain along his right shin when he walks so I interpreted that as medial tibial stress due to overuse.

I am a 'new' domiciliary Podiatrist. Most of my patients are elderly and most of my treatment consists of callus, corns, fungal nails, lesions and dressings. Biomechanics is a new area for me but fortunatley I remember my university days and teachings although lack confidence in putting this into practice and interpreting the results. I shall endeavour and any help is gratefully received.

Thank you for your response.

 

So Valerie, heres some stuff to consider when you see the patient.

If the foot is Rigid there will be no movement of any joints. What we need is is there motion available, to which joints and it what directions if any .

we also need to find out if it´s a boney pain or from muscles which run near the medial aspect of the tibia. ie a diagnosis ( there is lots of discussion about whether the pain is muscle or bone is Medial tibial stress syndrome), but it might help if you can pinepoint alittle more. Also follow the muscle down to the tendon and see if there is any palpation pain on the tendon and where, especially at the insertion points.

From there with all the info that you provide we can try and work out the cause. ie Medial deviated STJ axis leading to Posterior tibial overuse and we can then say it´s Posterior Tibial Tendon disorder (PTTD) and then discuss treatment options.

OR you might say that it Bone and then will dicuss Ground reaction force (GRF) and it´s effect on Bending moments of the tibia. The treatments here will mostly likey be very different depending on the amount of Range of Motion available to the joints. ie rigid, limited or say pronated to end range of motion.

Now the STJ axis and GRF can be the causes of both muscle and bone problems but we can leave that to one side as not to get into it too much.

So if you get a detailed picture of the patient it will help. The biggest question for me know it the ROM of the joints, if it is all joints rigid or not ?

As for Pes planus. The term works well but a more detailed picture can be used to discribe the foot using more words, but as Jeff said it´s not a diagnosis. That what we need 1st then we can work out the forces causing the stress on the area and build a treatment plan from there.

Hope that it helps.

 

Valerie,

The description you gave of the foot type or structure (pes planus) and the nature and location of the symptoms were a good start because it was enough information for us to start asking meaningful questions of you. The other factor that made me suspect adult acquired flatfoot is the age of the patient. The condition is often unilateral or more severe on one side than the other. The same description in a 25 year old would not lead me to think in terms adult acquired flatfoot.

Medial tibial stress syndrome is a broader term that can include the posterior tibial, but there isn't necessarily any associated foot deformity (compensatory changes) like you described. Adult acquired flatfoot/posterior tibial dysfunction would be a narrower and more accurate diagnosis, is this is actually what your patient has. If that is the case, the stage or severity of the condition and how it impacts the patient’s gait and quality of life are amongst the other factors which can govern how you might choose to treat the patient.

If you rule out adult acquired flatfoot, say because you determine that he has had a pes cavus foot his entire life, then we can discuss options to treat his symptoms which you indicated are at the base of the 1st met and in the leg. For his symptoms to be at the base of the 1st, he would likely have a charcot foot (rocker bottom foot type) or adult acquired flatfoot. Obviously a more complete history would help, including whether or not his has neuropathy and/or a history of diabetes. I don't mind offering advice, but I fear giving poor advice. This is always a concern and risk when offering advice based on limited information.

Respectfully,
Jeff

 

Dear Jeff

Thank you so much for your reply which I am going to study in detail. Seems like adult acquired flat foot but I will post another reply when I have seen my patient again and have gathered more information.

With kind regards,

Valerie

 

:good:

 

Dear Michael,

I've just returned from a short break to York and seen your reply for which I am very grateful. I shall follow your advice which is invaluable. I shall be seeing my patient again in a few days and will let you know the results.

With very kind regards,

Valerie

 

Upon further examination my patient's foot wasn't as rigid as I originally thought. These were my findings. I conducted eversion, inversion, plantarflexion and dorsiflexion range of movement tests whilst supine and prone.

Right Leg

1. His right leg is painful on walking and standing about. He described the pain as a dull ache. I palpated tibialis anterior tendon distal to proximal and although there is no tenderness when he is resting, this is where the tenderness is felt.

2. I palpated the peroneal tendon which was tender around the lateral malleolus area.

3. He also advised diffuse lateral forefoot tenderness.

4. When patient is standing on tiptoe his right ankle hurts around the navicular area.

5. An arch seems to appear on tiptoe. But the foot appears completely flat when weight bearing.

6. Right ankle area hurts when patient is prone and ankle is inverted and inverted. The right ankle is stiff on inversion.

7. I could not place the patient’s right foot in STJ. The ankle was pronounced and stiff to articulate.

8. Tenderness around insertion of posterior tibialis.

Left Leg

Articulations were fine. Good range of movement and no pain. Arch seen. There is painful callus area plantar met head approximately 6cms from 1st IPJ.

Overall

There was no lld.
Both 2nd hammer toes

I am disappointed with myself that I could not discover the angle of the calcaneum when I really believed it at first to be valgus. When I viewed the patient weight bearing, and I did disect the calc, the angle seemed fine. Must have done something wrong. I know this is an important mesurement for an orthotic. Perhaps I should have tried this when he was prone.

I want to thank you for your help which has pushed me out of my comfort zone and helped me be a better practitioner.

I have made foam impressions of my patient's feet which I am going to send to a laboratory for casting. However, am unhappy that I cannot tell the technician about the calcaneal stance.

I am pleased to say that my patient has acquired excellent footwear and that this alone has made him a much happier man.

 

Once again, a big big thank you to Mike and Jeff.

 

Hi Valerie,

Ok good that you found some more info.

A couple of things, I, a lot of people don´t tend to use STJ neutral measurments anymore. We tend to look more at the STJ axis location as this gives us important information about the length of the lever arms of the muscles.

In a pronated ( pes planus ) Foot type the STJ axis will tend to be more medially deviated and reduce the length of the lever arm to the Tibialis Anterior and Posterior Tibialis etc ( it works the same for supinatory muscle as well ie they get greater mechancial advantage with a medially deviated STJ axis with loner lever arms), thus increasing the work required by these muscle in slowing pronation and attempting to create STJ supination movement (and or moments). The Peroneas Longus is an intersting muscle as it is generally a proantory muscle ( depending on STJ axis position), but it attaches at the base of the 1st and is important in stabilising the 1st ray and can be overloaded during STJ pronation.

I´ll post up some threads and papers to get you started thinking about this stuff.

Now we understand your patients foot a lot better there is some things that you can do with your device to help reduce the load on the Post tib and other supinatory muscles.

Great the shoes helped.
Get the patient to ice his feet and legs in the spots that it hurts when walking for 20 min every night

ok device here my suggestion with the info we have, I would go with an EVA device, with medial skive (of say 4 mm, really it´s you to decide how much, the greater the force required the higher the skive but being older and somewhat reduce ROM of the joints in general, a good place to start I think ) and a FF Valgus post or Reverse mortons extension made from a soft material such as PPT. You may want to incorporate a higher arch ( reduce arch fill on your form) to reduce the Navicular drop which probably occurs with what you have written. I say probably and might as its important that you think about these things as you have seen the patient, I ´m making somewhat of an educated guess.

Heres some reading for you.

Threads on Posterior tibial tendon dysfunction PTTD

Challenging SALRE thread

also here some thought experiemnts once you have done some reading.

Thought experiments

Hope that Helps Valerie

Good luck

 

Dear Michael

I feel as though I have had my own personal tutor guiding me through this patient's problem. Thank you so much.

 

Your Welcome, Ive got mine as well . Thats the great thing about this place everyone learns something and helps others.

 

Hi again Valerie,

I forgot to add this in my last post, it would be great if you let us know how the patient gets on in a few weeks.

 

Hi Michael,

Yes, I shall let you know. At the moment I have sent my biomechanical assessment and diagnosis to the lab together with foam impressions. The latter weren't satisfactory as I find I cannot apply the appropriate pressure for a negative impression (my hands are small and the patient's feet are big) so I am going to try a plaster of paris sock. This will be the first time for me.

Kind regards, Valerie