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Advice on DMICS, LLD and orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by STfootcare, Nov 14, 2019.

  1. STfootcare

    STfootcare Member

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    I am taking the Biomechanics Bootcamp, not quite halfway through. I am unable to jump ahead but have read Dr. Kirby's paper and Dr. Payne's blog on DMICS. I have a patient with a lot of pathology and would appreciate any advice or feedback.

    54 y/o female presents with a chief complaint of severe pain on the tops of both feet, and on the anterior left ankle that began six months ago, worsening over time. Pain is described and an ache and also, "like the tops of feet are getting pinched repeatedly". Icing and Tiger Balm have not helped. She does not take NSAIDs.
    She walks 4 miles a day to commute to work. Her only other regular exercise is the elliptical which causes her feet to go numb - this is mentioned incidentally, has been a long standing issue, is transient, and not super concerning to her at the moment. No injury. No recent change in activity. No new footwear.
    About three years ago she was diagnosed with bilateral plantar fasciitis by another podiatrist. She was given custom orthotics which resolved the PF. These orthotics were made with a small lift in the right heel to also address right hip pain that she has had for years, secondary to LLD. She still has this hip pain everyday but it has lessened with the orthotics.

    Right ACL tear many years ago
    Limb length discrepancy, Dx'd at time of ACL tear - nothing was done about it until custom orthotics
    Right hip pain

    FPI is 3-4 on right, 4 on left (Most of this comes from navicular drop)
    RCSP is 0 deg bilat
    Minimal navicular drift bilaterally
    No abduction of the FF on RF
    Ankle joint dorsiflexion with straight knee is +10 deg. on the left 0 deg on the right
    STJ motion is 2/3 inversion and 1/3 eversion bilaterally
    1st MPJ ROM >65 degrees bilaterally
    No bunions or hammertoes
    Jacks test has immediate, easy motion bilaterally
    Supination resistance is harder to do on the left than the right. Seems high in both feet though - (I have little experience with this test).

    Tender to dorsal feet bilaterally - metatarsal shafts, cuboid, cuneiforms and left anterior ankle.
    Left achilles tendon and left foot peroneals in the sheath area are tender.
    Right ankle, achilles, peroneal are non-tender.
    Tender to distal heel at plantar fascial insertion bilaterally.
    Most tender with plantar flexion of the forefoot bilaterally - especially tender with plantar flexion of the 5th met. on the cuboid, left foot.

    During gait there is right shoulder drop, large arm swing on the right, unable to appreciate hips/pelvis due to clothing, patella straight, Right heel strikes inverted, left heel strikes perpendicular/flat, there is abductory twist bilaterally, narrow base of gait, right foot has 0 degree angle of gait, left has about 10 degree angle. Left appears to be in high gear, right is questionable - looks closer to low gear as best as I can tell (no visible fascial lines at propulsion, looks like weight is more on 4th, 5th met heads than on 1st, and pt. has callous under 5th met. head.)

    Current custom orthotics are a rigid shell, there is a 2 mm heel lift on the right, minimal varus post on the heels, metatarsal pads.

    I gave her 1/2 inch felt heel lifts to wear daily and asked her to stretch calves twice a day.
    On follow up less than two weeks later she has no top of foot pain when wearing the lifts. She tried to go without them one day and the pain returned - but not as severe as it used to be. New complaint is of soreness under forefoot bilaterally, an ache.
    I sawed off a piece of her orthotic shell under first met. to make and accommodation there. I removed about half of the felt on each heel lift, so maybe 1/4 inch now.
    She will use this until I make a new pair of orthotics.

    Advice is appreciated. Thank you.
  2. Craig Payne

    Craig Payne Moderator

    Sounds as though you are on the right track.
  3. Ted Dean

    Ted Dean Member

    Right heel strikes inverted, left heel strikes perpendicular/flat-
    NWB is the right foot in an inverted position?
    If so cue this Dananberg video up-

    Sounds like you are on the right track with the heel lifts possibly due to forefoot equinus as explained here-

    http://www.vasylimedical.com/pdf/VasyliMedical Thinking Straight Ahead.pdf

    See #4

    Skip lace technique over the exostosis is often helpful.
  4. STfootcare

    STfootcare Member

    She's doing better but developed pain at the end of the day with the lowered lift on only the left foot. Pain is mostly in lateral column so I'm going try a pad under the cuboid.

    Ted Dean, thank you for the video.

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