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Hi All,

Just after some ideas to see if I'm missing anything. I have an 11y.o. female referred by GP for heel pain.

Initial assessment shows-
right foot one size larger than the left foot -pt only noticed this a couple of years ago.
right foot major midfoot collapse with navicular bulging. cavoid left foot
right leg SLLD longer
no history of birth or early childhood development issues

As there is only minor discomfort on palpation and first step morning pain is present, I am treating it as plantar fasciitis.

I have issued a heel lift for the left foot which improved Jacks and resupination tests of the right foot. I have also advised a stretching regime.
I am reviewing next week for possible orthotic treatment BUT feel that there is an underlying issue which I have not addressed-(feeling this because of the big difference in foot sizes).

Any suggestions would be welcomed.

Thanks

SRD

 

The right foot might not be smaller, rather the deviation caused by the midfoot collapse may make it look, even measure shorter.

If the midfoot is corrected does this correct the LLD, foot length and reduce the heel pain? the answer maybe that simple;)

Try measuring heel against wall, wall to navicular, navicular to 1st MPJ both feet and compare

 

srd

This could be something or nothing at all

To review a couple of things

1. A 1 size difference in foot length is not that great a variance. The average 11 year old female will have size 3-4 feet? A 1 size difference, allowing for error in measurement or intra tester reliabitlity for measuring could be negligable. Equally, it could be more.

2. What is SLLD? Structural leg length discrepancy?

3. Gross deviations in foot alignment(especially transverse plane ones) can affect foot legth as David rightly pointed out. You said the right foot had the midfoot collapse and this was the longer. This would tie in well in my opinion. It may well be longer as a a result of the midfoot collapse. Reposition the foot to have a similar alignment to the left in weight bearing, then remeasure. You might find that the lengths are not that different

4. This is slightly controvertial but the longer leg (assuming there is a leg length discrepancy(LLD)) may pronate to functionally reduce the LLD - click here for some discussion on the topic. Evidence would suggest that this is not the case. Either way, you have given some resolution by reducing the LLD so the LLD is significant.

The thing that would be getting me would be why is there a collapsed Rt midfoot?

Major asymmetry always makes me think neuro first. In an 11 year old, it is unlikely that they have gotten this far without something major being picked up but not impossible.

Otherewise, I would be thinking more upon the lines of a deficient tib post on the Rt side. The plantar fascia could be absorbing residual pronation moments due to a defective tib post.

Also, 11 year old girl with heel pain, is there a chance of Severs? Heel squeeze test?

The bottom line is that you have reduced the tissue stress which is good. Investigation further may be interesting and getting a definitive diagnosis will help for the ongoing management.

Hope this helps

Robin

 

A couple of things come to mind.

1) Check for a potential scoliosis which could mislead the conclusion of an LLD

2) Get Floor to hip WB radiographs: This is truly the only way to measure an LLD. Once you get the films, measure each segment and then compare. Most methods of measuring LLD in the chair have too many variables.

3) Get isolated three view foot films WB to get a better idea of joint alignment.

4) Check the Hip ligaments for ante or retro version. Then check the femoral and tibia segments for torsional abnormalities.