This patient is suffering from lateral left ankle pain and right Achilles tendon pain. No stiffness in any of the joints. Currently seeing our physio but due to have orthotics fitted soon. Bit of a disagreement in the clinic, would love to hear some opinions on type of orthotic needed.
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Re: orthotic disagreement
Diagnosis
why it mechanically stress
ways to reduce the mechanical loads on stressed tissue
rehabilitation treatment
review
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so what is your exact diagnosis ?
and I will leave you with a few thoughts
It is ok to have different orthotic designs from one side to the other or even just one device.
it is ok to treat Achilles issue without using an orthotic at all
do not build a device which will increased the loads on the stressed tissue -
Re: orthotic disagreement
See thread on presenting cases
http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144 -
Re: orthotic disagreement
Left lateral ankle pain can be sinus tarsi syndrome or peroneal tendonitis. Those are treated almost exactly oppositely. Maximum eversion height test. If there is a lot of range of motion in the direction of eversion it's probably not sinus tarsi syndrome. If it hurts for them to evert while doing the test and there is a high range of motion available, it's more likely that it is a peroneal tendonitis.
Eric -
Re: orthotic disagreement
I spend an inordinate amount of time talking to physios, chiropractors, running store owners and orthopaedic registrars about myth busting when it comes to treating patients. eg pronation is bad and everyone should have a nice vertical heel. flat shoes are good for everyone, etc
It is our job to educate others, but you have got to use some hard evidence. What I think will surprise most people reading the original post is that orthotics are being provided without a diagnosis for the lateral ankle pain
Perhaps with the achilles tendinopathy, one could argue that making the TA more mechnically efficient will reduce the tissue stress and, regardless of anything else inverting the heel and raising the heel might work
However, the wrong device on the lateral ankle pain could make matters significantly worse. Completely agree with Eric, you need to form a diagnosis as the two aforementioned pathologies have diametrically opposing solutions. -
Re: orthotic disagreement
Sorry for the lack of detail but I started this thread on my phone while I was still in clinic.
On examination the patient presented with 'normal' ranges of motion at the stj, mtj and 1st mpj. She experiences pain when I maximally pronate at the stj which could be a sign of sinus tarsi syndrome. Pain is also felt when pressing around the anterior talofibular ligament and directly below the lateral malleolus.
Non weight bearing position looks 'neutral'.
Small heeled shoes are very uncomfortable and supportive walking boots are very comfortable.
The disagreement we're having is the photo appears to show a varus calc position when weight bearing. However, is this just ankle swelling and fatty tissue around the ankle and foot. -
Re: orthotic disagreement
ie if there is pain on pronation of the STJ - Supinate the foot
or vice versa
as for the Varus heel could be could be fatty tissue could be swelling - does not really matter
so if we have Richard on 1 side and Co-worker on the other - and in the middle reduce loads on the stressed tissue - I would go the white picket fence option.
:D -
Re: orthotic disagreement
Eric -
may be a bit rrude but may be obesity is the root of these issues...
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Richard Robley-This patient clearly has an uncompensated varus deformity, in the hindfoot at least, and perhaps in the forefoot as well. The swelling on the lateral aspect of the foot, is not just adipose, but, IMHO, swelling of the peroneal tendon sheaths. This patient is laterally unstable, because the patient is maximally pronated at the STJ, rendering peroneal function useless. An AP radiograph would show met adductus as a lifelong compensation for the rearfoot varus deformity. She probably has a history of lateral ankle sprains, cannot wear high heeled shoes, has felt like a "clutz" most of her life, and walks in a guarded fashion when stepping off of curbs, etc. Correct?
An orthotic needs to address the rearfoot, with at least a 6 degree varus wedge, a lateral buildup on the orthotic that extends to the C-C jt, no lateral skive to the rearfoot post...and that doesn't address the forefoot, which might also require a varus wedge. Make the orthotic wide. Let me know if this helps. -
I don't think that you can say definitively, from the picture, that this is an uncompensated varus, foot. You will be right some of the time making that assumption. The additional clinical information does make me lean more toward uncompensated varus. However, a rigid forefoot valgus can look just like that.
The peroneal tendons will be useless only in the sense that they cannot produce further pronation motion when the STJ is maximally pronated. However, they can still produce a pronation moment and are not totally useless.
Metadductus a compensation for rearfoot varus? How does that work?
I'm curious as to what you mean by a 6 degree rearfoot varus wedge. Are you talking about a medial heel skive or balancing the cast 6 degrees inverted? I'd have no problem with a lateral bevel under the lateral side of the rearfoot post if my goal was to increase supination moment. Why the flat rearfoot post?
One test to see if the patient needs a forefoot varus wedge is to have them stand relaxed and try and work your fingers under both the lateral and medial forefoot. The foot that needs a varus forefoot varus wedge will have little force on the first met head (you can get your fingers under there) and have a lot of force on the lateral forefoot (you can't get your fingers under there.) That's an old test that John Weed taught. However, I don't believe that he used forefoot varus extensions on his orthotics. So, I use his test, but use the information from it slightly differently than he did.
Eric -
Eric-I stated that the patient clearly had an uncompensated varus deformity because at static stance, she is still inverted. The met adductus is compensation, which begins early in life, to bring the forefoot, (medial column), down to the supporting surface. It appears from the picture, especially on the left foot, that this is barely achieved...thus the "C"-shaped foot. The sinus tarsi syndrome and swollen synovial sheaths of the peroneals are a result of this deformity, as the STJ is subluxed at static stance/forefoot loading, and the peroneals are experiencing overuse type problems. I stated that the peroneals are rendered useless, because at maximal eversion of the STJ, the peroneals can no longer provide lateral stability, (you called it a pronatory moment)...thus the patient tends to chronically sprain their ankles, "feel lke a clutz", and are cautious when engaging uneven terrain, or stepping off a curb.
I was referring to balancing the orthotic with a 6 degree rearfoot post, in order to hold the STJ in a more "neutral" position, ie., don't let the STJ maximally pronate, (evert). [This patient would have been a good candidate structurally for a Dwyer calcaneal osteotomy] But if the rearfoot is held in a more inverted position, then the forefoot would need to be evaluated for a varus wedge as well. Hope this helps explain my thoughts... -
I would correct the rearfoot inverted but just a few degrees from maximum pronation and use a very high lateral heel cup and a zero degree rearfoot post with a lateral post flare to resist further rearfoot inversion. If the forefoot is everted to the rearfoot, I would be sure to incorporate intrinsic forefoot valgus correction in the device and possibly use a valgus forefoot extension to the sulcus.
Jeff -
Now a rigid forefoot valgus foot will often have peroneal overuse.
EricLast edited: Mar 29, 2012 -
You can also have a laterally positioned STJ axis with an inverted heel and this is a foot that will tend to invert even when it is maximally pronated. The foot with the lateral axis is much less likely to have sinus tarsi pain as the pronation moment from the ground would be smaller as compared to a medially positioned STJ axis foot.
Eric -
Jeff -
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I have a rearfoot varus and a mild plantarflexed 1st ray resulting in an everted ff/rf relationship. If I widen my base of gait my tibia develops a greater angle of valgum and my heel remains stationary. This effectively increases my rearfoot varus angle (increases the inverted relationship of my heel to my leg). If I stand with my legs crossed my tibia are in extreme varum and my heels become markedly everted. So a wider base of gait does not always result in increased stj pronation. Large thighs can also push the knees apart and effectively increase the varus angle of the tibia, but I don’t see a significant tibial varum.
As for heel symmetry, I’m not sure the camera angle gives us an accurate picture of this.
Jeff -
Eric-the Talliard article? The Coleman Block test? Impressive. Frankly, I have grown to use my own criteria for assessing the patients' needs. When you've been practicing this art as long as I have, you will become acutely familiar with trends and patterns, ie., patients with similar maladies with similar structural presentations. I think I have learned more from my patients over the years, than from the myriad lectures from Podiatry pundits at the seminars I have attended. I have seen the foot pictured above a hundred times...but didn't really begin to appreciate the patterns until about patient #50. ;)
I have no desire to get into a "pissing" match about this subject with you, but I think it prudent to explain my familiarity with the picture above. If you notice the left foot, the first MPJ appears to be barely contacting the ground...and only Richard could tell us if it was easy to slip a finger underneath it...I bet it would be. That means, by definition, that the deformity is uncompensated. If Richard would be so kind as to post pics of the AP and lateral weight-bearing radiographs, I can assure you that a high degree of metatarsus adductus would be seen on AP, and the "see through sign" would be evident on the lateral view. While in theory, you're correct...a rigid forefoot valgus deformity can cause an inverted heel, but I can't tell you the last time I've ever seen one...they're rare. However, it's much more plausible that this patient has a skewfoot deformity...a combined rearfoot varus deformity with a forefoot varus deformity as well. She's beating the hell out of her STJ because it functions fully pronated at static stance, and the peroneal tendons are experiencing severe overuse syndrome in an attempt to offer lateral stability. A medializing calcaneal osteotomy with a lateral wedge removed would really help, but in the absence of surgical intervention, an orthotic that holds the STJ away from maximum eversion while supporting the forefoot deformity would offer her relief from peroneal tendinopathy, (lateral ankle pain), and significantly reduce the STJ pain.
My inclination is to not make biomechanics so difficult, as many would like to do. I don't set my criteria of evaluation to heights that cannot be achieved through the use of orthotics themselves, which are a lot more simple in practice than in theory. -
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The use of the word 'correct'? -
Jeff -
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When the ground is pushing the STJ into maximal pronation, in the rearfoot varus foot, the peroneals are more likely to inactive because the ground is making it stable.
I'm a big believer in simplification. However, you can lose information if you make it too simple.
Eric -
Effects of Simulated Genu Valgum and Genu Varum on Ground Reaction Forces and Subtalar Joint Function During Gait
Bart Van Gheluwe, Kevin A. Kirby and Friso Hagman
Journal of the American Podiatric Medical Association
Volume 95 Number 6 531-541 2005
Quote:
The mechanical effects of genu valgum and varum deformities on the subtalar joint were investigated. First, a theoretical model of the forces within the foot and lower extremity during relaxed bipedal stance was developed predicting the rotational effect on the subtalar joint due to genu valgum and varum deformities. Second, a kinetic gait study was performed involving 15 subjects who walked with simulated genu valgum and genu varum over a force plate and a plantar pressure mat to determine the changes in the ground reaction force vector within the frontal plane and the changes in the center-of-pressure location on the plantar foot. These results predicted that a genu varum deformity would tend to cause a subtalar pronation moment to increase or a supination moment to decrease during the contact and propulsion phases of walking. With genu valgum, it was determined that during the contact phase a subtalar pronation moment would increase, whereas in the early propulsive phase, a subtalar supination moment would increase or a pronation moment would decrease. However, the current inability to track the spatial position of the subtalar joint axis makes it difficult to determine the absolute direction and magnitudes of the subtalar joint moments. (J Am Podiatr Med Assoc 95(6): 531–541, 2005)
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Jeff -
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This just came in today. Sometimes you need to look at structure to determine that the lesion on the lateral side of this patient's foot is in fact, due to the head of the talus protruding laterally! He was casted for an AFO.
JeffAttached Files:
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Jeff
p.s. Not fair, you can't use more than five question marks! ;)
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