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Seeking the collective wisdom once again.

In a patient that has a leg length discrepancy(LLD)in the magnitude of 10mm caused by trauma, raising the heel inside the shoe is fine for ambulation

However, when the same person runs, they become a forefoot striker, never acheiving any heel contact.

Lets say the symptoms are related to the LLD, is it necessary to raise the contact point ie the metatarsal heads in the same way that the heel is raised for ambulation?

I'm sure this is a very stupid question and I am likely to be embarressed by the simplicity of the answer but I am struggling to justify why a raise wouldn't be appropriate. That then raises the question of how it is possible to raise the forefoot.......as easily as it is to raise the heel

Appreciate any help

Robin

 

A forefoot raise, either in the shoe or attached to the sole of the shoe is going to add a lot of bulk, weight, and stiffness to the thing attached to the foot. There's your problem. I don't see any way to predict what the patient will like. How much lift do they need to be comfortable running. Since there is a double float phase in running, do you need any lift at all? Do they choose to heel strike on the short side? I think you have to have them try several things to see what they like best.

Eric

 

Robin,

You could raise the forefoot the same a heel - Yes, would you do it not really

But the best thing to do would be to get the whole affected size raised the desired amount.

Forefoot strikers will heel strike at certain points when running and will have heel contact even 100m sprinters contact the ground with their heels. If you raise the Forefoot only the chances of overuse in the triceps surea muscle group would increase.

say you want 7 mm lift - get the whole sole increased by 7mm.

 

Quite. It's the accommodation of it inside a shoe that seems like it is not really feasible.

I should make it clear at this point that I made an error in the description, the LLD is greater thatn 10mm(approximately 18-20 mm although clearly there could be significant error). 10mm was arrived at via a combination of trial and error comprimised by what could actually be accommodated inside the shoe. Pt less comfortable with less than 10mm.

Agreed. Space in the footwear may allow 4-5mm raise to the forfoot and could taper to higher at the heel

Footwear is flat pitched football boots and his gait footage showed very limited heel contact on the treadmill although obviously I didn't get him to run on the treadmill with football boots. Closest I could simulate was barefoot as patient had a strange choice of footwear with him! Clearly this may change things but from what I could gather, he has always been aware of coming up on to the toes early for running. He has one of those sprinters type of feet....you know the ones

When the patient posed the question, i gave much the same answer and I also explained that the reduced limb contact time might make the LLD less significant but really, i couldn't give him a genuine answer.

Looks like a bit of trial and error might be the answer. More time consuming though.

I was hoping for...."you don't need to bother about it" so I could do nothing. ;)

Cheers chaps

robin

 

l dont like "heel raisers" any more then 6mm, shoes struggle to cup the heel plus we tend to see toes get crunched up in the end of the shoe and the shear action is increased, especially in athlete's.

l would try a full length lift, if done correctly it wont add a great deal of weight, yes it will effect the flex, so it will need to be rolled off at the toe.

 

i suppose
10 x 6 x 0 tapered raise might work?

 

External raise to sole. It gets tricky with modern running shoes because of the various sole pods. A patient was treating who was a pretty good marathoner used an old school shoe nike waffle type with a straight through Eva midsole. In these it just a case of stripping off the outer sole, adding the lift and shaping, then replace outer sole. Have a chat with Phil wells I seem to recall him saying they could modify the shoes with individual sole pods.

 

The football boots below come with approx 10mm heel raise and the heel counter is quite deep with a removable insole.

http://www.lovell-rugby.co.uk/Rugby...nial-IT-FG-Football-Boots/Froogle/size_10half

The lift is on both boots so probably not much help for this guy unless he wears a flat boot on the other side??

 

That is exactly what l would do,10 at the heel to 6 at MPJ and then roll off to zero.

Make up the actual build up before you attach, this gives you the best option for shaping and checking the measurement are what you are aiming for

 

Nice one Athol. I think this guy would have no problem wearing different boots - he's not vain.

Depending on the construction of the boot and the removable inlay, I reckon i could probably get the contralateral side lowered by 5-7mm by grinding away the pitch that is built into the base layer of the boot. What do you think David? I've seen some of the pics of football boots you have adapted. Do you reckon this would be possible without affecting the structural integrity of the boots too much?

Through inlay on the affected side of 4-5mm EVA, rockered to 0mm at the toe.

Nett result 10mm raise through

Brilliant. From at least one of these solutions, I think I should have a reasonable result, even if it means wearing 2 different boots.

Thanks all

 

Without seeing the boot that is hard to answer, but with most of the boots we handle, l would not, 5-7mm removed would compromise the boot/support.

We would see far too much sole missing and for some boots the entire sole:D.

 

Hmm, point taken David. Thanks

 

I'd be looking at gastroc/triceps surae stretching. Uncompensated gait requires min 10 degrees ankle dorsiflexion for walking and 25 degrees for running. This explains why you're getting lack of heel strike in running, sounds like they have enough ROM for walking gait. Try PNF's for a bit of extra oomph for competition. And static stretching for long-term increased ROM. Try giving the 10mm raise too and see how they go.

Whole lot easier than any full length raise....

 

Sally, the numbers you give here: 10 degrees; 25 degrees are a bit old school.

 

Hi Sally,

Equinous isn't a problem. Leg length is the problem. He isn't forefoot striking due to a lack of ankle complex ROM, it is his natural running style.

With regards to running ankle joint ROM, lunge test is most predictive of injury, not ankle joint ROM

Regards,

Robin

 

What is the current thinking on that then? More thinking along lines of uncompensated gait... Thanks