This thread is a subtext to David Smith’s exploration of 1st ray. FncHL and plantar pressures thread @
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http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=40738
The idea is to keep that thread nice and clean and allow diversion into nitty gritty of using observational video gait examination and cheap/fast/dirty clinical kinetic data for evidence to complement that. Also to consider limitations, value and justification for doing this.
So here we can take that data apart. Currently this is an active patient, please feel free to ask for more info, I’ll provide it if I can.
From a personal point of view I feel this is an opportunity to get some peer review of my own knowledge and approach. Recently there seems to have been an interest in other threads regarding using these tools but no attempt to I have seen to walk through a case history/ interpretation in detail.
Perhaps I could steer the process a little just to keep it focused and break off into sub threads if warranted. I will try and keep the topic momentum going till exhaustion but limit its acceleration if possible so as not to get overburdened.
The case is selected because of evidence of FncHL if diagnostic criterion is according to IPP (instant of peak pressure) but not IPF(force) (see thread above) or non weight-bearing passive ROM testing.
Here’s cut and paste of my initial consult SOAP for background.
54y old female.
PMhx; hypothyroidism otherwise patient reports to be in good general health. PSHx nil.
Medications thyroxine, patient reports no known drug allergies. Not seeking employment.
S: left foot longstanding plantar heel pain and inner longitudinal arch pain, gradual onset 2004. Patient attributes this to effects of having started running at that timer. Primary care physician diagnosed chronic plantar fasciitis, had foot orthoses from sports therapist 2005 which had limited effect. Currently left greater than right plantar heel pain and bilateral dorsal midfoot pain, onset 8 months ago, no prior workup for this. Pain worse on rising from bed and rising after resting, condition worsens with increased activity and improves with rest. Wears crox @ home otherwise running shoes with foot orthoses. Avoids high impact exercise because of foot pain, walks track 3X per week 90 mins. Concurrent non specific episodic mild knee pain.
O: posterior tibial pulse palpable, dorsalis pedis pulse palpable, digital hairs present.
No signs of swelling, erythema, heat or skin lesions, no plantar lesion pattern. . Left foot but not right point of maximal tenderness at medial process of calcaneal tuberosity. Palpable dorsal mid tarsal joint osteophytosis right greater than left but no pain with passive motion. No evidence of functional hallux limitus with passive non weight bearing dorsiflexion MCJ @ metatarsal head followed by passive dorsiflexion of hallux. Range of motion of metatarso-phalangeal joint seems normal and unaffected with plantar flexion or dorsiflexion of 1st ray. 10 X single limb stance heel raise caused slight left side plantar heel pain and right foot dorsal metatarsal/cuboid pain. Impression of elevated ankle stiffness with passive ankle dorsiflexion. Existing rigid polypropylene foot orthoses vacuum formed from plaster bandage slipper cast have poor match to foot contour with foot relaxed and unloaded. Footwear fits well. Observing barefoot gait in hallway; unremarkable other than large bilateral abductory twist @ HO.
A: most likely chronic plantar fasciosis of mechanical origin and mild midfoot joint overload/DJD.
P: Optimise protection with existing mechanical options; use foot orthoses and running shoes constantly. Start stretching exercise regimen for soleus and gastocnemius – written handout supplied. Patient to make an appointment to review progress if not improving within two weeks for US and gait exam to evaluate further.
On follow patient was not improved, Diagnostic ultrasound exam confirmed left side chronic plantar fasciitis (active inflammation) and right foot chronic plantar fasciosis (no evidence of neovascularisation). Gait exam was also done.
To download anonymized gait data go to
http://www.winnipegfootclinic.com/resourses.html
If you open the excel spreadsheet it will give you organised kinetic data as indicated by the various fields.
If you download the kinematic folder it contains an .html file which if you open will collate snapshots of key gait images which are synchronised for sag and frontal views.
I thought to kick off to look at this, compare what I do, why and how others approach the same.
My observational video gait examination template; I take from Chris Kirtley because I believe his assertion that it will pick up significant gait aberrations quickly and confidently in clinical setting. Here’s my note on this case most of which can be verified from the .html.
Here’s cut and paste of my Observational video gait examination.
The following simplified 10 point analysis was performed to select for key deviations from normal walking gait.
1. Temporal spatial parameters were normal, age adjusted cadence, stride length, and velocity were within normal limits.
2. Step lengths and times were symmetrical.
3. On both sides the heel made first ground contact with the ankle joint in neural (0 degrees dorsiflexion).
4. The knees were close to full extension at foot contact bilaterally. Stance side forefoot contact was a controlled decelerated ankle plantarflexion.
5. Both knees flexed to around 20 degrees shortly after foot contact, extending again as the contralateral limb passed.
6. Bilaterally knee extension was maintained throughout single limb support. Bilaterally heel rise began slightly AFTER the contralateral limb swung past (50% stance phase).
7. Bilaterally the ankle dorsiflexed to about 10 degrees in late stance and then rapidly plantarflexed to about 15 degrees. The posterior surface of the heel EVERTED during late stance and propulsion, suggesting that the sub talar joint was NOT supinating normally with external rotation of the lower limb. Additionally there was abductory twist at heel off.
8. Knee flexion was approximately 60-70 degrees during swing phase.
9. There was no excessive forward or backward lean of the trunk during gait.
10. There was no sign of abnormal frontal plane pelvic or trunk motion.
On this basis there were deviations bilaterally at 6 and 7 from a normal expected walking gait pattern.
I would regard this typical common finding for “late midstance pronator”
I will gladly go back to original video and get more info but cannot provide the video files to protect patient identity.
Any comments or queries on this so far?
Cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com
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