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Genu Valgum and Orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by hugs75, Apr 3, 2006.

  1. hugs75

    hugs75 Welcome New Poster

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    HI, I'm a 4th year podiatry student. I have a few queries with regards to a patient that presented to the uni clinic for treatment that I hope some fellow pods may be able to shed some light on.

    A 12 year old girl presented to the uni clinic with medial plantar arch pain and some tib anterior pain on palpation.

    On assessment I found her to have genu valgum, excessive STJ pronation, tight plantar fascia and gastrocs, abducted stance/gait and abductory twist.

    She had previously been prescibed orthotics which had been working very successfully at reducing her pain. However, the pain had come back.

    Upon viewing the orthotics, several adjustments had been made by different students and the rearfoot (RF) to forefoot (FF) alignment was totally out. The medial anterior edge had been wedged to try and improve the alignment. This does not seem to have been successful as it wasn't very stable.

    From reading the current literature and my limited biomechanical knowledge and experience, to treat a patient with these symptoms, I thought an inverted device with a fascial groove and 3mm heel raise could be quite successful in improving her symptomology. However my lecturer told me that there are just some people that you can't help. He said the an inverted device would invert the calcaneous and evert the tibia as genu valgum is a frontal plane deformity. He said that an inverted device changes the moments around the knee and cause greater valgus forces and so inverting the RF would not be very good.

    My questions are:
    1. As the STJ is triplanar, shouldn't using an inverted device actually increase the supinatory moments or decrease the pronatory moments, and cause external rotation of the tibia and thus abduction at the knee?

    2. Would an inverted device help this patient?

    3. Are there any other treatments that may provide some relief to patients like this?

    Many thanks for your responses :))
  2. hugs75

    hugs75 Welcome New Poster

    Sorry, Post Tib Pain Not Tib Ant
  3. Admin2

    Admin2 Administrator Staff Member

  4. Atlas

    Atlas Well-Known Member

    On this specific point, either you heard incorrectly or your lecturer is wrong.
  5. In this patient, inverted orthoses (i.e. medial heel skive, deep heel cup, 3-5 degrees inverted with slight heel lift and no plantar fascial accommodation) would be indicated to add STJ supination moment, decrease STJ pronation moment, and reduce her abducted gait pattern and try to reduce the pronated position of her foot.

    Even though genu valgum is a frontal plane deformity, many times these patients, and especially girls, have "malicious malalignment syndrome" where there is internally rotated hips, abducted-pronated feet and genu valgum deformity. http://www.rehabmed.net/patient_ed/patellofemoral1.html

    Correctly prescribed foot orthoses will actually, in the patient with maximally pronated feet, make the apparent genu valgum deformity improve by externally rotating the hips. This can be quite dramatic in some individuals, but is certainly noticeable in nearly all individuals.

    You may tell your lecturer that I have answered him/her as follows:

    1. Yes, there are some people that you can't help, but that those clinicians who give up too early on patients are not serving the best interests of their patients.

    2. An inverted orthosis does not always invert the calcaneus but will cause an increase in STJ supination moment which may or may not invert the calcaneus depending on the STJ axis position and prevailing STJ pronation moments from GRF and muscular forces (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989).

    3. An inverted orthosis will improve the apparent genu valgum deformity during gait in approximately 90% of individuals with maximally pronated feet.

    4. An inverted orthosis will decrease the abduction moments at the knee (i.e. decrease the tendency for genu valgum) by shifting the center of pressure medially on the plantar foot. An everted orthosis does the opposite (increase the knee abduction moments) and is used for treatment of medial knee osteoarthritis. http://www.osteowedge.com/foot-orthoses.htm

    You may also tell him that, if he or she doesn't agree with me, then I would be happy to discuss these topics further with him or her on Podiatry Arena.
  6. Donna

    Donna Active Member

    Hi hugs75

    Answering your 3rd question...
    I would maybe send for a physio assessment to see if there's anything they can do to speed up the healing once she has her new improved orthoses. She is likely to benefit from some calf "work" and stretches ;) I work within a physio clinic and we often share patients, the physios look at the soft tissue inflammation and apply massage/ultrasound/exercise to reduce pain and improve function, while podiatry treatment involves biomechanical assessment/orthoses to maintain correct function. We find that a team approach helps, particularly where there is long standing inflammation, eg. plantar fascitiis.

    Also, have a look at Kevin Kirby's Thought Experiments, especially #3 which looks at how the STJ axis effects the amount of pronation/supination moment and force required by Posterior Tibialis to stabilise the foot in each situation. :cool: Thought Experiment #3


    Donna :D
  7. achilles

    achilles Active Member

    Hi Kevin,
    I agree that the use of an inverted orthotic can reduce the abduction moments,but can also increase the adduction moments. If the genu valgum is structural in that there has been growth discrepancies in the femoral condyles, for example,an orthotic will not change the structural deformity, but could increased lateral compression forces.
    In creating an external rotation at the hip, this may externally rotate the limb, but will not fundamentally alter the genu valgum present.
    In many cases the presence of a coxa vara will fundamentally lead to a compensatory genu valgum.
  8. Cool Avatar Tony. Welcome to Pod Arena. Been to any good Greek weddings lately?? ;)

    If you will note in my posting, I made following statement:

    I define apparent genu valgum as a genu valgum alignment that is present during dynamic gait examination which may be very different from the frontal plane knee position measured during standing or on the table. In other words, apparent genu valgum is caused by changes in 3D position of the lower extremity during gait versus when the knee is fully extended while the patient is standing. For example, a knee joint axis that is internally rotated and then flexed at the knee (i.e. middle of midstance in the child with malicious malalignment syndrome) will have more apparent genu valgum than a limb that has its knee joint axis parallel to the frontal plane and is then flexed.

    And by the way, Simon of Spoonershire told me it was a pig. :p
  9. achilles

    achilles Active Member

    Glad to see you appreciate the picture!! :cool:

    I see your point regarding malignment syndrome, however, in the case of a structural genu valgum, would you apply the same protocols??

    Getting concerned about this pig obsession??!! ;)

  10. He just can't stand the fact that running makes him hallucinate Tony.

    Nice to see you contributing, obviously got too much free time on your hands ;) .
  11. Structural genu valgum will probably be visible on gait examination. However, some patients with little to no genu valgum will have an apparent increase in genu valgum deformity during gait when they also have internally rotated knees. For these patients, if the orthosis can cause external knee rotation then the apparent genu valgum should decrease.

    You mean this isn't a pig??? http://images.google.com/imgres?img...eer&start=40&svnum=10&hl=en&lr=&c2coff=1&sa=N

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