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Help for patient with LLD

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bombanna, Aug 26, 2008.

  1. bombanna

    bombanna Welcome New Poster

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    Hi everybody

    I had a lady in with quite rigid pes cavus feet recently. She had a forefoot equinus B feet and hence an ankle equinus.

    She came in complaining of pain in her right calf and right achilles tendon. I also noted that she had a significant LLD- the right leg being shorter.

    I felt she needed to be booked in for a casting but tried her with a heel raise in the R foot until she came back (with instruction re exercises too). I told her to remove it if it caused any trouble......which it did.

    This lady is a keen runner and went running painfree with heel raise in place, however when she took this out after running, she had severe pain along her peroneus longus tendon. This is still sore on palpation but not sore when I did muscle strength tests. In the last 2 days she is complaining of lat hip pain (along belly of TFL).

    I can understand that the position of the foot puts alot of pressure on whole lat side of foot and leg......but is this related to the heel raise? (she only wore it once when running and has taken it out since).

    Can a heel raise cause this?

  2. Bruce Williams

    Bruce Williams Well-Known Member

    Re: Limb length difference


    A LLD can and will cause teh foot to supinate to some extent. Using a heel lift will often negate the foots need to do this.

    Going w/o the lift may have returned her to a supinated foot position w/ teh peroneals attempting to pronate the foot in midstance adn late midstance adn may have caused some pain regardless of whether they seemed to function during your exam pain free or not.

    You did not specify which side the TFL pain was on.

    Just get her to where the Heel lift all the time since it seemed to work.

    Good luck;
  3. Admin2

    Admin2 Administrator Staff Member

  4. Adrian Misseri

    Adrian Misseri Active Member

    G'Day Bombanna,

    Quite often clinically, I tend to find that patients with an LLD will demonstrate a circumduction of the longer leg in order to get clearance. The issue with that is that the has to be more rotation at the weightbearing hip (shorter side), which will put pressure on the gluteals, and to some extent the peroneus longus and illiotibial tract in an effort to stabilize the weightbearing limb. With a heel lift, this rotation is reduced due to the reduced need for circumduction for ground clearance of the non-weightbearing limb. Bear in mind also, that when you add a heel lift, you are adding to one of the three components of supination (plantarflexion, the other two being inversion and adduction), so this will put further tension on the peroneus longus, which is already under tension due to teh cavus foot shape. I suggest retrying teh heel lift, but extend the length of it and ad a small cuboid filler under the peroneal groove to pronate the midfoot and take some pressure off the peroneus longus tendon. This can also be incorperated (and to a better degree) in your orthotic device when you order it.
    Good luck!
  5. Bruce Williams

    Bruce Williams Well-Known Member


    I appreciate your viewpoint on the short side hip mechanics. That is very enlightening to me and will give me much food for thought.

    I agree completely with your prescription above 100%.

    I'm curious as to your comment that the PFion of the foot from a heel lift will put more tension on the PL. Why do you feel this is true?

    I think that Bombana stated that the foot had a rigid pes cavus and an anterior equiunes. I find this to rarely be the case adn instead usually see a flexible FF equinus in most, but not all, of these patients. If that is the case, I doubt the PL is under more tension except in its attempt to pronate the forefoot in late midstance due to FnHL, not because of a possible rigid PF'd 1st ray.

    I question the thought process that the PL has to be under more tension in a patient with a fixed/ rigid plantarflexed 1st ray. I still have seen no evidence to assure me that the PL is under more tension in a cavus foot structure.

    If the primary purpose of the PL is to PF the 1st ray in midstance to early active propulsion, and a PF'd 1st ray already allows for this, then why does the PL have to be under more tension in a higher arched foot? Shouldn't it be more slack due to the positioning of the FF and midfoot?

    I will not argue that the PL is a primary pronator of teh foot, and that if the foot is supinated in late midstance to Active propulsion that the PL may become overtaxed from an attempt to pronate during this period. I feel we need to explore this reasoning more since in reality the PL is a PF of teh 1st ray which helps to allow re-supination of the STJ thru mpj extension. I just wonder where the cutoff is between it helping to supinate the STJ and it attempting to pronat the foot after heel off.

    I see this problem in cavus feet as a pronation problem / DFion problem at the 1st ray, not the other way around.

  6. David Smith

    David Smith Well-Known Member

    Adrian and Bruce

    Regarding peroneal tension -- To my mind, if we consider the PL and Pbrevis then these tend to plantarflex the ankle so plantarflexion will shorten them and reduce internal tension. The Ptertius tends to d/flex the ankle so P/flexing will tension it. The compliance of the 1st ray and the CoP progression on the plantar foot will also have some determination on the tension within the PL and indirectly on the magnitude of supination moments about the STJ and so again will affect the tension in all three tendon / muscle units. Can you agree with this?

    Bruce wrote
    Worth considering IMO.

    Cheers Dave
  7. Bruce Williams

    Bruce Williams Well-Known Member

    I agree.

  8. When a heel lift is used, whether built into the shoe with a increased heel height differential or added to the shoe with a heel lift, the kinematic effect that will be generally be seen is decreased subtalar joint (STJ) pronation and/or increased STJ supination during late midstance and propulsion. These effects may either be due to a decrease in force within the Achilles tendon or a dorsiflexion of the hallux and pretensioning of the medial band of the central component of the plantar aponeurosis (i.e. slight activation of the windlass effect of Hicks).

    If the patient has a cavus foot, then they are most likely to also have a laterally deviated STJ axis where the peroneals are probably already tonically active during relaxed bipedal stance. This patient's peroneals will likely show increased activity during late midstance and propulsion during walking. During running, the peroneal activity would also likely be increased therefore the possible cause of the peroneal pain.

    Put the patient back in the heel lift for running but this time along with a valgus rearfoot and forefoot wedge to increase the external STJ pronation moment. This will equalize out the limb length discrepancy and likely also make her peroneal symptoms gradually subside since now the central nervous system (CNS) of the patient will recognize that the valgus wedge will be "doing the same job" as the peroneals so that that peroneal activation can be reduced by the CNS to more normal levels.

    Hope this helps.
  9. bombanna

    bombanna Welcome New Poster

    Thanks for all the help guys!!

    To answer some questions:

    Yes the patient does circumduct the long leg when walking.

    The pain she originally had was in the belly of the calf and the insertion point of the achilles tendon

    Yes the pain only happened when she took the heel raise out, however she felt that the heel lift must have caused her the pain so threw it out straight away......so she hasn't been wearing it since. The hip pain that has followed since only happened approx 1 wk after taking out the device.
    I agree with you guys that I would expect the peroneal and lat hip pain in this foot type due to the excessive supination.......I was just shocked that she had never had this pain before and only experienced it after wearing the device. It confused me!!
    So thanks for confirming that a heel raise wouldn't do this

    Also thanks for the prescription advice

    At present I have her in a v short term insole with MLA filler and valgus rearfoot posting to offload the peroneals- I did this after her last consult so thanks for confirming that this was worth trying Kevin.

    I have her booked in for casting soon and will take all of your advice on board
    Can I ask- Adrian Miserri and anybody else.......
    I have never made the adaptations you were talking about in a proposed prescription- have you any sites/pics/diagrams of this?

    Thanks again guys

  10. Adrian Misseri

    Adrian Misseri Active Member

    G'Day all,

    Bombanna, all of these orthotic additions/modifications are quite common across a variety of biomechanical/orthotic texts, however I've fond 'Foot Orthoses' by T.C. Michaud to be great when it comes to learning the basics about orthotic fabrication and biomechanics. Once the fundamentals are there, all additions that you do will be different and varied, so have fun experementing!

    Bruce, I suggested that the peroneus longus will be under tension with the heel lift for a couple of reasons.
    1. The peroneus longus tendon runs along behind the lateral malleolus, through the peroneal groove on the cuboid, then back up along the underside of the base of the metatarsals and inserts into the base of the first metatarsal (primarily). It's primary function if to plantarflex the first ray, but other moments/forces due to the peroneus longus include plantarflexing the ankle joint, everting the midtarsal joint and abducting the forefoot at the midtarsal joint.
    As a result, in a cavoid foot, the peroneus longus has to work over a longer area and therefore constantly under tension to start with, as the medial arch height (and the base of the first metatarsal) is physically higher than the cuboid, making the insertion of the peroneul longus tendon further away from the origin. Yes the heel lift will reduce the ankle joint plantarflexory moment of the tendon, thus reducing part of the tension in it, however by plantarflexing the foot throgh the use of the heel lift, this will contribute to the supinated position of the foot. This means that any pronatory forces required in the foot will need to be of a higher magnitude to exert the same effect. As the peroneus longus is a secondary everter and abductor of the foot (i.e. exerting a pronatory force), the amount of force required to exert the evertion and abduction moments of teh peroneuls longus will be increased...
    or so I reason it?

  11. Stanley

    Stanley Well-Known Member

    I agree with your treatment, but not your explanation. A short leg with an equinus is prone to cuboid subluxation. A lift that is too short in length (not height) will put more strain on the calcaneal cuboid joint, so you were right in saying a longer heel lift. You were also correct in saying use a cuboid pad. Additionally, a subluxed cuboid can give a reflexively weak ipsilateral tensor fascia lata muscle, and hence the IT band syndrome.
    Manipulation will work quicker, but the orthoses will work also, and orthoses would have to be fabricated to maintain the joint integrity. I don’t manipulate anymore, I just do the soft tissue work. In this case the of the cuboid, I find that distal friction on the cuboid fifth metatarsal ligament and the lateral most portion of the long plantar ligament will eliminate the subluxation of the cuboid.

    I am just curious how you determined which leg was short. The fact that there is pain in the “calf and Achilles” indicates that this side is definitely functioning shorter, but it may not be that way structurally. If you do any manipulative therapy, the best way to measure is the ASIS to the ground. If you do not, then the best way to measure is the PSIS to the ground and to watch the patient walk.



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