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Help Needed - Back pain from orthoses use

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sspod2001, Mar 14, 2007.

  1. sspod2001

    sspod2001 Active Member


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    Hi Guys,

    A little help is needed with a biomeech pt.

    He is a 5 yr old boy who has very poor feet which are excessively pronated in RCSP. I prescribed him a pair of Root type functional orthoses with a 4 degree rear foot post and a Kirby grind, with a 4mm heel elevation. They were made to a standard width with a medial flare.

    On fitting these orthoses they seemed to correct the excess pronation very well, so pt was sent home with the usual orthotic information about breaking them in etc.

    yesterday the pt returned with concerned parents regarding severe lower back pain and pain in his right hip, he had been to an osteopath who performed and ajustment, the osteopath found no LLD!! the pt's lower back pain then went away.
    He then put his orthoses back in and his lower back pain and hip pain returned.

    On further examination right hip Rom is good, also there is no functional LLD, also muscle flexibility is good.

    This pt is due back for another casting in a few days but i'm am at a loss as to what could be causing the lower back pain, any help would be much appreciated.

    thank you steve
     
  2. Andrea Castello

    Andrea Castello Active Member

    Hi Steve

    Just a couple of thoughts.

    1. Do both feet function the same. Ie. is the supination resistance higher in one foot than the other etc. It is not uncommon to have feet that function differently.

    2. Does it impact on his ability to pronate at all, therefore increasing shock attenuation into his lower back and hip joint. For example if the STJ axis is more laterally placed in his right foot, the orthotic might have the effect of increasing lateral instability or preventing "normal" or "required" pronation.

    3. Footwear. Is the child wearing his devices in a shoe that may be providing significant medial column support (dual density EVA etc)? This could again have the effect of amplifying any shock attenuation.

    Without knowing too much about the case, these would be the first things I would check.

    Good Luck

    A
     
  3. sspod2001

    sspod2001 Active Member

    Hi Andrea,

    Yes we did look at the functioning of the orthoses which seemed good and placed him on our f-scaning machine to test for incresed shock/pressure, no significant increase observed. orthoses reduced pressures according to results. also both feet do function pretty much the same.

    At present our casting method is a scanning machine called scan any. and we think that when modifying the scan, an adducted forefoot has been formed and so this 5-6 degree internal rotation of the casts may have caused an anterior tilt of the pelvis?????

    then any slight increase shock would cause the lower back pain. we think?

    we have recasted the pt using the more traditional plaster technique and remaking the orthoses to see if this changes anything.

    thank you for your imput

    steve
     
  4. Atlas

    Atlas Well-Known Member

    Plan a. Rip off the posts.

    Plan b. Depends on the effect of plan a.
     
  5. DaFlip

    DaFlip Active Member


    Steve,
    my weekend job as a part time rocket scienctist has led me to do a lot of thinking about this specific problem. Orthotics in = pain, orthotics out = no pain. So thinking real hard about your question as to what could be causing the LBP and hip pain my conclusion is it is the orthoses.

    Now i know i have made this look real simple and call me a genius if you need too, but i think the evidence is there.

    Can orthoses can create pathobiomechanical function?
    I have a feeling inversion, skives, flares and elevations may be too close to rocket science for this 5 year old kid.

    DaFlip :mad:
     
  6. Scorpio622

    Scorpio622 Active Member

    Other than what is mentioned above, why did you put this boy in orthotics (pain, dysfunction, etc) ????
     
  7. Simple:

    1. When in doubt...UNDERCORRECT...the theory of MORE overpronation thus MORE arch height and increased medial hindfoot posts (e.g. 4 versus 1 degrees) = DISASTER...IF he has a rigid flatfoot and you put that kind of orthotic you claimed in his shoes...of course he will do back flips with that kind of orthosis. Don't try to MAKE him look neutral...that foot cannot and will never take that kind of correction....if you made a more flexible shell ( say 2 mm polypropelene versus 3-4 mm) with LESS arch height and less of a degree or 2 of hindfoot varus extrinsic posts AND added a nice 1/8" heel cushion...dimes to donuts he would do better.....there is no need to re-cast or re-scan...that is not the problem......nor is an adjustment... you simply need to make a different orthotic Rx and take it from there...trust me I learned the hard way too.....when in doubt, take it off.......when in doubt, undercorrect....when in doubt....KISS ( we used to call that keep it simple stupid)!!!!

    Don't ask why....just go with the flow....it should help. If not, then he may NOT be a candidate for orthotics.

    Later dude and good luck

    Let me know what happened..............this advise is only a guideline...the decision is up to you and your patient ( if it produces killer pain.....STOP)
     
  8. My inclination is that the initial orthotics were too much too soon. You did'nt mention what you made them out of so i'm assuming its polyprop or similar. In which case the kid has gone from (presumably) little or no control of pronation to no pronation allowed at all. It's not all that surprising that such a radical shift is causing problems. Is his back pain muscular?

    Personnally i would drop to a simple device with calibrated resistance initially to see how he does.

    I rather think steve knew it was the orthotics. I suspect he wanted to know why. Did you do much work on the arianne 5 espa?

    Regards
    Robert
     
  9. Robert,
    Can you explain this please?

    BTW, I agree with DaFlip regarding what the problem is here. Me, I don't put 5 year-old tiddly-peeps into rigid devices- never had that much self-confidence. ;)

    And to re-iterate Scorpio, I would ask: what are you treating with all of your technology? Flat-feet?
     
    Last edited: Mar 26, 2007
  10. DaFlip

    DaFlip Active Member

    You mean Steve knew it was the orthotics all along! You think?
    As for the ariane 5, as a matter of fact, and i think you will find this hard to beleieve, i only had a very small part to play. I mean it is my weekend job and all, my knowledge of geostationary transfer orbits is only just OK yet i would consider the success of the launches since i came on board in 2004 to be singularly related to my involvement.

    I second Simons request here please.

    DaFlip :mad:
     
  11. I'll have a crack.

    When prescibing for children the most common problem i come across is global ligamentus hypermobility / hypotonic musculature. My view on these patients is that to blockade pronation altogether deprives them of a shock absorbtion / ground position accommodation mechanism which is there for a reason. As such my ideal outcome is an insole which allows the foot to pronate, but not in the way which is causing concern. Assuming that in children who are that hypermobile the foot is often inverted almost before heel strike (based on observation of medial heel wear) i often work on the basis that the foot effectivly starts from a maximally pronated position or close to it. This makes the lever arm beween the stJ axis (frontal plane) and the medial part of the foot and insertion of the tibial muscles shorter meaning more muscular energy is required to generate an appropriate supination moment.

    The orthotic i prescribe will be based on the minimum compressibility / flexibility (depending on whether the device is a shell or shank dependant) required to hold the foot near enough to a neutral position to allow the amount of muscle power available or the amount of additional GRF medial to the STJ axis I wish to provide via the elasticity of the material of the device after the foot has pronated,to generate sufficient supination moment . Further, in the case of shank dependant devices, the nature of the recoil of the material will be informed by what the problem is with pronation. If, for example, the foot pronates an acceptable degree but too fast and with little effective decelleration i might consider a memory type material such as diabet which compresses but has slow recoil. If the foot pronates an excessive amount i might laminate a springy material over a dense material (ie poron over EVA) to decellerate the foot for the first few degrees and then prevent movement beyond a certain point.

    Essentially i want to know 4 things about a pronating foot. When (does the pronation take place), how long (does the foot stay pronated), how fast (the foot pronates) and why (the foot behaves in that way) . Then device i use will be informed by these things.

    Thats what i mean by calibrating the device to the foot. I try to apply a principle similar to pharmocology to use the minimum dosage to acheive the desired effect.

    I hope my inarticulate ramble explains where i'm coming from. I shall now rub myself with garlic butter, sprinkle myself with thyme and await a good roasting on gas mark 4. ;)



    Regards
    Robert
     
    Last edited: Mar 27, 2007

  12. http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=12883&postcount=1

    This statement seems to assume that foot orthoses block foot motion; do they?

    Here's a little experiment to try at home: take a pair of orthoses, stand on them and pronate your feet. Not found a pair yet which stopped me from pronating.

    "Yeh, that's the real trick"- Han Solo.

    You got me Robert: how do we differentiate "good" pronation from "bad" pronation? At what time/magnitude / velocity does pronation turn from being something we want to something we don't? When it's pathologic right? When's that?

    This is getting toward the crux of what I was asking.
    OED definitions first:
    calibrate 1. mark (a gauge) with a standard scale of readings. 2. correlate the readings of (an instrument) with a standard. 3. determine the calibre of (a gun). 4. determine the correct capacity or value of.

    Taking 4. from above:
    Lets say we have a five year old male weighing n kg's, who's foot pronates at a rate x radians/second to a magnitude of y radians (degrees) (take your pick) at 60% of the contact period. What is the formula which allows me to determine the degree of posting required and the shore of the material to use based on these (and which other?) measurements that will hold the foot in neutral with minimum force (furthermore when do you want to do this?)

    In other words, how do you "calibrate" your device?

    These be grand words Robert, I'm just not sure how you are determining all of this. How are you measuring supination moment about the joint (STJ?) axis?


    Again, how do you know when pronation is too fast or too slow or too much or too little? How do you assess this clinically. What is a normal pronation velocity in a 5 year old?


    Not trying to be harsh, just eager to learn new facts and techniques that I may not have come across as I'm currently doing some FEM work on the effect of orthoses shell parameters.
     
    Last edited: Mar 27, 2007
  13. Stick a fork in me, i'm done.

    What you? Harsh? Thought never crossed my mind! :D ;)

    Ok here goes.

    http://www.podiatry-arena.com/podia...883&postcount=1

    Certainly this seems to contradict the idea that rearfoot eversion impact forces. However as the abstract says, modeling does suggest that it may yet be the case and that
    I am therefore not entirely willing to discard that theory just yet. I'm pretty certain that pronation does something useful along those lines.

    Fair question. Based purely on the shape of feet in relaxed stance, the shape they are in when i cast them and the impossibility of foot and orthotic sharing the same space i'd say yes. Hovever i do not have any pure science to back this up.

    Have you found a pair which, in shoes, allow you to pronate your feet without lifting the lateral side of your foot? Surely (a word i know you are not fond of ;) ) Pronation must cause navicular drop unless the lateral side of the foot rises. That being the case if you shove a load of polyprop under the navicular how can the foot still pronate? Having said that i've never made myself a set of solid neutral shells so i reserve the right to say "bugger you're right" until I get time to do that.

    Originally Posted by Robertisaacs
    but not in the way which is causing concern.



    Very true. As you know and as you are (i guess) trying to get me to realise there is no definitive answer to that question. As a follower of the tissue stress model i would say, at the point is causes sufficient tissue stress to cause injury. As somebody who tends to intervene with asymptomatic peadiatric hypermobility i would say, at the point i think it's GOING to cause that level of tissue stress at some point later or if i think the foot may undergo structural change due to davis law. However i think this is something everyone has to decide for themselves in the absence of hard data.


    Ok here you have me. I have no quantifiable formula for establising this. Not even close. Calibrate is possibly the wrong word to use, i which case i apologise for using it. The way in which i "calibrate" my device is based on the mass of the patient (approximatly), the residual moment of the foot in static relaxed stance very aproximatly measured (possibly too grand a word) by the force required to supinate the foot by hand and my knowledge of how materials behave. I then observe the effect of the device on the foot by watching the patient walk with the insole and, perhaps most significantly, the effect of the device on the symptoms. I then adjust in either direction as required.

    Highly unscientific, entirely subjective and utterly useless to everybody else. I use the word calibrate purely to indicate some attempt to match the shape and compressability of the foot to the minimum force required.

    I'm not. Not in any quantifiable way. However something does not need to be measurable to exist. How do you measure how much nail to remove when doing a PNA? Do you have a formula for this based on curvature of nail, overlap of toe and percentage of nail to be removed? Does that mean there is not a correct amount of nail to remove, that too little will cause the surgery to be unsuccessful and too much will mean an unneccesary amount of nail has been avulsed?

    I refer the right honorable gentleman to my earlier answer.

    If the point you are making is that my method is not quantifiable, transferable, measurable and scientifically bulletproof, i agree. If you were hoping i was sitting on the next great breakthrough of force measurement and orthotic design, sorry to dissappoint. I stand by my opinion that trying to judge the minimum amount of support is a better idea than using rigid devices on general principles but i would not presume to tell anyone else that i was right and they were wrong.

    Thankyou for your input and questions. As always intelligent, thought provoking, pedantic, bloody frustrating and above all educational. ;)

    Regards
    Robert
     
  14. Steve:

    Even though I have treated many children this age with flat feet with foot orthoses over the past 22 years, I have yet to see a 5 year old with pes planus deformity develop back pain from foot orthoses. If you are certain that the orthoses are the cause of the pain, you may first try taking off any heel lifts, especially any asymmetrical heel lifts that you may have added for a "supposed" limb length discrepancy. Next, grind some of the varus correction out of the orthoses both at the anterior edge and rearfoot post of the orthosis. This reduction in varus support will likely reduce or eliminate the back pain. Even children can develop back pain with over-corrected foot orthoses, but it is much less frequent than that seen in adults.
     
  15. That was the only point I was making Robert. You are not calibrating anymore than a certain other individual who claims to be "calibrating" orthoses is.

    As for blocking motion- t'was a geniune question- some researchers show kinematic change with orthoses while others do no not. Me, I'm not too worried about kinematic change.

    One last point re feet and orthoses occupying space- if it is the velocity, magnitude or timing of the motion that is important. What difference does the space in which this occcurs make?
     
  16. Fair nuff. Could'nt think of a more accurate adjective. "matching", "customising," etc don't really seem to cover it and calibrating as you say implys more quantative measurement than i can claim. I would mention that unlike
    i'm not trying to sell anything so my mistake is more down to a limited vocabulary than self aggrandisment for the purpose of profit.

    Not sure i follow you here. Any chance you could trim this sentance down into chunks that will fit the available space within my brain? If the orthotic is solid then Motion cannot occur through it at any velocity. If it had calibrated :rolleyes: ;) resistance then the space it occupies will define when the movement starts to be affected by the device.

    Regards
    Robert
     
  17. That's right, so the motion just occurs on top of it: in a different space. Hence the number of studies which show no change in hindfoot kinematics with orthoses.
     
  18. With you now. Thanks for once again making something simple complicated and forcing me to re-evaluate my assumptions. You do know your post cause migranes ever time i read them don't you. :mad:

    :eek:

    I protest, i never calibrated your arse. Would'nt know how. Never been near your arse.

    Actually if we're being pedantic that wasn't introducing new terminology, it was misusing existing terminology. :p If i was going to introduce new terminology I would be making up words

    Calibridensimalisationing (Cal - e - bry - den - see - mall - ace - iron - ing) Vb, to take a best guess at a quantifiable variable which defies conventional attempts at measurement in a clinical setting due to its complexity or the number of variables involved.

    Oh fine, rub it in. :(

    Regards

    Robert

    PS
    Here's another star wars quote (paraphrased)
    "Yoda is teacher. He cannot stop himself, he teaches like drunkards drink or like killers, kill"
    Yoda
     
  19. Robert and Simon:

    When I lecture, I will use the term "fine tune" to describe the process that Robert described as "calibrating". I agree with Simon that the term "calibrate" implies a much different process than how clinicians arrive at optimal orthosis design.
     
  20. David Smith

    David Smith Well-Known Member

    Robert

    Having visited you at your clinic I can understand your thinking and I like your explanation of your technique.

    One can intuitively imagine that a thick soft material attenuates force more slowly than a thinner rigid material. This is also scientifically proven and obviuos to anyone who has fallen on to a hard surface compared to a mattress. So perhaps we can apply this to the construction of an orthosis and imagine that a combination of materials will attenuate force in a variety of ways.

    I can also understand that Simon is sceptical about the precision of your 'calibration'. However seeing how you work and the enormous stash of materials you have in your store to work with (he has about 10,000 different types of foams and plastics No Exaggeration! :D ) I can see how you can build a feel for the type of attenuation you require based on your observations of your patient and your experience with the materials you work with. Human experience is an underated commodity in these times of evidence based medicine. Which may seem as a bit of a U turn in light of the fact that I like to use scientific methods to prove how things work but I think science is just sometimes a way of proving what some of us knew from experience. The more scientific we become the less we allow ourselves to trust our instinct and experience. (and unfortunately you can't get a degree in empiricism. ) Someone's foot note say's something like ' Anything that is worth knowing can't be taught.

    All the best Dave
     
  21. Kind words Dave. However you do exaggerate, no more than 8000 types at most ;)

    Dave knows what he's talking about here! Believe! You'd go a long way to find somebody who knows more about falling than a (3rd, 4th?) Dan in Judo! :D

    Regards
    Robert
     
  22. Stanley

    Stanley Well-Known Member

    Steve,

    Instead of looking at the orthotics, why not try looking to see what the orthotics does to the patient. :confused:
    Instead of taking the osteopaths opinion of there not being a leg length, try evaluating it for yourself. :cool:
    With these two things in mind, let's go step by step in how to fix this problem. :)

    You can undercorrect, and that will eliminate the back pain, but what would you do in a case of plantar fasciitis that you find with undercorrection the pain in the foot recurs, and when you correct the foot with the orthotic by posting, or raising the arch, the back starts to hurt. :confused: For this reason, I will tell you how I approach the problem.

    You have to evaluate for extrinisic pronatory factors, that are causing compensations in the foot. When you eliminate a foot compensation for one of these extrinsic pronatory compensations, then another area of the body must compensate (ie the back).

    The two extrinsic pronatory factors are equinus and leg length. So evaluate for the equinus, and then remember that you will be thinking of using a heel lift for the side with the equinus or bilaterally for bilateral equinus. This will take care of the problem in a high percentage of cases, but not all.

    You can stop at this point and see what happens if you are not comfortable or confident with leg length evaluations. You should learn how to do this, as this will help remarkably for you to understand how the foot is affecting the body. You will also see how insignificant most of our measurements are and use this evaluation (in addition to your dorsiflexion measurement) as most of your biomechanical exam.

    Check the relationship of the ASIS (Anterior Superior Iliac Spine) to the ground in 3 positions: Neutral calcaneal stance position, relaxed calcaneal stance position, and standing in the shoes with the orthotics.
    Repeat by checking the PSIS (Posterior Superior Iliac Spine) to the ground in 3 positions: Neutral calcaneal stance position, relaxed calcaneal stance position, and standing in the shoes with the orthotics. You also need to watch the patient walk. Look to see the height of the head when the foot is in midstance, and compare it with the other side.

    From this information, you can tell a primary shortage, an ascending asymmetry (a shortage or iliosacral dysfunction from pronation), pronation secondary to a long leg, iliosacral dysfunction. If have evaluated someone with a short leg, and find the head rises when the short side is in midstance, then the asymmetry is coming from above the ilium (descending asymmetry). You can tell if your orthotics are causing an iliosacral or functional leg length. At this point, I am assuming that you can figure out what it means. If not, there is an article coming out in Podiatric Management this month that explains it.

    If you are good at manual therapy. Then we can proceed to the next step. If you find that the ASIS drops on one side in the pronated position, look for a foot joint that is in dysfunction. The most common is the lateral cuneiform, followed by the middle cuneiform, the medial cuneiform, the base of the metatarsals, the talus and finally the calcaneus, in that order. After manipulation, work the associated ligament (ie posterior talocalcaneal ligament for a subluxed calcaneus) by rubbing in the direction of ease, not dis-ease (the direction that hurts the least)

    If you find an equinus on a long leg, this is indicative of a descending leg length. Conneely discusses the Quadratus lumborum syndrome. I just find you also have to check the opposite scalenes. The most tender of the three is the affected one. Lately, I find that reverse strain-counterstrain on the scalene on the side of the equinus, and strain counterstrain on the opposite side will handle most of the descending asymmetries. Also look for the related stress receptors for these muscles and treat if active. If this doesn't correct the high hip, then refer to an osteopath for cranial sacral mobilization, unless you are trained and allowed to do it yourself. What is a side effect, is when you correct the scalene/quadratus lumborum, or cranial sacral system, then the equinus is eliminated (unless caused by some neurologic disorder of boney block).

    I hope that helps.


    Regards,

    Stanley
     
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