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Hi folks, hoping you can help me with this case.

31 yr old, healthy, active female presented to the clinic with pain along the distal aspect of the medial tibial border. No pain elsewhere.

Gradual onset of pain 6 months ago, sport / exercise makes it much worse. Plays soccer, netball and runs at least once a week, but is now unable to do these activities due to the pain.

No other relevant medical history.

Brief assessment revealed a supinated, slightly cavus foot type in resting stance. Combination of forefoot valgus and rearfoot varus were noted.

Biomechanically speaking this is not the foot type I am used to seeing when someone presents with MTSS... Should treatment include an orthotic? What is the aim of the device if there is no excessive pronation to treat in the first place? Am I missing anything?

Thanks for any advice.
Berms.

 

Berms,

Think about the tibial architecture (varum expected in this case) --> then think about bone bending moments

Read the thread Admin2 links above, and also Kevin's chapters on MTSS and its management in his Precision Intricast newsletter books. Should then all fall into place. Did for me.

 

Berms:

I had a patient like this about 10 years ago that had the exact same foot type and symptoms and was a competetive triathlete. We made him a 5 mm polypropylene orthosis that was made over a positive cast inverted about 6-7 degrees with a 4 mm medial heel skive and with 18 mm heel cups. We also used a minimal arch fill with a 3-4 mm plantar fascial accommodation so that the orthosis almost looked like it had a medial flange. I remember the lab calling me and asking me "Are you sure you want to do this?" I said ,"Yes, go ahead and make it exactly as I ordered it!"

The patient, who had medial tibial stress syndrome (MTSS) for a year before, was pain free with running with that orthosis within a month...no more medial tibial pain. The important thing I learned from this patient was that in feet like that also have MTSS, the feet need to be supported with the orthosis with very good congruity in the portion of the medial longitudinal arch that is medial to the medial band of the plantar fascia. These higher-arched feet will pronate on the ground with more medial translation of the midfoot than flatter arched feet which pronate with more flattening of the longitudinal arch (more inferior translation). Therefore, the orthosis must be designed with good medial-plantar arch conformity to prevent this medial-midfoot-translation motion that occurs with closed kinetic chain subtalar joint pronation motion of the higher arched foot that is the probable cause of MTSS in these feet.

You may want to check out this article I wrote for Podiatry Today Magazine two years ago on this subject:

Current Concepts in Treating Medial Tibial Stress Syndrome

Hope this helps.

 

Hi Ian, thanks for the advice.... the link above posted by Admin definitely helped!

 

Thanks Kevin, that really helps!