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Help please. Lost - supination

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Scotty89Uk, Apr 3, 2014.

  1. Scotty89Uk

    Scotty89Uk Member


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    Hey

    So I had a patient come in for biomechanical advise, the patient suffers from pain when walking or sitting on a bus and feeling vibrations, the pain started in his knee, and now goes to calf, knee and upper thigh right to the glut. The pain has gotten so bad that he can't sit on his sofa. His foot is over supinated. I am unsure on how to treat him. Any thoughts?

    Scotty
     
  2. Griff

    Griff Moderator

    Hi Scotty

    I think the first step when making decisions on how to manage any pathology is to identify the pathology. In this particular case, given the limited information above, the architecture of the foot would not be on my radar initially. A diagnostic work up is the place to start. What do you think you are dealing with here?
     
  3. Scotty89Uk

    Scotty89Uk Member

    Hi Ian,

    Well he is 40, a smoker, no problems with blood supply or muscles, a little below average rom and his gait is a little everted but nothing that screams out to me....
     
  4. Griff

    Griff Moderator

    Anything of note on neural provocation tests?

    The key thing (in my opinion) is that if we don't know what we are dealing with then our 'treatment' should probably be onward referral..
     
  5. Scotty89Uk

    Scotty89Uk Member

    No abnormalities in neural provocation tests either. looking at tread marks on shoes you can see the wearing away of lateral edge. In the past 2 weeks he has been to the gp 4 times who has referred him to us. He is housebound due to the pain. My thoughts were to treat the supination by using a insole such as slimflex simple with a tilt, maybe something to cushion- don't know what else to do....
     
  6. Griff

    Griff Moderator

    Slump testing and Straight leg raise testing both negative? Still smells neural to me based on your descriptions.

    How is "treating the supination" with foot level intervention going to change his pain when sitting? Do we know that observations at foot level are correlated with his pain (can we know if we dont have a diagnosis?) If someone is housebound due to pain are orthoses appropriate? If this did not work what would the next step of your management plan be?

    Doing something for the patient doesnt always mean you have to do something. Refer on now in my opinion.
     
  7. Scotty89Uk

    Scotty89Uk Member

    So I take it I should refer to the neurologist?
     
  8. Griff

    Griff Moderator

    Personally I'd send them in the direction of a good Physio initially, to check their lumbar spine amongst other things.
     
  9. Dananberg

    Dananberg Active Member

    Sure sounds like some type of lumbar entrapment syndrome. Symptoms appear sciatic in nature, and may be lumbar disk related or perhaps early spinal stenosis. Pain with sitting and walking also point in this direction. How far can he walk before pain develops? If it is limited, then I would consider the stenotic diagnosis. Smoking is also a known risk factor for spinal disk disease. Also, with chronically supinated feet, other neurological issues come to mind. Time to ship this guy out for a serious workup.

    Howard
     
  10. Scotty:

    Like the others said, this type of pain is generally neurological since his pain is worse with sitting. Things to consider include piriformis syndrome, a L4-L5 radiculopathy or more likely a L5-S1 radiculopathy or some other spinal nerve root irritation. My first recommendation would be a referral to an orthopedic surgeon or a physical medicine and rehab specialist and/or neurologist and possibly a NCS/EMG and lumbar MRI. The supinated foot could be due to loss of motor function to the peroneals.

    Also, I would suggest also you read the following chapter to become more familiar with various nerve-related injuries, their diagnosis, presentation and treatments for your future patients.

    Diseases of the Peripheral Nerves and Motor Neurons
     
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