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Help with a case - athlete rehab

Discussion in 'Biomechanics, Sports and Foot orthoses' started by FunGuy, Mar 18, 2005.

  1. FunGuy

    FunGuy Member

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    Hi all

    I have an athlete I am seeing for rehab of his right ankle following surgery to remove a posterior talar impingement and lateral ligament tightening operation 4 months ago. Pain levels are returning to pre surgery levels and he feels unstable whilst running.

    Complaining of pain around lateral malleoli and anterior ankle and posterior ankle. Position of pain changes from day to day. Mostly though located anterior ankle/neck of talus. No pain is reporducible through palpation of sinus tarsi or any strucutres proximal, and through extremes of ROM, or through manual muscle testing. Only occurs during running.

    ROM returned to pre surgery levels, tight calves, mild pes planus foot in stance, internal tibial rotation leading to large degree of patellar squiting.

    Gait: (all quite pronounced during track session)
    - large runners varum
    - large degree of compensatory pronation to enable foot contact
    - large degree of talar anterior and plantarflexion displacement
    - long stride pattern
    - pain at it's worst from heel strike to foot flat whilst running.

    Taping to reduce plantarflexion of the ankle and subtalar inversion has helped mildly. Thinking of a device to reduce talar head plantflexion/add moment but needs to fit in track shoes.
    Any advice/thoughts would be appreciated would be appreciated.


  2. Atlas

    Atlas Well-Known Member

    Although you suggest that no pain is reproduced through extremes of ROM, I would go back and double check.

    How is the lunge test? Is it comparable to the contra-lateral side in terms of range? More importantly, where does the subject feel the restriction?

    Pre-op, ankle plantarflexion would have been the major clinical pain-reproductive test? Now that pain is returning to pre-op levels, how is end-range ankle plantar-flexion? I noted that taping to restrict this helped minimally.

    Victorian Occupational & Sports Medicine Clinic
  3. gavin

    gavin Guest

    why not try a few ankle joint mobilisations, these can improve joint rom and quality of rom also by breaking adhesions around the joint and scar tissue
  4. pgcarter

    pgcarter Well-Known Member

    Everything you have said suggests significant end of range motion at STJ during running and very few people palpate/rom test with anything nearing the force levels occurring during running. Why not think about Sinus Tarsi type pain being generated during running....swelling? Sounds like that region is getting a pounding. how long ago was surgery? residual sensitivity from that sort of thing can go on a long time....in the case of my knees I'm up to 12 yrs now....good luck with it.
    Regards Phill
  5. FunGuy

    FunGuy Member

    Thanks all for your replies

    Scans revealed the anterior talar head had reduced caritilage formation with increased bony odema over this region. There was also increased swelling through his sinus tarsi. It's easy to see why when you watch his running mechanics. We are thinking of a orthtoic device to limit/slow down end range pronation if not only by a small proportion to try and get pain free running and returning to full training in the near future.

    Thanks once again. One other question any experience with carbon fibre orthoses with such huge pronatory forces - likely to bottom out/snap?? I have heard "stories". Need a pretty thin material for competition spikes.


  6. pgcarter

    pgcarter Well-Known Member

    Just an opinion but why do you need a thin material if you are only putting it in voids under the foot?
    I have used 4.5mm polypro in dance shoes and athletic shoes....just grind the heel until you can see through it and the actual thickness of the sheet has no effect of "lifting" the foot and taking away shoe volume....in fact less pronation will often mean a shorter and less wide foot.
    Be careful of how rigid some of the carbon fibre materials get....too rigid I think.
    Good luck...regards Phill
  7. Mark,

    I agree with Phil that the most logical place to look for increased stress in this athlete is in the sinus tarsi. I am assuming that since the patient is wearing track spikes that he is fairly competitive. I would be interested in his level of competition (10K PR) and his age.

    I am not a fan of graphite or composite orthoses in runners due to their high rate of breakage. I use plastazote #3 with a Spenco topcover for many runners who are under 170 pounds in weight for their training flats. However, for competition or training spikes, I will often simply add multiple layers of adhesive felt to construct a lightweight varus heel and medial longitudinal arch wedge to the shoe (to simulate a medial heel skive and medial arch of an orthosis) since orthoses won't generally fit these shoes well and they add considerable weight to the shoe.

    Having been a competetive track and cross-country runner from the age of 13, I know that runners do not want anything heavy on their feet to race in. When you toe the line to race, the last thing you want to feel is "heavy on your feet". Therefore, if you want to impress competetive runners, then make lightweight orthoses for them. Studies have shown that there is increased metabolic cost to run in heavier shoes for the runner. Therefore, I use lightweight materials such as adhesive felt to make a "minimal orthosis" for the racing spikes or racing flats of athletes. Any other comporable material can be made into a "modified cobra pad" to place into the track spike or racing flats. I have described this "modified cobra pad" before in my first book (Kirby KA: "Temporary Foot Orthoses", November 1993. In Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, ppl 273-274.)

    Sinus tarsi pain generally responds better with orthoses that increase the subtalar joint supination moment. Inverting orthoses and adding medial heel skives will increase the STJ supination moment. Also, addition of heel lifts to the shoes often helps relieve sinus tarsi pain.

    If the patient hasn't already had cortisone injections into the sinus tarsi, I would try at least one to see how it helps. This may allow the runner to run with less pain and may help "soften" the scar tissue within the sinus tarsi.
  8. FunGuy

    FunGuy Member

    Thanks all for more useful replies

    The athlete is a middle distance runner aged 26. He has already had 3 or 4 cortisone injection 1 into sinus tarsi and 2 into the posterior calc area by sports physician. This gave little improvement of syptoms.

    We are trying the semi-flex carbon fibre inverted devices for his spikes, but very cautiously. and an EVA orthotic for day to day wear as he previously did not tolerate polyprop. He has been in a CAM walker to settle the inflam down. seems to have helped and will start rehab and return to running with his new orthoses.

    What thickness felt would be warranted granted you have not seen the fella but imagine huge pronatory forces. Is felt that effective to reduce velocity and rate of pronation? I imagine it would have to be upwards of 15mm+.

    Thanks again

  9. pgcarter

    pgcarter Well-Known Member

    I get pretty nervous when someone wants to put courtisone near articular cartilage....but that's just my paranoia.
    I think you are going to learn a lot about this guy with a few iterations. He is going to do stuff that is not really in his long term therapeutic interest by the sounds of things. You may well find that todays right answer only works for a while.
    The challenge is to find out how much change he can tolerate so that you can do the best for him, before he gets sick of you and the whole problem and goes of to someone else that knows less about him than you will by then.

    Good luck,
    Regards Phill
  10. Mark:

    Adhesive felt will work well for occasional use in racing situations but I wouldn't want to use this material for everyday use. I would at least try a modified cobra pad type of insole modification using multiple layers of 1/8" (3 mm) adhesive felt inside the track spikes to simulate the varus wedge and medial longitudinal arch effect of an inverted/medial heel skive orthosis and see how the patient responds. The response of the patient should help direct your treatment and costs practically nothing. I don't charge the patient any extra for putting this padding inside their shoes since it only takes me a couple of minutes to do this in the room with the patient. If you can put it on a removable sockliner, then this makes things much easier.

    If you don't feel comfortable with adhesive felt then you could try some other material that would fit into the shoes to accomplish the same mechanical goal.

    And in response to the sinus tarsi injections, I wouldn't get too worried about these injections hurting the joint cartilage. I have been giving them for 20 years and have found that about 2 out of 3 patients respond well symptomatically to these injections. I have never seen any radiographic or clinical evidence of permanent harm from these injections, even though some patients can get a rather painful "flare" reaction for a day to a week in response to the cortisone.
  11. Atlas

    Atlas Well-Known Member

    Is this within the T-N joint?
  12. pgcarter

    pgcarter Well-Known Member

    Off thread...but do you know anything about courtisones effect on chondroblast function?
    I have not pursued this subject specifically...but the bit of stuff I read in this area a few years ago left me impressed with how fragile the whole internal joint environment is, and how minimal the ability of chondroblasts is to actually produce cartilage in a joint.
    In principle, putting an anti-mitotic in the space makes me a little paranoid about the long term side of things....pain relief acknowledged.
    Regards Phill
  13. Phill:

    Don't know much about the effect of cortisone on chondroblast function. Sinus tarsi injections do not necessarily all go into a joint since some of the injection may remain extraarticular witin the interossous ligament area of the STJ. I use them frequently and they are remarkably effective in many patients.
  14. FunGuy

    FunGuy Member


    yes the anterior talar head is part of the t-n joint. The talus is plantarflexing and adducting into the navicular with bit of force in this guy. Trying to create a supinatory moment to correct reduce this on the sustenaculim tali. The ligaments through the sinus tarsi have been injured previously also.


    If repetitive cortisone injections can effect plantar fascia and achillies inflammation but cause atrophy and possible snapping of these structures, could this process be similar with interosseous ligaments also, eventual weakening of the supportive structures in this region. Does the poor blood flow to the talus and sinus tarsi region play a role also? (I always remember the being taught that the talus lives in a deep dark hole and is fed 'crap' to quote the lecturer at the time - funny analogy i thought)
  15. I don't believe that the STJ interosseous ligaments are under that much tensile stress during normal gait so I don't worry if they may potentially become slightly weakened by a few cortisone injections. I don't know if the blood flow to the talus is a factor. I tend to doubt it.
  16. pgcarter

    pgcarter Well-Known Member

    From my now rapidly becoming less up to date time immersed in joint/cartilage publications I like the analogy about a deep dark hole. The knee joint space is a fragile chemical soup with an eqilibrium that is easily upset. So other joints with even less major local blood supply should be even deeper darker holes. And I would see a steroid as an anti-mitotic that could upset this fragile balance....maybe. Far more experienced people than me are happy to use the stuff and it clearly helps decrease many peoples pain...so I just hope the long term effects are not significant.....as I said my paranoia.
    Regards Phill.
  17. Getting back to the original complaint...

    If he had posterior impingement surgery, has that left him with less talar dorsiflexion? Is his talus anteriorly displaced? And you say he has a tibial varum? And his anterior ankle is eroding?

    If he has either a gastroc or articular lack of dorsiflexion, a robust antipronatory orthosis, regardless of how lightweight it is, will only increase the mischief at the anterior tibiotalar interface as ankle dorsiflexion proceeds (see below). If he were a sprinter, this wouldn't matter (nor would orthoses), as he'd be running in plantarflexion, disengaging his anterior ankle from interfacing, and his foot from interfacing with the orthoses.

    If he's middle distance, the orthosis will inhibit the retreat of the talar neck from the advancing tibia, increasing mischief at the already pathologic anterior tibiotalar interface. Of course, if there's no lack of dorsiflexion, then this is not to worry. If there is a lack of dorsiflexion, he's gotta get that freed up (mobilized) or he'll hurt, limp, or quit. If orthoses help if this is the case, there will be a certain anmount of luck (what else is new) involved.

    One other thought...does he have a bunch of uncompensated forefoot varus (which wouldn't surprise me if he has a tibial varum)? If so, see if you can sneak some extrinsic forefoot varus posting onto his EVAs, and see how they work in his LSD shoes. If they help, try extrinsic ff varus posts on a pair of slimthotics for his racing shoes.
  18. Mark,
    I am a new member here and I have followed the posts with this particular case. Just curious to se how this case ended up? Did you try the modified cobra padding fo his track shoes?

  19. FunGuy

    FunGuy Member

    Things have turned out quite good with this guy, his pain levels have decreased quite considerably and he has been doing full training for the past few month with little to no pain. We ended up using the inverted carbon fibre devices in his spikes with another pair that he uses for everyday use that control his foot function best. Unfortunatley though his feet slip out of the spikes with the second pair no matter how hard we try. He has just strained his hamstring during training so more physio required. Pretty unlucky guy.



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