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Help with patient with arch pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bartypb, Dec 20, 2010.

  1. bartypb

    bartypb Active Member

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    Hi everyone, wonder if anyone can help with treatment of a pt I am seeing:

    43 yo female high impact level as works in a gym, was referred to me with pain in her left 'arch' - following a massage? Described the pain as sharp/ burning pain.

    examination reveals - pain on palpation to FHL tendon along the MLA especially painfull around navicular and medial malleolus in the tarsal tunnel. Pt has two massages a week and is in agony when the masseuse starts on the calf area. I tested resisted power to FHL, tib post, FDL, all were negative, the patient stands RCSP rectus foot type, hubshers 2 both feet no medial deviation of STJ. All joints have good range and quality on mobilisation. Giat - normal heel strike through to mid stance where there is slight frontal plane pronation and navicular drop ( not excessive) propulsion normal. The patient complains mostly when she is doing lunges when her left foot is the back, flexed foot ie when mpj's are fully extended. Tinnels to the area was negative?

    originally I gave her an insole with bevelled/skive medial - lateral up to behind 1 MPJ and some eccentric toe raises as I thought it was a tib post problem she did get better but then relapsed after about 3/12 now she can't really do a lot in the way of exercise - walking is ok

    I have given her advice to ice 3-4x day, massage, intrinsic foot muscle exersises and also added slow concentric toe raises with knee bent to try to strengthen FHL.

    anyone else got any ideas for treatment, or am I barking up the wrong tree altogether?


  2. CraigT

    CraigT Well-Known Member

    Re: help with patient

    Myofascial trigger points?
    When being massaged in the calf, is the agonising pain in the calf or the foot?
    Have you tried also low- dye taping?
  3. Griff

    Griff Moderator

    Re: help with patient

    Stop her doing lunges ;)
  4. Ella Hurrell

    Ella Hurrell Active Member

    Re: help with patient

    I assume you check that she is still using her orthoses? An obvious one I know, but patients often stop wearing them when the pain goes away and don't always think to put them back when it happens again :bang:
  5. footdoctor

    footdoctor Active Member

    Re: help with patient

    Trigger point in tibialis posterior proximally(upper 2/3's of post musculature) and probably associated t'p in flexor hallucis longus.

    Try myofascial trigger point therapy, using dry needling technique

    P.s T.p's don't like ice too much !!

  6. efuller

    efuller MVP

    Re: help with patient

    The FHL tendon is quite deep in the MLA (Medial Longitunal Arch). With the fact that it doesn't hurt with testing of plantar flexion of the IPJ I woud say that it is not the FHL tendon that hurts. In 1989 I was reading a text by Hoppenfeld on examination of the foot and it claimed that when you dorsiflexed the hallux you could see the FHL tendon bowstring. I think that text was wrong because the plantar fascia is more superficial to the FHL tendon. Although, if you thought it was FHL you could cite the text to prove you were right..:rolleyes:

    Last edited: Dec 21, 2010
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: help with patient

    Eric, very true. Most podiatrists are 'taught' (incorrectly) that when they palpate the prominent band of tissue in the MLA that sticks out with hallux dorsiflexion it is the FHL tendon. Obviously, with some basic anatomy revision, it cannot be so.

    Only the plantar fascia is visible and readily palpable. The FHL tendon is miles deeper and forming the Knot of Henry at this level.

  8. CraigT

    CraigT Well-Known Member

    I actually find it is physios that seem to be taught this... or at least presume this.
    I remember seeing a physio do an examination and commenting on the 'tight FHL' and thinking to myself .. EH???
    And possibly Abd Hall?
  9. I agree abd hallux is something to consider.
  10. bartypb

    bartypb Active Member

    Thanks guys the main reason I think Its FHL is because it is very painful to palpate around the medial malleolus ( tendon wise can only be tib post, FHL FDL,) and also underneath navicular - possibly sust tali - I am in the nhs and have not done any trigger points before- maybe a referral to physio to get the trigger points frictioned may be the next step?
  11. footdoctor

    footdoctor Active Member


    When you say arch pain, where about in the arch does it hurt?

    Like others have said it going to pretty difficult to palpate FHL in the plantar arch area, doesn't mean to say that its not the affect tissue though.

    Trigger points in abductor hallucis will usually mimic insertional p/f pain and medial calcaneal pain not usually MLA pain.

    Indeed the FHL courses the sustentaculum tali and inferior to the med malleolus so possible.

    What about the medial band of the plantar aponeurosis? Certainly more palpable in the plantar arch than the FHL, though wouldn't explain the calf pain and inferior med malleolus palpation pain. Hence why prob trigger point in gastrocnemius, distally.Try needling this point.

  12. paulbuttel

    paulbuttel Welcome New Poster

    Dry needle and massage. Get her to stand on broom handle full length of arch. It will hurt like hell to begin with but will break up any adhesions in fascia and potentially address AbHallucis triggers
  13. drsha

    drsha Banned

    I have reserved this comment for a time in order to expose the continued lack of clinical thought on the part of The Arena for LLD as a component in assymetrically symptomatic cases.

    What about The Inclined Posture as a component of this case?

    I would consider all of the above but add either a heel lift under the left side (if FEJA short) or B/L lifts, with the left higher, to be weaned away as symptoms subside.

    Dr Sha
  14. Orthican

    Orthican Active Member

    I was looking in the table of contents for sustentaculum tali .....for these patients I use a sustentacular bolster ie: just plantar to the F.H.L.T. and on an angle from the S.T. along the first ray ending proximal to the 1st met. Sort of a shortened "Feiss Line" contour follow if you will. Biomechanically a rotational moment is created frontally at the S.T. that is strong enough to overcome the weight applied. I can do it with a very low profile device of sub ortholene that is both useful in the morbidly obese as well as the 105 pound runner. And yes the patients are out there on them and have been for years. You only need counter the coronal rotational moments with a lateral heel bolser that ends proximal to the base of the fifth ray ...
    All I'm going to say is it works very well, And no, I have nothing but years of subjective clinical to back it up. As an orthotist my time is spent in clinic. I spend free time outside of work reading about this and many other topics, educating at AAOP, CAPO, and whatever else I see I might need to pay attention to.

    It does not make me "better than" or "smarter than".....................
    It means I use my ears to listen, my eyes to see, and my hands to make. The results are only based on my best efforts utilizing what I know from what I have learned in school and what I see after time has passed educating myself at every opportunity..
  15. drsha

    drsha Banned

    Your interpersonal observations seem to coincide with some of mine and like you, I monitor The Arena as one of the best sources of biomechanical minds.
    Its a shame they are so closed and so biased.
    I hope your approach finds better acceptance than mine.

    You Feiss Line Bolster is a sagittal plane and to a lesser extent transverse plane ORF and hence its impact on the S.T.
    It is a form of Vaulting in my language.
    It obviates the need for frontal plane ORF's and in doing so promotes leverage and healthy function of Peroneus Longus distally in opposition to a varus heel post or a medial skive promoted here for similar complaints.

    I have two questions.
    1. What is your casting technique for shells?
    2. Do you find less need for frontal plane correction of the rearfoot in your platform?

    Most of all, thank you for making a post that did not contain a theoretical root like FFT or Tissue Stress so that it can be debated biomechanically and not politically.

  16. RobinP

    RobinP Well-Known Member


    I'm not sure what you are describing, would you have a picture?

    Pardon my ignorance, but what is a Feiss line?

    What patients? Patients with arch pain? What is the problem you are treating?


  17. Orthican

    Orthican Active Member

    My intent with this type approach is to create a force couple in the frontal plane using the area of the Sustentaculum to provide control of a valgus hindfoot with use of the GRF and negates my need for any type of post, wedge or skive at the heel whatsoever. I'm not sure what you mean here regarding vaulting but it is a rotational moment coronally I am creating to be sure. By doing so I reduce the overall size, thickness, and width to give as minimal impact within the shoe I can but still give me the desired result which is stability of the hindfoot in the first part of stance. The type of patient this works best with for me is the flexible planus with valgus hindfoot.

    I do not find the group here to be closed minded at all actually. And this approach I use for this is not and can not be my only approach. One must have many tools in the tool box. There is no one true way of handling any of these problems. There are approches that work better than others to be sure, but just as each person is an individual so too must the biomechanical solution fit the individual and thier problem. When I was younger I used to look for a way to group together types of patients and thier presentations in an attempt at simplification, but I found that to be somewhat of a red herring. Each person I see may present similarly sometimes to a previous one but there are always the little differences that the individual presents with that negate any kind of pigeon holing and cookie cutter approach to these problems.

    To answer your questions I have used sub talar neutral casting long ago when I was just out of school because that is what we were taught. I have found over time that this too is a red herring. I then went on a search and used force plate systems, different hand cast techniques, pin boxes, foam boxes, slipper socks to replace plaster, laser scanning, .........

    I find that my hand casted technique has evolved into not "sub talar neutral" castings but talar neutral for the individual based on whether the STJ is medially or laterally deviated, the tibial stance angle, the knees and the hips and moreover what forces I am trying to reduce or control or add. I have had to find this out on my own. Therefore I have developed what I do over time with trial and error and talking with others as my guide.

    I have made almost every type of orthosis over the years from neck to toes and used many, many materials to do so. I stopped banging my head looking for a perfect way quite a while ago and realized that perfection in the outcome is in the eyes of the user and not me. I am not the one wearing these appliances I design and make ...they are. So while I might see a perfect gait post fit I must still accomodate the patient and thier comfort in using what I have given them. Some people just do not tolerate what we do sometimes. That's just the way it is. There has to be a mix of compassion in there.
  18. Orthican

    Orthican Active Member

    I will take a picture to post here..... Then I should ask how we post our pics..:eek:

    There is a discussion on feiss line here:

    I use this for planus/valgus feet that are flexible and correctible where there is a medially deviated STJ .

    Works very well for tib post dysf. as well.

    But again it is only a way I have found that works for me for these patients and it is not to be thought of as a "technique" or anything definitive ...always am I a work in progress....
  19. drsha

    drsha Banned

  20. Orthican

    Orthican Active Member

  21. drsha

    drsha Banned

  22. Orthican

    Orthican Active Member

    I very much appreciate your input DRSha.

    I have given this some thought. You most certainly would I hope for obvious reasons have much more surgical experience than I in that I have none and rightfully so.

    My interpersonal jargon with you here was meant as such and I believe also now after review outlines the communication problem I may have with you or others here. It was noted on some other threads regarding relationships between orthotists and podiatrists and a sort of conclusion was that it was shall we just say "orthotists think different" ....and I will tell you they are not the same as a podiatrist. Not even close from what I am reading.

    I was taught at a period in my program before the current system we now have in place there. So My descriptions of what I "see" are just that. What is noted externally at examination. What is noted with ROM. What is noted with sensation. What is noted with load. What is noted with gait. What I propose to do about it based on the available information and the materials I have at my disposal. That was how I learned at that time. It gets habit forming to be sure, and confusing as hell when it came to the foot. Other areas are simplistic in comparison. But I think where perhaps I am falling down here is that I can say what is seen from an epirical point of view, but I have no access to even a simple x ray.... I have few "objectives" to go on to really find out everything I sometimes would very desperately want. If I suspect it is OA I am at best guessing based on a set of symptoms that present "like" OA. I could request the MD have one ordered but would have to wait as long as he thought it was worthwhile as I am not what would be considered priority. That is how it is set up where I am.

    So I have the subjective from the patient in what they "feel", I have the subjective examination I perform, and I have the Rx from the MD...sometimes...Have I told you yet that in Canada we are to work from a script given by one of the specialties? That is how my work here is driven. It is driven by the script because a diagnosis is supposed to be provided. So if they happen to show up with one we at least have "an Rx". And they are always quite descriptive when it comes to feet....other areas of the body? sure... but feet?...."foot pain" or "heel pain" or "treat as deemed needed" . Now who's diagnosing? Much of what I do (and trust me I do test to see if the valgus in a heel is flexible or not) is based on what was taught and what I have learned over time. I have taken courses, and talked to colleagues, but trial and error are also a part of learning.

    My educational experience was to bring me so far where feet were concerned and to show focus on a whole host of areas in a short period of time. We had to digest a lot fairly quickly and the focus obviously was both clinical and technical prosthetic application and orthotic application. In school you learn both in two years. You specialize after for two years and then write exams. That's how it was done when I went. I'm most certainly not making any excuses for it because it was one of the best times of my life. If I had had the opportunity to focus study on only the foot and ankle and everything about it in those four years we would be or shall I say I would be on better ground to discuss things according to the way you describe things. The specialist in that arena is the DPM. This is lost on none of us. I think this is why the communication of an orthotist will not be the same as the podiatrist. Or at least this is what I see the problem as from my point of view.

    So for guys and gals like me who want to do better we do so on our free time. We have to ...days are spent doing other things than feet. I do one heck of a lot of knees...You have been afforded the opportunity to really specialize in feet and lower extremity over many many years. It shows...it shows in all of you. This too sort of helps you over me a fair bit don't you think? I understand this. And yet in a lot of ways I think we are speaking the same language regarding feet but do not realize it. I am trying, and by taking part here I am determined in making sure to read and learn more from all. I am implementing things I read here and sharing what I am learning.

  23. Orthican

    Orthican Active Member

    I like how I go from bieng "wise sir" to useless in one thread...Maybe I should not have been so honest. But for me to learn more about what is considered "the latest and best information" that can take me from my rootian upbringing to where I need to go and where I need to be... that means bieng straightforward and accepting of where I am and what I need to do.

    I'm feeling "old school" about now...
  24. Todd I enjoy you contribution so far - there is a lot of bi-play involved here.

    I would suggest that if you want "the latest and best information" the arena can help with that and be a fun place ( mostly)

    as an example or 2 if I may these are the threads that I started which are my FavĀ“s and have some great info ideas and discussion, which not all sides agree with and no bi-play.

    Leg Stiffness

    Midtarsal Joint Equilibrium Theory

    ps lots of articles in the threads for further reading.

    Stick around Todd :drinks
  25. RobinP

    RobinP Well-Known Member

    Ditto - don't let this experience ruin your view of the arena. Lots to gain from hanging around here

  26. blinda

    blinda MVP

  27. Orthican

    Orthican Active Member

    Your ecouragement is most welcome. I will be seen by the mods as "here" sometimes but not posting things...why?...because...downloading and reading...downloading and reading...

    And I'll tell you what...so far it seems we are speaking of similar things but I just need to get up to snuff. Thankyou very much Mike for the links to those discussions. Very very helpful and very nice to know that what i have been doing and thinking all along was actually on the same path but needed to be re organized in my head..Does that make sense? I need to be up to speed with HOW one thinks of these things. Although I must admit that Simon is waaaay over my head but he is so interesting to read. I have catching up to do.
  28. drsha

    drsha Banned


    My only advice is that you, Orthocan, hold onto what brought you here and modify and upgrade your thoughts without selling them out cheaply. All of us deal with the bias and bullying of the orthodoxy here at The Arena in order to stay around as Mike suggested. Only a few, like myself have the stamina and perserverence to voice opposition.

    Biomechanics is a wonderful blended science with a bell curve of practitioners and ways to skin the cat.

    The Arena is the place to learn about tissue stress, ORFing and the need to keep striving for valid and applicable research but even those have their limitations and problems.

    I think it is less valuable when it comes to new paradigms, DPM practice, morphology-position biomechanics, kinesiology and anything that is not in their Biomechanical Fundamentaliam.


    PS: I believe your ST Bolster to be a wonderful tool for many to have to have in their tool box but The Arena will never acknowledge or promote that as they will never promote any utterance of mine.
  29. Todd:

    I think you will find that the vast majority of individuals that frequent Podiatry Arena are very open to new ideas, as long as they aren't attached to a product being sold by the individual suggesting these new ideas.

    I like your attitude and hope you aren't discouraged from your interaction with some of the individuals here. If you have any questions which you feel are rather basic, I would suggest you ask them since you will probably be helping the learning of not only yourself, but also of many other lurkers here on Podiatry Arena who didn't have the courage to ask the question.:drinks
  30. Been there Todd enjoy the journey :D
  31. drsha

    drsha Banned

    See what I mean Orthocam:

    Dr. Kirby chimes in with one of his dictums that he has etched into these threads guarded by him and the Bullies of The Arena that you have already and will again be confronted by.

    He is so obvious in his pedjudice, personal agenda and arrogance yet he thinks he's stealth enough to hide under the radar screen.

    What's wrong with having an idea attached to a product? I ask you all.

    Those who invented Mercedes
    Those who invented Boeing
    Solar Panels
    Those who invented and invent Safety Equipment

    all attached to products. Imagine if we eliminated their thoguth and ideas.

    I don't understand why men/women and their products cannot be open to fair review on The Arena instead of blackballing them instantly?

    Last edited: Sep 30, 2011
  32. RobinP

    RobinP Well-Known Member

    Pardon my ignornace here but I can believe that there were people called Boeing and Mercedes who attached their names to products, but is there someone called Safety Equipment who gave his name to ....safety equipment.

    What would his first names be?

    Ian Dustrail

  33. LoL. Personally, I'm considering changing my name to Keith Vaccine. Either that, or Dennis Shovelsomesh!t.
  34. RobinP

    RobinP Well-Known Member

    Did you like what I did with the Ian Dustrail thing....I was laughing myself when I wrote that one
  35. Frankly, no. T'went over my head until you pointed it out :eek: cause I ain't that clever.;) Anyway, if you laugh at your own jokes it just shows how narcissistic you are. You see how clever I was spelling narcissistic all on my own? Have a good one Robin, England vs Scotchland tomorrow- early doors in crappy weather, me thinks.:drinks

    As a request, can we actually have some live world cup rugby at drink O'clock please. If (laugh) England do find their way to the final, it would be nice to get on a session at such an hour when you wouldn't start to label yourself as an alcoholic. "Six O'clock in the morning, you're the last to hear the warning, been trying to throw your arms around the world"... I'm thinking the solution is to stay out all night- Oh to be in my 20's again.:empathy::drinks:empathy:
  36. RobinP

    RobinP Well-Known Member

    Will Scotland beat England by huit points? Unlikely but being Scottish, one lives in a constant state of optimism about such things. Care to wager a pint (to be redeemed in Belgium - if the BFL lets me go)?
  37. Tell you tomorrow at about 11.00 am
  38. blinda

    blinda MVP

  39. RobinP

    RobinP Well-Known Member

    It is cockney rhyming slang. Bag for life.....wife

    I forget that not everyone uses rogers profanisaurus and ridiculous abbreviations to communicate on a daily basis. Sorry.

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