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Help with prescription orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bkelly11, May 7, 2008.

  1. bkelly11

    bkelly11 Active Member

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    fellow pods

    Young gentleman, 10 years old

    normal height and weight.

    presented with pain in Both ankles, specific to post tib pulse area, after cross country running at school and after participating in most activities. Pain is described as dull ache and relieved by rest.

    MLA no elongation on weight bearing
    No eversion calc RCS
    No eversion STJ in chair
    F/F to R/F relationship STJ neutral=F/F valgus P/F 1st ray

    Gait-very hard on heels particuarly when running
    early heel lift and abductory twist

    T/t stretcting exersizes for gastroc's
    5mmpcp heel pad for shock attenuation

    presented today with reduction in symptoms VAS 7- to 4

    Was thinking of EVA shell STJ neutral cast intrinsic F/F lateral wedge???

    Not 100% sure, any help is much appreciated

  2. CraigT

    CraigT Well-Known Member

    Just a couple of things...
    Consider what are you actually treating. Do you have at least a theoretical diagnosis?
    This is important when you think about an orthotic prescription.
    From your information, you may be thinking Sever's or perhaps Tib Post irritation?
    Ok... then you can look at his mechanics and decide how this may be effecting his problem. If in doubt, use taping and padding as a trial. Remember that the orthotic is not the treatment, it is what you do with it that is the treatment.
    Do you think that the PF first ray is significant? Does he have a positive Jack's test? You may need to decrease the load on the 1st MTPJ via some rearfoot control- difficult to know with limited info, and not seeing the foot itself...
    Quite possible this is no help at all...
  3. bkelly11

    bkelly11 Active Member

    Thanks for the reply Craig.

    Diagnosis = Uncompensated R/F Varus, compensation with P/F 1st ray foot type.

    No pain posterior aspect of the calcaneum, so severes is ruled out.

    never seen this before Craig.

    Patient Unstable standing on one foot and can stand on tip toes no problem albeit very unstable. Hops on one foot however, fatigues very quickly in the triceps surae. Pt claims "it's tight and really sore".

    Slight ankle equinus knee extended. more than 10 degrees in ankle flexion.

    Pain is really speific to the area as before.

    Finding this quite testing. I'm thinking medial R/F posting could increase the risk of inversion ankle sprains??.

    I have also emphasized the importance of good fitting footwear with a firm/rigid heel counter.


    Every day is a learning curve

  4. Kent

    Kent Active Member

    As Craig said, try to develop a diagnosis. This should involve specific anatomical tissue such as posterior tibialis tendinopathy.

    is not a diagnosis.

    If you know what specific tissue(s) is affected, the orthotic prescription is much easier.
  5. Adrian Misseri

    Adrian Misseri Active Member


    Sounds to be a bit of poost tib iritation as Craig pointed out, but we need a lot more information. Whats the quality and quatity of motion at the subtalar and midtarsal joints like? Also at promixmal 1st ray, at 1st MTPJ, is there a functional hallux limitus. The abductory twist quite often somes with a sagittal plane block so check that out. Also might be worth seeing where the longitudinal axis of the subtalar joint lies, is it medially deviated, whihc may increase reafoot pronation and put extra forces through tibilais posterior. Also look at lower limb position and function, i.e. check for excessive femoral anteversion with secondary excessive external tibial torsion which may increade pronatory moment throgh the foot if there is a significcant medial heel strike and may affect resupinatory power of tibilais posterior.

    Bear in mind though, that all of you assessments are of a 10 year old child, and the biomechanics can be quite different to that of an adult, depending on his stage of development. Essentially you need to work out what these biomechanical measurements/markers/signs are telling you about the effect they are having on the feet in the medial ankle area and what structures will be under strain and potentially damaged. Then you can look at reducting teh straining forces to promote healing.

    Good luck!
  6. kevin miller

    kevin miller Active Member

    All of the above is good. You also must take into acount the origin or the issue.....I would bet, cross country running. If that is the case, certainly FF varus posting is not sugetsted as it could reult in further FF damage and stress FX. How does he run? What is the quality? You may very well get your diagnosis from watching him run and doing a thorough gait analysis.

    Good luck,
    Kevin Miller
  7. bkelly11

    bkelly11 Active Member

    Thanks for the reply's

    took on board all advice and I'll let you Know how I get on.
  8. Brian:

    First of all, you should be able to determine which anatomical structure is symptomatic in the "post tib pulse area" of the medial ankle in order to give your patient the best treatment. This is critical to you becoming a more effective clinician. Palpation, muscle testing and a detailed knowledge of foot and lower extremity anatomy are key!

    Assuming it is a posterior tibial tendon injury in your 10 year old runner (the most likely diagnosis), then this is easily resolved with 3 mm heel lifts, varus heel wedging and medial longitudinal arch support. I would not use a forefoot valgus wedge but would use a slight forefoot varus wedge to decrease the subtalar joint pronation moment during running. A forefoot valgus wedge would tend to cause more pronation in running. Forget about "establishing the windlass" for running injuries.

    Have the patient ice the ankles 20 minutes daily, replace any neutral or worn out running shoes, avoid barefoot running and either make him a custom orthosis or modify an over-the-counter orthosis as per my ideas above to give him more permanent relief of his pain. This type of treatment works in 95% of cases.
  9. bkelly11

    bkelly11 Active Member

    Thanks for the reply Kevin.

    My head was in a pickle with this boy.

    And i take on board about being more effective as a clinician.

    I will be back on to let you know how i get on.
  10. kevin miller

    kevin miller Active Member

    You are welcome, kind sir. :drinks
  11. bkelly11

    bkelly11 Active Member


    New footwear = No pain

    New job, new location, so no follow up guys

    Thanks for the advice
    Last edited: Jun 25, 2008

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