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Orthoses appropriate for hip deficiency?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by psturdy, Mar 28, 2011.

  1. psturdy

    psturdy Member

    Members do not see these Ads. Sign Up.
    I am seeking some advice from someone with more bio-mechanical experience than I have...
    A 63 year old lady came to see me with pain in LF mpj and met heads. Bunions stage 3 in BF.
    h/mille met heads BF and small amount of callus build up on med edge of hallux BF. Reasonable arch in evidence. Static weigh tbearing to be forefoot valgus but more so RF. In gait this forefoot valgus is more pronounced AND limp. Has no pronation phase in gait so rotates on forefoot before toe off . No apparent leg length discrepancy.
    Then she tells me that as a 20 year old she had three operations for eventual successful removal of tumour in right hip joint leaving her with a very mal functiolning hip (and no gluteus medius??)
    Has had no advice AT ALL with regard to this problem and has just accepted all these years that she is lucky to be able to walk at all.
    However, wants rid of mpj pain.
    FINALLY - question:- what would any of you out there suggest to help?

  2. RobinP

    RobinP Well-Known Member

    I must confess that I am not sure of the problem here. Is it the pain in the mpj? If so, what is causing the pain? Other than potentially contributing to the potential biomechanicsl problem, is there any pain in the hips?

    Give us a diagnosis or an objective with some more exanination detail amd we will try to help
  3. psturdy

    psturdy Member

    No, she has no pain from the hips at all and has never had - the problem appears to be that she has developed the bunions because of her gait, which is clearly very fixed. Despite everything, she is stable on her feet. My first instincts are to provide relatively accommodating orthoses, with arch supports to give the mpj some leverage and met pads to open up the dropped anterior arch to relieve the feeling of cramping she is getting in the metatarsals. Don't think there should be much rearfoot control, though. Does this make sense to you?

  4. What is this anterior arch you talk of ?

    Also how does bone cramp?

    Start again, what and where is the pain ?

    Stay simple in your discription of symptoms.
  5. David Smith

    David Smith Well-Known Member


    If you could answer these more clearly then we might be able to help you.

    Regards Dave Smith
  6. psturdy

    psturdy Member

    She has pain in the bunion on left foot and radiaitng across the foot to the lateral edge
    H/mille on the 2/3/4th met heads
    Callus build up medial to the body centre line
    Longtitudinal arch both non and weightbearing is in evidence
    When standing, turns both feet outwards at front, the right foot more so than the left but feet are in contact with ground
    The limp is not due to pain - it is due to the hip dysfunction
    The STJ is not completely rigid but less flexible than it should be
    It's as if her arch doesn't give at all so she is almost missing out that phase due to whatever is being dictated by the hip
    So the result of years of this is the bunion deformity and associated discomfort
    I hope this makes it a little clearer - thank you for your help!
  7. Lizzy1so

    Lizzy1so Active Member

    It sounds as if you could do with a second opinion. Why not refer you patient to a collegue with more biomechanical experience and tag along, you might find it useful for the future.
  8. Sound advice Lizzy. I agree
  9. David Smith

    David Smith Well-Known Member


    Your'e probably wondering "why people are recommending me to refer on instead of answering my questions"? They are politely saying that you are not communicating anything useful and this tends to indicate that you do not have the knowledge to do this. This may or may not be a correct assumption but your communication skills leads one to make it.

    What your'e trying to do is a difficult thing. I don't mean fixing your patient, I mean communicating medical and technical data in a precise, useful and understandable way in the written word and by this medium.

    Prof Kevin Kirby, many years ago, metaphorically took me aside and told me, perhaps taught me would a better description, on a number of occasions, about precise communication. He said write, think about it, rewrite and think about it again. Think about how your words are communicating your ideas to a huge number of people who can only interpret your meaning through your written word. You can't point to the bit that hurts, no one can see the expression on your face or hold your patients foot in their hand.
    Your terminology needs to be precise and universal or acutely descriptive (like the bunion you mention, you still don't say if it is 1st mpj with HAV or 5th MPJ with DQV you probably mean 1st mpj but we must guess and might be wrong and when you say bunion do you mean adventitious bursa or an exostosis? I would guess the former, but some people mean any lump on the 1st mpj! and this is just a bunion description:eek:)
    Getting your precise meaning down on the page takes a lot of practice but it is well worth it as eventually your posts will be better answered and more respected. This was excellent advice for me years ago and will still be great advice for you, which is why I pass it on as Kevin Kirby did, keeping it to myself would not only be selfish but diminishing and weakening to the whole forum in the future. (not unlike other words that I pass on in another subject that is not so well received:rolleyes:)

    Being precise means you must check up on your terminology and assess the accuracy of your descriptive terms, check if what you think you know is really correct or was it just a persisting assumption. Does that word you just used really convey the meaning you had in mind, or is it just good enough (that's lazy) get the thesaurus out (online) see if there is a better word.

    It takes time but practice makes it easier and quicker. In this process you will increase your knowledge of any subject you post on and greatly improve your communication of it. Its a marvellous process and I thank God that He gave Kevin the will to put me straight early on. I truly believe that small (but potentially huge) lesson (that could appear to be a rebuke but rebuke given and received with a good heart is an opportunity to change) allowed me to grow exponentially in academic terms. So please don't take this the wrong way, I didn't just spend and hour and 15mins writing this just to have a cheap shot at you.:boxing:

    Precise Communication is the key to successful exchange of ideas, and when its ideas only communicated through the written word then they must be extremely precise.

    Regards Dave
  10. Well said Dave -

    Heres a thread on Presenting Patients for Clinical Advice which may help.

    On the other Subject maybe one day over a beer or 3 we can sit down and converse face to face. I would enjoy that :drinks
  11. David Smith

    David Smith Well-Known Member

    Now that would be something!

  12. footdrcb

    footdrcb Active Member

    sometimes we think too much .....the other comments on the forum were great ..but you have a great insight...
    well done

  13. RobinP

    RobinP Well-Known Member

    This was one of the best threads I ever read. My first case presentation on Podiatry arena took me 2 hours 30 mins to compose because I followed the advice Dave is giving you. However, having done it, I was given advice and guidance by some of the best names in biomechanics and I was able to diagnose a really tough patient and offer effective treatment.

    As time moves on and you read more on here, you will find that you need to ask for less help.

    Good luck

  14. psturdy

    psturdy Member

    Thanks, Dave - I was actually trying to write my descriptions more simply (as suggested) for you to envisage the situation but have clearly manifested an amateurish approach that has not gone down very well with those of you who are evidently more familiar and comfortable with all the technical language. Never mind, I appreciate the time you've taken to respond to my questions and shall heed your good words. Unfortunately, I will be very much more hesitant to seek advice this way in the future for fear of this reaction, despite you not meaning to shoot me down and not wanting me to take it the wrong way.
  15. Lizzy1so

    Lizzy1so Active Member

    sorry to hear that Psturdy. Its hard to ask for advice, you did the right thing even if you did'nt get the answers you wanted. Don't give up posting. No one knows it all, everyone has their field of expertise (or not - I am a very routine podiatrist) the problem with biomechanics , IMO, is that it unless you spend alot of time learning and practising it you will inevitably need to ask someone something sometime. Good luck with your patient, take the advice above and you will be on the right track.
  16. psturdy

    psturdy Member

    Thank you, Lizzy1so for your encouragement! Has given me a little boost at the end of a pretty tough week! PSturdy
  17. fronny

    fronny Active Member

    I think you should be commended for attempting the grasp the nettle here, so don't give up yet! Might be worth contacting Algeos/Interpod and asking if they have any copies left of Craig Payne's biomechanics DVD. Very clear and relevant - highly recommended!
  18. psturdy

    psturdy Member

    Thank you, too, Fronny - when the instincts tell you something but the knowledge or experience is compromised, constructive comments are a great help! PSturdy

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