Knee pain after using orthoses for achilles problem

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Have recently dispensed an athlete a apir of soft cad cam orthoses with bilateral 4mm heel raises. These were for treatment of Achilles tendonopathy. The patient responded well to copelands style taping and had previously worn orthoses for this conditiion. Biomechanically he has bilateral flexible pes planus. He weighs over a hundred kilograms. resupination and jacks force tests require a lot of force to achieve any outcome, as you would expect with a flat foot and 100+Kg!
the patient has had major symptom relief in his achilles 2 weeks after dispense. However he is now getting left knee pain medially and in the patella tendon. He has also had a mild hamstring strain. I am not convinced that hamstring strain is related but I thought I would throw that in for the sake of completeness.
I am thinking that The orthoses may be slightly over controlling( I haven't actually seen him again yet, only spoken on the phone) any help or advice is appreciated.
cheers

 

knee

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its probably not possible for

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sorry when I say soft orthoses I mean they are an EVA density of about 300.
It is certainly not due to them being not controlling enough as I have tested his jacks force, resupination and lunge tests on his new orthoses, old orthoses and with no orthoses. The results were graded as you would like to see in new orthoses with barefoot being the worst, old orthoses slightly better and new ones were much better.

 

Maybe he needs his pronatory collapse in order to compensate for something not yet picked up? Maybe the 300D EVA devices are too full under foot, these things can be about as forgiving as golf balls when shape is not correct. Maybe the more sudden stop has resulted in higher med knee compression forces, shorter stopping distance, shorter stopping time means elevated peak force. .....just thinking out loud for you
Regards Phill Carter

 

And how about the geometry of the patellofemoral joints?
Perhaps they are perfectly aligned (congruent) when the foot is allowed to assume it's uncorrected position, but move into misalignment once the foot has been corrected.

Fitting orthoses is not a precsie science. Sometimes you have to apply a bit of SI and C (suck it and see).
Regards,
davidh

 

I meant to add...don't confuse EVA orthoses with soft....underfoot they can be far more rigid than polypro or other so called rigid devices...depending on how they are made/shaped.

 

I think that you will find that if you reduce or remove the heel lifts that the knee pain will likely resolve. I'm not exactly sure of the mechanism but I have seen this repeatedly in my 20+ years of practice.

 

I agree with reducing the heel lifts because the midtarsal joint could actually be pronating more to compensate for this "equinus". I would also wonder if the midtarsal joint is trying to pronate over the orthosis, but since it is prevented from doing so, that the first ray would dorsiflex more, which would lead to functional hallux limitus, and other associated "nasties" from the altered weightbearing pattern. Have you tried stretching? And if so how did the patient respond to this?

 

If any my patients have medial knee pain as a result of wearing orthoses then i would would maybe remove the heel raises but i would also consider reducing some of the control as it sounds as though you may have over corrected with too much posting

chris