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Orthotics & rehab of pes planus, functional hallux limits & early heel lift

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Sarah Jane Walls, Jul 22, 2018.

  1. Sarah Jane Walls

    Sarah Jane Walls Welcome New Poster


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    Hi hope this is okay to ask for some help? I'm heading into 3rd year at GCU - with a great interest in MSK. My background is working as a manual therapist and I've taught comprehensive Pilates for 20 years. I do have a bias towards rehabilitation due to my background - orthotics and their use is still very new to me so I thought, you all with your years of clinical experience could help this student pod out.

    Today I was working with a client - she was seeing me for medial knee pain having been referred over from her physio - I'm a qualified manual sports therapist - so this is normal practise. However when working with her and I was doing her history she advised she was wearing custom made orthotics (had them 2 years)

    Other relevant information;
    Female
    38
    2 stone overweight
    2 knee operations - has no ACL
    No medical problems/no medication
    Active at gym 3 times per week
    Desk based job

    From my pilates and sports therapy background the assessments we would carry out for the feet would be limited to Posture assessment, joint ROM open chain, muscle strength, balance/proprioceptive and gait assessment. However with learning at university today I carried out with the clients permission some tools we have been taught at university.

    On assessment of her gait I could see her lifting both her heels early, an abductory twist was present on the left foot - and callus present under the 2nd/3rd met head of the left. It also looked like she was taking a low gear propulsion on the left. The left hallux was laterally deviating with the 2nd toe rotating under the hallux. (on left side only)

    Findings;
    I found her soleus was tight on both sides - thinking this might be linked to the early heel lift.
    Trendelenburg gait - indicating glutes may be weak (medius & minimus)
    No limitations in joint ROM on closed chain assessment - just the soleus.
    Standing posture pes planus - left side significantly more.
    Jacks test there was no arch lift or tibial rotation on the left and I did have to apply a significant force to lift the hallux to try and activate the windlass. Right side both arch lift and tibial rotation with less force needed to activate.
    Medial knee pain on both knees. Genu valgum on dynamic posture only not on static.
    Balance was poor


    The orthotics she is wearing look to be correcting pes planus . I assessed her standing with her orthotics underneath and found no change to the function of the left hallux or activation of windlass - this is however only static posture - so I appreciate the findings are limited.

    Question;

    My natural instincts are rehabilitation. Working on the intrinsics, balance, building propriocation, working on her foot, knee hip connection, gait re-training, building her strength and flexibility - that all just feels instinctively my go to. In terms or orthotics there is no structural reason this client can't rehab this, I don't understand why we would give her orthotics without rehab - am I missing something? From the orthotics side In my head I would be wanting to get her out of pain - so yes a corrective orthotics but with the view of it being temporary. I would love to hear from you all with more experience on this.

    The orthotics prescription I am thinking a pod would want to reduce the amount of force needed to activate windlass, get more dorsiflexion at hallux, medial arch support to help with giving the foot that ridged lever for propulsion. I'd possibly consider a heel rise temporarily until the soleus is stretched out to try and reduce the force onto the forefoot as early - with the early heel lift.

    I'm brain dumping here - hope this is okay. Am I on the right track? I would love to hear your ideas and thoughts and what you would all do.

    Most appreciated.

    Sarah Jane Walls (Student pod)
     
  2. DaVinci

    DaVinci Well-Known Member

    Based on the question, you seem to be on the right track!

    When you did the gait observation, was she wearing the foot orthotics? Were they actually making a difference?
     
  3. Sarah Jane Walls

    Sarah Jane Walls Welcome New Poster

    I observed her gait both barefoot, and with the orthotics in her trainers. No change in terms of heel lift, dynamic posture and she looked like she was still coming off on the lesser toes for propulsion - but definitely hard to see exactly. Hope this makes sense.
     
  4. Sarah:

    You have included a lot of information about this patient, but you haven't described if the patient's medial knee pain was bilateral, or on the right or left knee. Also, the medial knee includes many structures. Which structure is most tender or which medial knee structure do you feel is injured? This is very important. You need to know your knee anatomy and clinical tests for the knee if you are to best help this patient.

    Foot orthoses, if overcorrected in varus, can cause medial compartment pain in the knee. If, however, the patient has a medial collateral ligament strain or pes anserinus bursitis, extra varus wedging of the orthosis may cure her of the knee pain.

    The key to using Tissue Stress Theory to improve patient's symptoms is making an accurate diagnosis based on your understanding of anatomy, your history taking, your access to the patient's diagnostic tests, and your knowledge of foot and lower extremity biomechanics. Without knowing anything more than "medial knee pain" about the patient, it's very hard to help you....and your patient.

    Here is a thread I started nearly 10 years ago, especially aimed at newly-trained podiatrists, on how best to present patients to other clinicians for advice.

    http://podiatryarena.com/index.php?threads/presenting-patients-for-clinical-advice.22144/
     
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