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Pain when standing still only

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Alank, Jul 24, 2009.

  1. Alank

    Alank Member

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    A 43 yo otherwise very healthy, athletic male was seen complaining of pain in his arches when standing more than 10 minutes. He is fine when walking, running - as long as he is moving. When he stands there is pain to the point where he must sit down. He came in with three pair of orthotics (2 semi rigid and one accommodative, all well fitted) from other podiatrists that do not help and indeed make his pain worse. Biomechanically he has a modest forefoot varus bilaterally and no leg length discrepancy. No joint pain elsewhere. He does calf stretches regularly and is not tight there. He appears to be neurologically intact. He reports that he does have a positive marker for an autoimmune disease but does not know which test it was and the results are not available. In the absence of other symptoms I'm not sure that is relevant.

    Had I been the first to see him I would have made orthotics, accommodated the FF varus and given him calf stretching exercises. Given his history that would likely have failed. Any ideas?
  2. Sammo

    Sammo Active Member

    Can you tell us any more about the foot type, quality and RoM of the joints of the foot, exact location and type of pain (joint lines, muscle belly, bone, ligament, nerve?), duration of pain when resting? Photo's would be wonderful...


  3. Alank

    Alank Member

    He has a mildly rigid flatfoot. Adequate dorsiflexion - he does lots of stretching. But overall he has a somewhat stiff foot. Moderate FF varus (I don't find it useful to measure as I don't seem to get the same #'s twice). That is the most obvious thing looking at his foot ROM and relative joint positions There is relatively mild pain along the medial band of the plantar fascia when palpating. It is much more tender he reports after standing. The post. tib is nontender as is its insertion in the navicular. No leg length discrepancy. ROM is mildly diminished in STJ. Tine's sign neg. at the post. tib. nerve.
  4. Sammo

    Sammo Active Member

    It's just a thought but... If he has that slightly rigid foot with a good arch profile it could be the intrinsic muscles trying to dorsiflex the 1st ray to contact the floor.. How much rearfoot eversion does he have?? I have a patient who is a little similar. Arch pain resolved when the patient is walking and running since I got him in some good insoles, but standing he starts to get aching type pain that gets increasingly worse. Quite alot of pain along the abductor hallucis muscle belly and in the centre of the foot, no typical plantar fascia like symptoms.

    Problem is I'm not entirely sure how to treat my guy either (if (a) it is the same thing and (b) I'm not horribly wrong with my diagnosis). I am basing my treatment on the fact I believe it to be more of a muscle spasm or fatigue than a ligamentous strain. So... Looking at getting the patient to do some fairly deep type massage with something like a golf ball to work on a few of the trigger points I could find in his intrinsics and perhaps some intrinsic muscle exercises for the foot. I have no evidence for this treatment, and I only provided it monday so will see when the guy returns in a month..

    Hold on for the cavalry though, I'm sure that minds greater than mine will be along to help more with this shortly..
  5. Alan:

    I have a very similar patient to this and I have yet also to find a permanent solution for his pain, other than having him tape his foot. Try seeing if a low-dye strap will help reduce the strain on the plantar fascia and make his pain better. That has seemed to help my patient when he stands. How does your patient respond to NSAIDS? Maybe a course of oral prednisone may be in order to see if it changes anything?
  6. not sure if this will help but...

    is it possible to get him to stand in your office until the pain develops and then measure the level of dorsiflexion available. Also check if a forefoot equinus develops. Not sure if thats likely with the foot type you have described. I´m getting quite into FF equinus and questioning if it could be a aquired soft tissue change like a FF supinatus.

    So my though might be too far left field that when standing his soft tissue is working hard to stabilize the foot and changing the foot type, and developing a foot type with will then cause the symptoms you discribed.

    So if you think there is any merit in the idea I would suggest have the patient stand in you office with just a heel lift and see if there is any change with less pain and if so add a heel lift to the orthotic and continue with the stretching program. You may want to try just the heel lift if ás you say the orthotic seems to make the pain worse.

    Just some left of centre ideas that just might work ??
    Michael Weber
  7. Alank

    Alank Member

    A bilateral heel lift?
  8. definately.

    If you try it out let me know the results. I have a patient with similar problems and she wears a heeled shoe which means she can stand at a cocktails party painfree.

    Michael Weber
  9. CraigT

    CraigT Well-Known Member

    I have found that with 'non-typical' symptoms like these, myofascial trigger points are often the culprit. Targetting the Abd Hall belly and FHB muscle belly may be of value... as Sam described above, or by using dry needling.
  10. david3679

    david3679 Active Member

    I would start the ball rolling by isolating the indvivdual joint movements of this patients foot.
    secondly check that we dont have a situation were the intrinsic muscles aren't over working and if so follow craig's route of dry needling or accupressure.
    thirdly I would reduce the amount of calf stretches the guy is doing or be mechanically strict when he does his stretches. This may be antagonistic.
    four and has worked for similarly weird patients of mine when i have had trouble in resolving a problem. get them to try doing the exact opposite of their daily actions, I.E kneeling use the other knee to start off with. has worked suprising well. I have found in the past it silly things that patient doesn't see as relivant that courses the problem.:D

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