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Pes anserinus bursitis and foot function

Discussion in 'Biomechanics, Sports and Foot orthoses' started by domcl, Mar 10, 2011.

  1. domcl

    domcl Member

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    I'm trying to understand the relationship between forefoot striking and pes anserinus bursitis, in order to reduce the bursa irritation.

    Medial knee bursitis is often caused by a too flexible forefoot and late stage forefoot pronation.

    However in stead of adding a varus wedge and continue heel striking, would forefoot striking not reduce forefoot pronation, hence calm down the bursitis?

    Thanks for your advise.

  2. cpoc103

    cpoc103 Active Member

    Dominique, my understanding/ dealings of medial knee bursitis, is usually a result of an imbalance from quads more notably the VMO.
    When you say add a varus wedge forefoot I'm assuming the Pt/ client has a forefoot varus??if not you can create more of an issue, most forefoot issues arise from the rearfoot and midfoot collapsing too much, and rotational position of the STJ, so to decrease the moments and strain at the medial knee I would look more at these structures.

  3. Craig Payne

    Craig Payne Moderator

    Why does pes anserinus bursitis have to be due to problems with foot function?
  4. domcl

    domcl Member

    Thanks gents.

    Medial knee problems are closely associated with arch collapse and excessive pronation, espe-
    cially in sports participants, who experience greater tibia rotational forces.

    I'm trying to understand if midfoot/forefoot striking would put less stress on the pes anserinus bursitis, compared with heel striking.
  5. Craig Payne

    Craig Payne Moderator

    Actually they not. Every single study (and there is over a dozen of them now), except one cross-sectional study, have found no relationship between foot pronation/arch collapse and knee pain.

    You might want to read these threads:
    Foot pronation and knee pain
    Does the tibia drive the foot or does the foot drive the tibia?
  6. 90% of the patients I treat with pes anserinus bursitis respond very quickly to treatment with varus heel and medial arch wedges and/or custom foot orthoses. Nearly all of the patients I have seen with pes anserinus bursitis are women over the age of 50. I think pes anserinus is caused, to some extent, by excessive foot pronation since it responds so well to varus heel and arch wedges.
  7. domcl

    domcl Member

    Thanks gents.

    Despite all studies my practical experience is that knee bursitis is related to foot mechanics. Orthotics/varus wedge, or even a neutral running shoe with stable midfoot and stiff forefoot have often a direct effect.

    Based on all comments it looks like midfoot/forefoot striking have no/little effect on knee bursitis.
  8. Craig Payne

    Craig Payne Moderator

    I NEVER said foot orthotics do not work in helping knee problems; all I said is that evidence clearly does not support the model that we used to base it on; ie foot pronation --> tibial rotation --> knee problems. We need another model to explain why foot orthotics work at the knee. The evidence is being used to "beat up" on the use of foot orthotics in knee pain and we can't ignore what is being said about it. Ignoring the data won't make it go away and won't stop the criticisms and cynicism.

    The model of foot orthoses reducing the rearfoot inversion moment (rather than chanege alginment), so the proximal motor control can do its job at the knee is one that is consistent with all the data.
  9. My bet is that if you designed a study where you took a varus heel and medial longitudinal arch pad of sufficient size and placed it under the feet of patients with pes anserinus bursitis, that at least 75% of them would have some relief of their symptoms. It really doesn't matter what the foot posture is and foot motion is in these patients before the pad is placed underneath the foot. What does matter is the change in kinetics and change in kinematics that has occurred because of this varus heel and arch wedge. Therefore, unless the study takes the changes in knee kinetics ane knee kinematics that have occurred as a result of the varus heel/arch wedge into account, the study will be worthless for confirming what I, and many other podiatrists, have observed numerous times in the treatment of patients with pes anserinus bursitis.

    In other words, if you are relying solely on studies that measure how pronated the foot is (e.g. foot posture index, RCSP, medial arch height), and see if this correlates to pes anserinus bursitis, then you won't find a correlation. In addition, if you are relying on studies that look at "knee pain", then that is very similar to relying on studies that look at "foot pain", this is a futile exercise in generality.

    Pes anserinus bursitis is a very specific diagnosis and responds quite differently to in-shoe arch/heel wedging to many other types of knee pain. Therefore, pes anserinus bursitis should not be lumped in with other types of "knee pain" such as ITB syndrome, patellar tendinitis, medial and lateral compartment knee OA, popliteal tendinitis, medial collateral ligament strain, plica syndrome, tibial plateau stress reaction, internal derangements of the knee, etc. We must be specific in our discussions on these topics when we make statements like "Every single study (and there is over a dozen of them now), except one cross-sectional study, have found no relationship between foot pronation/arch collapse and knee pain."

    In addition, both distal effects on the foot (e.g. from varus wedges or foot orthoses) and proximal effects on the knee (e.g. from hip joint muscles) alter the internal and external rotational moments of the knee. Therefore, both proximal and distal contributions at the knee affect the moments and can mechanically affect a change at relieving pain and improving function. I don't see how other researchers misinterpreting research on what they call "foot orthoses" on their effects on knee kinematics and knee kinetics is our fault or our problem. This is especially true when one hears world-renowned lecturers and authors calling simple varus heel wedges or arch cookies or over-the-counter arch supports "foot orthoses" and then saying that because these wedges, cookies, OTC supports didn't cause a change, then that means that "foot orthoses don't work". In other words, we need to place some of the blame on many of these researchers for not being knowledgeable enough about the profound mechanical differences between different orthosis designs and specific enough in their criteria as to what constitutes a "foot orthosis" since, if we don't do this as a profession, then who will?!:craig:
  10. domcl

    domcl Member

    Thanks Kevin for your great help and feedback! Appreciated.

    Do foot orthoses need to be specifically made/adapted to treat PAB? Does PAB respond better to a specific design (besides varus heel and arch support)?

    My experience is that choosing the right neutral running shoe supporting the orthoses is equally important.
  11. Depending on the history of the client, I agree with craig. I see some of my middle distance and sprinting clients with Pes anserinus bursitis. Some of these athletes seem to be more prone when introduce into speed work, and coaches have noted an overstriding where the foot strike is forward of the CoM. So the extension angle of the knee increases, however the flexion angle of the hip remains similar from tempo to speed work. So these athletes responded to a 'awareness' drills being incorporated into their warm up, of increasing hip flexion in an attempt to decrease an 'overstriding' pattern as such!
    But in short, if the client is getting these symptoms from running based activities such as pes anserinus bursitis or even those developing proximal tib/fib joint/biceps femoris issues, sometimes it wouldn't hurt to look at the sagittal plane mechanics?
  12. domcl

    domcl Member

    Excellent feedback.

    Is there a risk to ''over" correct the problem by making orthotics with a too high varus heel and too strong arch support?

    In other works will running on the outside of the foot make the bursitis worse?
  13. efuller

    efuller MVP

    Forefoot striking will increase pronation moment from the ground with all but the most laterally positioned STJ axes. When you heel strike, the center of pressure of ground reaction force is very close to the STJ axis and hence you have a small pronation moment. When you strike on the forefoot, the center of pressure will be much farther from the STJ axis (with average and medially positioned axes) and will create a much larger pronation moment at the STJ.

    You can still pronate the STJ with forces applied to the forefoot.

  14. domcl

    domcl Member

    Is there a risk to ''over" correct the problem by making orthotics with a too high varus heel and too strong arch support?

    In other works will running on the outside of the foot make the bursitis worse?
  15. drsha

    drsha Banned

    Perhaps the problem here is the way we are looking at foot mechanics.

    If our orthotics work and we don't know why and there is no EBM that is coming out to differ with that perhaps it is time to inspect the current platform for diagnosing and treating biomechanical pathology because SALRE and TS are not providing the necessary answers.

    Forefoot contacting is certainly one possibility. Why not?

    In your experience, do patients have their pathology or weakness or collapse in the rearfoot, the forefoot or both when it comes to The Vault of The Foot when it is looked at as a keystone in the pedal truss system?

    In my experience, most of my patients with superstructure problems have more forefoot need for care than rearfoot. This means that by research focused on rearfoot focused biomechanics will not provide EBM for how our orthotics work, just that they do. The dozed or more fruitless studies that Dr. Payne alludes to prove this point for me. I don;t need three or ten more.

    At what point in this entire issue do the good posters here on this thread and The Arena in general hypothesize that it is their unnecessary focus on the STJ Axis in many cases that is at fault and needs upgrading and revisiting.

    I on the other hand think that from a general perspective, when looking at all feet without subgrouping them into types, it becomes totally opinionated and without EBM to state that underlying forefoot pathology is not often the culprit.

    In those cases, rearfoot varus wedges, even if they work (and we don;t know why), IMHO, incite new compensations that would produce new pathological tissue stresses and eventual new breakdown, such as medial knee pains that would then require rearfoot valgus wedges according to the Arena biased EBM and it might be better to treat the forefoot primarily.

    Perhaps treatment aimed at the primary location which as you properly state is in the forefoot, would lead to less compensation and better EBM? I say perhaps!

    Try forefoot vaulting technique, a 2-5 varus extrinsic forefoot leveraging post and an aggressive 1st ray cutout with a 0 or 1 degree Rearfoot Varus Post in these cases and see what you get clinically and when researched.


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