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Pes Cavus and Hypermobile?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by rhetoric66, Apr 9, 2010.

  1. rhetoric66

    rhetoric66 Member


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    Hi all,

    I was hoping for a bit of help with a recent case; apologies in advance as I only saw this pt for 15 mins and may be unable to answer all your questions.

    Pt is female, aged 17, and plays tennis to a reasonably high standard.
    She began experiencing "hip pain" approx. 6 weeks ago and attended a local physio for an opinion; I have no information or working diagnosis, and the pt had no idea what his findings were only that he felt sure that the problem was with the foot translating proximally. Pt indicated to me that pain was experienced in the abdominal region superior to the hip, bilaterally. Pt states that the pain as subsided since.
    I have been unable to reach the Physio at this time.

    O/e distal sensation and deep tendon reflexes were intact, and no atrophy noted in peroneals or post. leg muscles, muscular strength unremarkable (leg muscles only). Pt had a pes cavus foot type with FF equinus and PF 1st rays, ankle ROM restricted to neutral, and a pronounced genu recurvatum. Further investigation revealed a hypermobile state.

    I still have to complete the assessment next week but this case has been playing on my mind a bit over the last few days. I have seen plenty of hypermobility cases, but all have been accompanied by flexible flat foot deformities. I am however relatively inexperienced in biomechanics and would welcome any opinions and will try to answer any questions you might have.

    I intend to treat the foot type, and check the strength of the quads (which I expect to be weak) and roll out some strengthening/lengthening and core stability work. Can anyone recommend gait retraining in such cases? I did eye ball a very brief gait which fits that proposed by a paper I found (Genu Recurvatum: Identification of Three Distrinct Mechanical Profiles); specifically the External Rotary Deformity Recurvatum.

    Thanks in advance,
    Scott.
    :D
     
  2. Hi Scott

    When you say I intend to treat the foot type what do you mean by that ?

    I would think that once the tissue which has been overstressed has been identified we look for the mechancial cause of the pathology and then treat according to that.

    so if the FF equinus is the cause a heel lift maybe the treatment required to reduce the patient symptoms- there maybe many but you get the idea.

    As for the combination of cavoid and flexiable foot type I see them all the time and they can be intersting to treat.

    Notsure that helps I hope it does - but good luck
     
  3. Here the full text of the paper Scott quotes ( I hope, same name) For those who want a read.
     

    Attached Files:

  4. Griff

    Griff Moderator

    Hi Scott,

    I'm in agreement with Mike - before you do anything you need a diagnosis. (Or at the very least a list of differential diagnoses). You say this patient has pain superior to the hip in the abdominal region - and then say you are going to 'treat the foot type'. You need to be clear on your rationale for doing this and the mechanism by which you think it will benefit the patient.

    On the one hand you refer to yourself as being relatively inexperienced with biomechanics, and then on the other you say you are going to 'roll out some core stability work'. Do you know what this patient requires? If they need to be put on a programme of bent knee fall outs and side lying turn outs are you confident you can teach them how to execute these with perfect technique? It seems to me you may be better off liaising with the physio and leaving the proximal stuff to them.

    Perhaps you could tell us more about the patients 'hypermobile state'. Do they have ligamentous laxity (as er the Beighton Scale for example) or was it simply a reduced dorsiflexion stiffness of certain joints? (this being the preferred term now instead of 'hypermobility').

    Ian
     
  5. efuller

    efuller MVP

    Did you get any sense as to what "the foot translating proximally" means. Is that the genu recruvatum. If this is what the the patient told you that the physio said, I'd say we can ignore it.

    To understand biomechanics you have to start with the terminology. I'm not what you mean by a forefoot equinus. Some feet keep the high arch when loaded and other feet signiicantly reduce arch height when loaded. From your description I'm imagining a foot that assumes a cavus attitude non weight bearing and then when the forefoot is loaded you get an average or lower than arch height. Although I don't really like the terminology, I've heard this described as a flexible cavus. Is this what you saw? (With this foot you will often see diffuse callus on the met heads.)

    I can see how limited ankle dorsiflexion can cause a recruvatum. There are other causes.

    Does the patient have any foot complaints or is it just the abdominal pain?


    Regards,
    Eric
     
  6. rhetoric66

    rhetoric66 Member

    Hi all,

    Sorry for the delay in getting back to you, I’ve just returned from a short holiday.

    I’m afraid I won’t see the pt again until the end of the week, and although I have contacted the referring practitioner (seems it’s not a physio, more some hybrid remedial massage/joint manipulation technique) I am still no clearer…..lots of slang terms about “stripping down” and “unstable foundations” (which I think relate to the foot), although there was mention of tight hamstrings and sciatic pain tossed in too.

    Anyway, I take your point Mike, I don’t make a habit of treating the foot as a matter of course, but in this case the presenting symptoms appear to have resolved.
    However, there is perhaps the potential to improve efficiency of gait, muscular strength, posture, and overall performance by treating the things I have already noted. I will of course finish my assessment first.

    I am also aware Ian that the ‘preferred term’ is ‘reduced dorsiflexion stiffness’, although I don’t prefer it, and have had no trouble to date making myself understood using the term ‘hypermobile state’; and yes I am referring to ligamentous laxity which was indeed assessed in part using the beightons scale. I do take your point about the core stability work, and although I do have a fair bit of experience in this area, I do usually go next door to my sports physio colleague.

    Eric, I think the forefoot equinus descriptor has prompted debate before; there is a recent thread on arena (which incidentally both Ian and Mike have contributed to) which discusses the various applications of the term ‘equinus’.
    The Pt does have reduced ankle dorsiflexion but the equinus I refer to is evident when the level of the met heads is lower than the calc in the transverse plane, common in cavus foot types – I have an old article (“Thinking Straight (Ahead)” by Howard Dananberg relating to sagittal plane facilitation theory which describes it.

    What I was really hoping for when I posted the thread was some ideas about how these cases come about, it seems to me that a hypermobile state….sorry, state of reduced dorsiflexion stiffness (not sure that mouthful will catch on you know!)…and a rigid, pes cavus foot type represent a bit of a paradox??
    Also, what about gait re-training in these circumstances, presuming for now that there is a proximal weakness? This is certainly a weakness in my practice, can anyone help?? I’ll post more once I follow up and hopefully provide all the information required.

    Thanks for all your comments so far,
    Scott. :D
     
  7. efuller

    efuller MVP

    Is that with the forefoot loaded or unloaded. There is also some potential for circular reasoning in the definition. What is the position of the ankle when you assess whether or not the met heads are below the calcaneus in the transverse plane. Can you define that position of the ankle without using the metatarsal heads? That was my point about not really knowing what a forefoot equinus is.


    I don't think I can really comment how these cases come about, because I don't feel that it has been described well enough. Is there a normal arch height in stance and a high arch non weight bearing?

    There is a plausible mechanical explanation for why you usually see increased midfoot rigidity with higher arches. However, you do not always see more rigid with higher arches. I call the higher arch more rigid effect the joist effect. A 2" x 8" piece of wood is much more rigid when you stand on the 2" side as compared when you stand on the 8" side. It has to do with the distance between the part(s) under tension from the part(s) udner compression. So, everything being equal a higher arched foot will be more rigid than a lower arched foot.

    Things are not always equal. Compare two feet with same height non weight bearing. One of those feet could be at the end of range of motion of dorsiflexion of the forefoot on the rearfoot and the other could be in the middle of that range of motion. I'd define end or range of motion as the point at which the plantar ligaments become taught. This point could also be thought of as the point where there is a dramatic change in stiffness as the forefoot is moved from a maximally plantar flexed position to a more dorsiflexed position. Even though these feet have the same arch height non weight bearing they will have different arch heights weight bearing.

    Compare two feet that have the same arch height in static bipedal stance. One has a calcaneo-cuboid with an "s" shaped another has a flat joint. The part of the calcaneus in the "s" shaped joint" foot that overhangs the cuboid can provide additional forces to prevent dorsiflexion of the forefoot on the rearfoot when compared to the foot with the flat c-c joint.

    Another thing that can cause feet to appear different in gait even though they have the same arch height in static stance is the position of the joints when the arch height is assessed. For example, you could have one foot standing in its maximally pronated STJ position. Another foot could be 5 degrees away from maximal pornation of the STJ. In gait, the foot that has range of motion available could pronate to it's end of range of motion and lower its arch height.

    Those are some possible explanations of why you could have a cavus foot that has a low amount of stiffness.

    Regards,
    Eric
     
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