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Pes Cavus with hypermobility

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brandon Maggen, May 28, 2009.

  1. Brandon Maggen

    Brandon Maggen Active Member


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    Hi all

    Any thoughts regarding this interesting patient would be most appreciated;

    62 year old female, overweight patient, referred by Neurologist following a follow up from spinal fusion (L3/L4). She complians of pain down her legs from behind and in her hips and was diagnosed with Sciatica. There was no comment on any hip investigation or findings yet. The neuro has put her on tegratol and triptiline and has asked for a biomech exam. Findings as follows;

    Bilateral Pes Cavus with hypermobility! Especially at the STJ. Her feet show atypical (for Pes Cavus) callus formations of central PMA and medial hallux, bilat.
    Gait analysis showed adduction left and abduction right with pronation. The left has a semirigid first ray. She complains of no symptoms in her feet. Hip range of motion is limited and painful on passive and active request. Knees similarly but less so.
    Her legs go through much torsion during ambulation and hip pain can be differentially diagnosed, clinically as degerative due to gait abnormality.

    Besides hip and knee xrays, any suggestions as to the type of orthotics to be used here. I could make gait plates to achieve abduction in her left and adduction in her right, but I also want to palliate the impact on her knees and hip, and correct torsional forces through her tib and femur.

    Thanks in advance for any advice

    Regards

    Brandon Maggen
     
  2. JMD

    JMD Member

    Is there a limitation of ankle joint dorsiflexion? If so this will have to be taken into account when prescribing orthotics
     
  3. leesan

    leesan Welcome New Poster

    Looks to me like there's leg length discrepancy with shorter left leg in this patient.
     
  4. MelbPod

    MelbPod Active Member

    I agree with leesan. Rule out LLD first
     
  5. Sydpod63

    Sydpod63 Welcome New Poster

    sounds like the rigid first ray may be creating a blockage in sagittal plane motion - possibly explaining why there is medial hallux callousing (from a medial D1 toe-off). Have you looked at her tibial torsion? Perhaps that will explain why she is intoeing on the left and out toeing on the right. Are the hip ranges of motion symmetrical i.e. is internal limited more than external on left and right or are there differences (usually these ROM's are compensations for underlying osseous torsions).
    I dont usually use gait plates after people have finished growing unless there is a neurological problem (e.g. UMN lesion). I would be checking limb length via CT scanogram if you suspect it and perhaps blocking MPJ ROM if it is painful and severely limited.
     
  6. Griff

    Griff Moderator

    Hi Leesan,

    Just wondered how you came to this conclusion with the given information?

    Thanks

    Ian
     
  7. leesan

    leesan Welcome New Poster

    When there's a difference bet the rt n left foot as in this case - toe-in left foot (likely supinated) and toe-out right (pronated) - I think LLD. Usually the supinated foot belongs to the shorter leg and the pronated, the longer. The presence of sciatical symptoms is a clue. Best wishes.
     
  8. Griff

    Griff Moderator

    Leesan,

    We've had similar conversations many times on this forum and I think its now generally accepted that in the case of a structural LLD it can be either foot which is in a more pronated position, and not just the longer leg as we were historically led to believe. The most common compensation seen on a longer leg is an increase in knee flexion.

    See here for more

    Ian
     

  9. Leesan:

    Limb length discrepancy would be very low on my differential diagnosis list for causes of asymmetrical angle of gait. In addition, many times the longer leg is more supinated than the shorter leg, contrary to popular podiatric myth. I find that very few angle of gait asymmetries are caused by limb length discrepancy, contrary to your suggestion.
     
  10. Brandon Maggen

    Brandon Maggen Active Member

    Hi All

    Thank you for the replies.

    Initially there was thought to be a LLD which was ruled out by the Neuro.
    On follow-up however I checked, measuring from the ASIS to the plantar medial aspect of heel. I did this 5 times and found indeed a LLD R < L by 2cm.

    Since the neuro had initially ruled LLD out, I called him to discuss my findings and his method of clinical measurement.
    He was a bit surprised (perhaps because he missed it or measured incorrectly or both) and I suggested if he feels it necessary, to order a radiological investigation.

    In the mean time, I am making her gait plates for each foot, taking into account each foots' requirments and adding a 1cm heel raise to the R.
    I will follow her up and assess and modify regularly.
    I am most keen to see how this will affect (positively) her sciatica and hip pain.

    Thanks all, again.

    Regards

    Brandon
     
  11. pgcarter

    pgcarter Well-Known Member

    It seems to me that you have not actually delineated, diagnosed and defined the mechanism of the problem yet, but have already decided how to treat it?....can you explain what you are thinking?
    regards Phill
     
  12. Sinex

    Sinex Member

    Could you please further explain this?
    I'm used to believe in this myth, without being dogmatic, of the "shorter leg = supination / longer leg = pronation". When i read your comment i tried to figure out how the real mechanism should be.
    Tonight i came out with this idea: if the longer limb presses more on the ground, than a greater grf reaches the foot of that limb, generating a higher dorsiflection moment on the foot around the ankle and a higher moment pronating the stj. Thus the foot reacts by
    Eccentricaly contracting it's plantarflexor and supinator muscles, resulting in a more supinated foot. On controlateral limb, foot is "loosing" ground support so that lower grf is generated and less calf and supinator muscles moment is needed. So the foot rises and pronates. I am wrong isn't it?
    And for greater discrepancies? Like 2 centimeters or more? I think in this case the old myth is still valid because shorter limb foot eventually doesn't touch the ground and needs a greater calf contraction....
    Please help me :D
     
  13. efuller

    efuller MVP


    Only true when standing in angle and base of gait with the pelvis level. How often does that happen? In gait, the short leg falls farther so shouldn't the forces be higher on the shorter leg? ;) But, the body has to accelerate upward more over the longer stance limb. ;) You can only go so far with arm chair biomechanics.

    Depending on where ground reaction force is, you may get a plantar flexion moment. So, even if there was a greater amount of ground reactive force, it would not necessarily create more plantar flexion moment.

    If you are "walking" both feet will always touch the ground. If your leg was really really short, you might resort to hopping.

    Eric
     
  14. Sinex

    Sinex Member

    Thank you for your answer dr. Fuller.
    It seems to me that i was lacking reasoning on a dynamic point of view. Still i can't understand why the longer limb should lead the ipsilateral foot to supinate as expressed by dr. Kirby and not vice versa. Think i miss something. ..
     
  15. efuller

    efuller MVP

    I believe what he was saying was that the long limb does not correlate with either more pronation or supination. I agree with that. Sometimes the long leg will have a greater pronation moment from the ground and other times the shorter leg will have a greater pronation moment from the ground.

    Eric
     
  16. Sinex

    Sinex Member

    :santa2:thank you again:D
     
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