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Pronation, leg pain and hypermobile 1st ray

Discussion in 'General Issues and Discussion Forum' started by dingo, Jun 3, 2006.

  1. dingo

    dingo Member

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    I have a friend who has diabolical biomechanics and experiences chronic symptoms that I believe can be controlled by the use of appropriate orthotic therapy. As I am recently qualified I would appreciate advice regading my diagnosis and whether my choice of orthotic design would be appropriate.
    The person in question has broad feet that bilateral grade 2 HAV The feet are very flexible and the medial column is hypermobile. In the NCSP the feet are more or less vertical, however in the RCSP the fall into a position that is in excess of 10 degrees everted. The person experiences continuous knee pain, posteriomedial shin pain and pain radiating behind and below the medial maleolus, all of which I suspect are the result of the excessive pronation. As a result of the continuous pronation the foot has developed into a supinatus position and, if I am correct then according to Davis's law eventually the soft tissue structures within the foot will eventuallt tighten and shorten and the foot will assume a more rigid forefoot varus position. Therefore, as the repetetive inversion of the forefoot will eventually cause the foot to rigidly assume that position, if I am right, it would not be appropriate to use medial inverted forefoot posting to control the forefoot.
    Here is the point that I have been building up to. Even though the pronation is not the result of excessive motion at the STJ, the fact that the medial column offers no stability caused the STJ to pronate anyway. Therefore, is it appropriate to post the rearfoot into inversion and post the forefoot with 2-5 wedging to slightly evert these metatarsals and use a 1st ray cutout to try to encourage the 1st ray to plantar flex and hopefully over time become more competent as a weight bearing area of the foot. Advice would be really appreciated. Cheers.
  2. Kenva

    Kenva Active Member

    I would cast the foot with the hallux in dorsiflexion to invert the calcaneum and plantarflex the first ray.
    I would still add a MHS in the orthotic even though you have the pronation is not a result of excessive motion at the STJ.

  3. DaVinci

    DaVinci Well-Known Member

    I will get in first with this question: How did you determine the medial column was hypermobile?
  4. Craig Payne

    Craig Payne Moderator

    If this is correct, then what do you mean when you say this:
    Cast with the rearfoot vertical or inverted and first ray plantarflexed (as you load the lateral column with thumb, reach across foot with fingers to plantarflex first ray) --> cast will be very creased in arch area, but lab will smooth it out. Use plenty of mobilisation of medial column when orthoses issued, otherwise high risk they will take long time to adapt to.
  5. dingo

    dingo Member

    what I meant to say was that when in NCSP the calcaneum is more or less vertical and when relaxed it is in excess of 10 degrees everted.
    My thinking regarding the pronation not being the result of excessive motion at the STJ was that(please correct me if I am wrong) as a result of the hypermobility of the 1st ray, this would be the main reason that the foot was forced to pronate so far ,due to the fact that once the mid tarsal joint was unlocked and the forefoot was maximally inverted on the rearfoot, the rearfoot would naturally be forced into eversion due to the fact that no stability was being given by the medial column to control the degree to which the rearfoot pronates. Please help me to clarify.
  6. dingo

    dingo Member

    what do you mean when you say to use plenty of mobilisation when the orthoses are issued.
  7. Craig Payne

    Craig Payne Moderator

    If you cast out a supinatus, then there will be a very poor fit between the foot and orthoses initially --> uncomfortable orthoses. As the supinatus is a soft tissue contracture, it needs to be 'stretched' out --> mobilised/manipulated.

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