Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Sciatic nerve stress with reduced stj pronation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Apr 21, 2009.

  1. Members do not see these Ads. Sign Up.
    Hi all,
    This is my 1st post. Im an New Zealand trained, Australian reg Pod living in Sweden working and teaching at the new Pod school in Stockholm.

    I have a patient with classic Sciatic nerve symptoms, which with nerve mobilisation, muscle stretching and core strength training we have stabilised to where he can work and walk with a constant level of managerable pain. Great...

    BUT when I stabilse the subtalar joint using a modified low dye taping the pain returns and even gets worse, but if I dorsiflex the 1st ray the pain reduces and the best combination is low dye taping with a pad to dorsiflex the 1st ray.

    Any ideas why?

    Michael Weber
    BHsC (POD)
  2. what is the range of motion like in the hallux mentioned? is there rigidity?

    It may be that by dorsiflexing the 1st ray you are assisting the windlass mechanism and allowing the foot to propulse rather than the foot having to compensate by pronating (possibly causing the lower back and sciatic problems?).

    rather than trying to stabilise the subtalar joint have you tried a simple orthotic with a 1st ray cut out?
  3. Alex Adam

    Alex Adam Active Member

    Most Sciatic pain is associated with how the pelvis/hip complex compensates for the degree of transverse plain motion being produced in the gait cycle. If internal hip rotation is limited and there is higher than normal transverse plan motion being generated the piriformis and glemeli are over active producing spasm and inflammation where the sciatic nerve passes over them.
    If the peroneus longus tendon is not acting on the cuboid correctly then the potential degree of transverse motion at the subtalar joint can be high causing an impaction at the lower acetabulum of the hip this produces a proprioceptive response in the rotators as well as creating a fulcrum effect throwing the pelvis anteriorly and causing impingement at L4/5 S1.
    The treatment of using a first ray pad also indicates a possible supanatus or forefoot varus, both producing abduction of the forefoot around the oblique axis of the mid tarsal joint and adding to transverse plane motion.
    Once an accurate biomechanical is carried out if you do a suspension cast with the knee and hip in their appropriate plane and stand with your body parallel to the forefoot then balance the cast to perpendicular and correct forefoot to rear foot the device should then stabilize the pelvic region reducing the inflammatory effect on the sciatic.
    If supanatus is part of the reason then reassess after 12 months and there should be an improvement and then recast if necessary.
    Hope this throws a little light on the subject.
    Alex Adam
  4. drsha

    drsha Banned

    I agree completely with the prior advice but would like to add one other important thought.

    Why are you treating the feet? Is one more complaining than the other (assymettry), Is the low dye being applied unilateral?

    My point is that I believe that TIP is in play here and that you need to add to your prescription a lift to the FEJA Tested short side in order to stabilize the pelvis on the transvers plane.


  5. Atlas

    Atlas Well-Known Member

    Another example that the dogmatic recipe for podiatric success
    - plantar-flexing 1st rays
    - achilles stretching
    - buy a pair of good supporting shoes "brand name" etc. etc.

    doesn't always work.

    The other thing you probably haven't considered is the double crush, or distal extra-neural compromise effect of your low-dye taping. Otherwise a device with FF varus wedge should work.

    Physiotherapist (Masters) & Podiatrist
  6. Alex Adam

    Alex Adam Active Member

    The Coplan strapping may interest you then, based on Havlac's work in neutral control.
    If podiatrists continually only consider the foot then they will not understand the full skeletal system and while Physios only consider the soft tissue!!!!

    Let's face it we need the disciplines of all health professionals to help our patients.

    I feel your comment 'Another example that the dogmatic recipe for podiatric success'
    Doesn't help anyone
    We all need to work together, diagnosis of Pain can be hard enough taking into consideration every aspect of mental and physical pathology
    Alex Adam.
  7. Ron.
    Im not sure if you read the post. I stated that Nerve mobilisation, core strengthening etc had stabilised the pain. ie no foot focus.

    My question was why... If I dorsiflex the 1st ray does the pain reduce. If you have any ideas let me know.....
  8. stevewells

    stevewells Active Member

    eh? Hmmm - care to rethink that?
  9. Atlas

    Atlas Well-Known Member

    First and foremost, my post that you referred to was intended to compliment M Weber for his pragmatic, left-of-centre approach to podiatric care. I might be wrong, but I thought forefoot varus forces weren't the flavour of the decade in podiatry circles.

    The other thing is terms-of-reference. I don't beleive that any profession has a limited territory; and hence I am all for a wider terms-of-reference. If the podiatrist thinks he/she knows a bit about LBP, the SIJ/pelvis, and neurodynamics of the PNS, then good on them, and all the best to them and their patients.

    My concern is, tick the boxes that should be ticked first. Accordingly do the common things uncommonly well. Moreover, the podiatry profession (in general) struggles with ankle conditions. This should be the ordinary thing that podiatrists do extra-ordinary well.
    BTW, the physio approach of "peroneal strength in combination with core strength" is overrated rubbish as well.....as is core strength for every back pain presentation...but that is for another time and place.

    There is no sugar-coating the state of play here, and I'm sorry that "this doesnt' help anyone". Podiatry (new asics and achilles stretching) and physiotherapy (core-strength) as I've seen it in Melbourne is too recipe based and too predictable.

    I for one liked my medicine a bit sour. My first boss in the mid-90's cut through and labelled my physio clinical reasoning and treatment as "crap". He was right.

    As for your description of the pathogenesis of sciatic pain....
    ...it is theoretically plausible no doubt; but it is a big call to associate it with "most sciatic pain". Can I extrapolate from your theory that most sciatic pain would be helped signficantly with orthotic therapy?

    What about other causes of sciatic pain? What about compressive disc pathology? What about the (sometimes) centralising effect of McKenzie's extension that would actually accentuate the pathogenic "fulcrum affect" you referred to?

    In this "holistic" era, I realise that a huge emphasis has been placed on mental and physical factors in pain. But when a physical therapist goes on adnauseum about psychological issues, it invites the question, how well have you covered what you should have covered. For goodness sakes, I have been at uni allied-health for 2 undergraduate degrees and 1 post-graduate. This grounding (psych 101)no way gives me any confidence to opine on ones mental factors. My job, despite current holistic thinking, is to the the physical stuff sorted out. BTW, I have found that reducing someone's signs-n-symptoms usually helps reduce their mental-health issues...not vice versa.

    Finally, I applaud your highly theoretical, thorough, co-operative altruistic approach to health care...there is a place for it. I just question the numerous assumptions and adherence to complex theory.


    The other thing that hasn't been considered is the different biases of neuromenigeal tensioning in the lower limb. Tensioning/mobilising/facilitating sural, tibial and peroneal nerves all involve different ankle, subtalar and midfoot positions. I think Butler and Selvaratnam have written about this. Therefore there may be a place for pronation in some sciatic cases....and not just the dogmatic correction of navicular drop and drift.

    But as always..no recipies. Keep doing what works. Interesting discussion.

    Physiotherapist (Masters) & Podiatrist
    Last edited: Apr 24, 2009
  10. drsha

    drsha Banned

    Ron Stated:
    BTW, the physio approach of "peroneal strength in combination with core strength" is overrated rubbish as well.....as is core strength for every back pain presentation...but that is for another time and place.

    Dennis Replies:
    Your combined expertise is very impressive to me. But as I have no claim to great treatment expertise, I rely on the PT community to maximize what I can do podiatrically.

    I have developed unique relationships with PT's in my area for them to diagnose and rehab foot, postural and lower back complaints after dispensing Foot Centrings and about 2 months of my "diapers rehab and PT" that I do.

    Most of them have a background in dance and many of them state that their ability to train p.longus and what they call the "core intrinsics" are enhanced in these orthotics as they compare them to STJ Neutral Pod devices. As some level of EBM of this statement, they refer patients to me for Centrings when their care in these kinds of cases has not met expectations.

    My question as to your posting is: If p.longus and core strength is "rubbish", what should I be looking for them to do.
    (Maybe you could start a thread?)
    BTW: do you have a PT I can consult with in the NYC, USA area?
  11. Atlas

    Atlas Well-Known Member

    I will use a back analogy, which is easily applied to the ankle/foot.

    In the "good old days", your decent PT would classify what type of back pain was endured.

    It was either a compressive type pattern, which could be a "squashed disc" in lay terms. These backs hate weight-bearing; prefer decompressive bed rest etc. and perhaps therapeutic traction.

    There was the McKenzie back, which hated prolonged flexion activities like ascending from prolonged sitting. These prefered extension type activities like walking/standing.

    There was the spondylolisthesis or hyperlordotic back that likes flexion. Like sitting slouched. Hates standing at cocktail parties or walking or running.

    And I could go on and on and on.

    Why patients of the past had it so good, was that there were quite a few physical therapists that would actually CLASSIFY what type of back they were dealing with. To get to this classification conclusion, the subjective and objective assessment had to be A1. Once classified what type of backpain we have, then the appropriate specific treatment could be administered.

    If these old guys failed, they had no convenient excuses (compliance; psychological issues).

    Now we have the misconception of "modern medicine". Despite all the advances, the MRI diagnosis, the communication explosion, the internet, the evidence base, the research, the PhDs, the masters.............we are actually in the dark ages clinically. Why? Because suddenly back pain has ONE solution. If all back pain has one solution, why bother assessing at all. Don't need to because the end result is all the same. You just spurt out "your core is not strong enough" now these pilates exercises are going to make a man out of you".

    Back pain is suddenly "non specific". It is non-specific because it doesn't need to be specific because we have ONE SOLUTION. As a result we have lost a generation of thorough back pain assessment.

    Added to this we have all these predictable pathetic recommendations for back pain. "Don't rest, keep walking. Don't wear braces, they make you weak. Use ice first then heat". Dogmatic rubbish that will suit some back pain, but not all back pain.

    I could discuss the same mistakes and assumptions with lower-limb pathology...but not now.

    I have no idea about professionals outside of Melbourne Australia. But what I will recommend is this. Find a PT that can answer these questions about your back referral. "What sort of back pain is this person enduring? Why does he like/hate standing/sitting/walking/bed-rest? Why is this back pain different from the last person I sent you? And if its different, shouldn't we treat it differently?"

    And if the answer you get is full of research article citation....then just move on. You want pragmatic clinical reasoning not automated regurgitation.

    This back analogy is virtually mirrored by ankle pathology. Why is the post-op rehab consist largely of peroneal strength +/- core stability. What about the lunge discrepancy? What about the existence of impingement? Rehab is about restoration. But not only restoration of strength and control; it is about restoration of length; it is about restoration of end-feel.

    Good luck.:bash:

    Physiotherapist (Masters) & Podiatrist

Share This Page