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Tight everything

Discussion in 'Biomechanics, Sports and Foot orthoses' started by WillMo, Feb 23, 2018.

  1. WillMo

    WillMo Member

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    Hi all,

    Having some difficulty with a patient at the moment. He came in experience pain around the anterior margin of the ankle joint. He says it's OK after he's "warmed up" a bit, but then starts to cane when he cools down so to speak. He used to work in a warehouse, where at the end of a long day on his feet, he could "barely stand up". Interesting case, as he also has a Hx of clubfoot... Info:

    - 25yo
    - Ankle DF is -5 degrees on the left (doesn't even reach neutral, and o degrees on the right in NWBing. In a lunge to the wall test, his right foot is right up against the wall ie no distance recordable.
    - His MPJ only has 30 degrees ROM on (L) side, and 40 degrees ROM on the (R). He has very low 1st ray stiffness, so he has a great deal of FnHL (I'm able to get greater ROM when I manually PF the 1st ray, but it is still greatly restricted
    - Past Hx of a right achilles rupture (his achilles are basically a tight band)
    - He is also tight through his hamstring and his back
    - I sent him for x rays, which found some anterior impingement from dorsal talar beaking and tibial beaking on the right side, but they found NOTHING pathological on the left (he experiences pain on both sides.
    - So I think this patient has some degree of anterior ankle impingement, but some of the pathology may also be coming from his gross sagittal plane blockade...
    - My management so far has largely been set around trying to restore his ROM in AJ and 1st MPJ through mobilisation and stretching. I'm also trying to reduce the impingement through a heel lift and some KT tape to reduce dorsiflexion moments somewhat
    - Pain has improved so far, but he's been on holidays. Returns to work this week, which will be interesting to see how he goes....

    Does anyone have any ideas of what can be done here? His huge degree of equinus is worrying to me, and I wonder if a surgical option would be advised (perhaps an achilles tenotomy and possible clearing of osteophytic debris from the impingement). He is only 25yo so would rather not have an ankle fusion if it can be avoidable
  2. Craig Payne

    Craig Payne Moderator

    I would keep doing lots of manips and mobs ...
  3. footplant

    footplant Active Member

    Hi WillMo,

    Thanks for sharing this case. A few questions occur to me:

    1) Was the clubfoot bilateral or unilateral?
    2) Does he have any surgical history? - did he previously have a TA release or bony surgery related to the clubfoot?
    3) I believe dorsal talar beaking is often associated with tarsal coalition. Is there any possibility that he has a coalition? No c-sign on the lateral view? What does the rear foot inversion/eversion feel like?

  4. WillMo

    WillMo Member

    Thanks for the questions Josh:

    1) He's actually unsure himself, but I would deem the clubfoot to be bilateral, as he has a hypotrophic navicular on both sides
    2) He is unsure as to whether he was casted up at birth. But he had a surgery on the left foot (the side with no talar beaking or impingement on x ray despite Symptoms) at the age of 2. He is unsure what type of surgery exactly, but it was definitely a bony surgery for his clubfoot. On x ray he still has a screw in his talus from this surgery
    3) I queried this on my x ray referral due to the patients age (mid 20s) and symptoms. I'm personally not able to see a C Sign on the x ray, and there was nothing to suggest it on the report. His foot inv/ev is normal. But I am still keeping tarsal coalition in the back of my mind due to his symptoms, and wonder if an MRI or CT scan might be a good option for further investigation

    Any thoughts/comments on this?


  5. WillMo

    WillMo Member

    Thanks Craig,

    I do intend to continue with mobs. But from my perspective, the issue is that even with all the mobs in the world, he is still going to be far below normal in sagittal plane ROM in all of his foot/ankle joints. But my theory is that if I can at least get a 10-15% improvement in ROM, it might be more 'liveable'.

    I'm also a bit dubious as to how far I can drag this out. I don't want him to have to come back just for mobs every 1/2 weeks if there's only a chance it will lead to improvement. I'm not entirely sure if this is a commonly done thing in cases like this, as I am but a poor newgrad!

  6. WillMo

    WillMo Member

    I should also add as well: I talked to one of the foot and ankle orthopaedic surgeons from my work after making this post - he saw the x rays too. This surgeon is of the opinion that there is little that could be done surgically at this age. A talonavicular fusion is unlikely to 'take', as his navicular is so hypotrophic, so he'd have to also fuse the cuneiforms. The surgeon suggested that it would be too extensive of a fusion to put on someone in his mid-20's, and should be reserved for a future option in 20-30 years time. The patient also stated to me that he would rather not have a fusion at this age, so I would agree there. The surgeon also told me that to reduce the dorsal beaking would require having to "open a lot of things up", and it would likely return in a matter of months to years.

    So he suggested I continue managing him conservatively with orthotics, possibly forefoot rockers, ongoing mobilisation and stretches.

    Would you be in agreeance here?

    Thanks again
  7. efuller

    efuller MVP

    The functional hallux limitus is a completely separate issue from his anterior ankle impingement. Yes, both of those things will cause sagittal plane blockade, but he hurts in the anterior ankle. Functional hallux limitus will not cause anterior ankle impingement. I'd focus on the anterior ankle pain.

    I have a little problem with your terminology. I also wonder if the KT tape is capable of what you are trying to do. If the pain is caused when his ankle joint is at maximum dorsiflexion (from the top of the talar neck hitting the anterior inferior aspect of the tibia) then something that created a plantar flexion moment at the ankle could reduce the compression forces on the talar neck. After writing that, your terminology is actually pretty good. You are trying to decrease the net dorsiflexion moment on the foot.

    In theory, KT tape running on top of the Achilles tendon could create an ankle plantar flexion moment. The amount of that moment would be the frictional force from the skin attachment x lever arm the tape has on the ankle joint. It's hard to imagine the frictional force of the tape being high enough to create significant moment without being so high that it caused pain on the skin.

    If there is a bony end of range of motion of the Ankle joint, Achilles tendon lengthening will not help.

    Dorsiflexion with knee flexed vs extended?
    In gait is there an early heel off or a very short stride for heigth.
    Is there genu recurvatum?

    Post club foot is not normal anatomy. Imaging of the foot at maximum dorsiflexion would be interesting.
  8. footplant

    footplant Active Member

    Hi Will,

    A rocker sole adaption might be worth trying. We often use these with ankle arthrodesis, placing the apex at the centre of the shoe (e.g. - http://journals.sagepub.com/doi/full/10.1177/0309364612474920). If footwear adaptions, heel raises and other approaches you've mentioned didn't work, and the pain is still a real problem, I might consider a custom AFO. A snugly fitting rigid AFO is a little bit like a temporary/removable ankle fusion. For patients with similar presentations I've found they can reduce pain, although obviously it's a larger device to wear.

    Hope it goes well, will be interested to hear about the outcome.



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