A 34 y/o white female stay-at-home mom with a dorsal pain on left foot for more than 18 months.
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Past medical history is unremarkable. Patient is overweight.
Gradual onset started with beginning of running on a treadmill. Has done 2 sets of physiotherapy with manual therapy, ultrasounds, strengthening in dorsiflexion and inversion without much improvement. Has less pain in high heels. Known for an accessory navicular in both feet.
Neurological: WNL
Dermatological:WNL
Vascular: PT and DP 2/4 BL.
Patient has low arch in decubitus. 5 degrees in ankle joint dorsiflexion knee extended going in abduction to get more dorsiflexion. STJ axis is medially deviated bilaterally in relaxed bipedal stance with mid-tarsal break in abduction. Forefoot varus less than 5 degrees bilaterally. Too many toes sign. No palpable edema. Maximum tenderness is following course of extensor tendon of 3nd and 4rd toes over the metatarsal base and proximal stopping and the ankle joint on the left foot. No pain in resisted toes dorsiflexion. Pain in passive inversion with plantarflexion.Also pain palpable around the navicular BL. Pain in bipodal
Slight pronation in contact phase, then midstance pronation, a moderately early heel off with and abductory twist. Angle gait is in abduction.
Pes plano-valgus caused by accessory navicular bone.
Toe extensors tendinopathy left foot
Did orthotics with neutral casting in neutral posting forefoot with medial heel skive and a retrocapital pad. Also, recommended three times a day gastrocnemius stretching exercises.
The patient does not tolerate orthotics. It causes pain around the navicular and pain in the arches in the end of the day. Also begin to feel pain posterior heel. Patient feels better when adding heel lift 4mm and adding heel wedge in varus.
My question is how can I do better, the patient still has her initial pain but also has now new pain. What am I missing?
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