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Trail Shoes and a patient with functional hallux limitus and chronic peroneal injury

Discussion in 'General Issues and Discussion Forum' started by Leah Claydon, Oct 18, 2012.

  1. Leah Claydon

    Leah Claydon Active Member

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    I would be interested in anyone's thoughts on the following case history:

    42 year old female (medical doctor)
    55kg (122 lbs)
    Keen trail runner with no previous history of injury
    Med History:
    1. Autosomal dominant polycystic kidney disease taking anti-hypertensives
    2. Asthmatic mild but needs daily corticosteroid and salbutomol as required
    3. Benign joint hypermobility - markedly hypermobile

    RCSP: Left STJ neutral, hallux dorsiflexion normal.
    Right mild STJ pronation, unable to dorsiflex hallux.
    Right leg measures 1 cm shorter than left from 3 reference points. Appears to be from shorter femur, there were no obvious upper body compensations
    All joint ranges were excessive (BJHMS) except for functional hallux limitus in right

    Treadmill observations - noticeable rearfoot pronation at heel strike on right plus heel adduction prior to toe off consistent with low gear propulsion compensation for FHL. Left foot to human eye appeared neutral.

    RSScan confirmed pronation on right throughout gait cycle and extreme loading on hallux. Left foot revealed forefoot supination consistent with limblength discrepancy compensation.

    History of injury

    10 months ago trail running sharp inversion of right ankle
    She states she often "goes over on her right ankle"
    There was little pain at time and she carried on running
    Next morning there was acute pain along the lateral border of her foot and extending to under the arch.
    There was not any noticeable swelling but there was pain along course of peroneal tendons from distal third of leg.
    As a doctor, she self diagnosed a peroneus longus strain.

    The pain would not go away and after a while the she began to get pain in her tibialis posterior tendon. This then became worse than the original pain.
    She also experiences "tingling sensations" in the tips of her toes which can now occur in both feet. She now occasionally gets pain along the lateral borders of both feet.

    She visited a local Professor Rheumatologist who runs a clinic for top athletes that utilises physiotherapists, sports scientists and a noteable podiatrist.

    She received 6 weeks of physiotherapy - which only consisted of ultrasound (!)
    A MRI revealed an accessory ossicle near the post tib tendon that the Prof believed was causative in the pain. This resulted in the performance of ultrasound guided corticosteroid injection - this made the condition worse.

    She was then referred to their podiatrist who made orthoses: rigid polyprop shell with 1st met cut outs, 6 degree half medial rearfoot varus posts plus 6mm kirby skive, deep heel cup, extreme arch height and cut out 5th metatarsals. These orthoses were extremely uncomfortable, made her lateral foot & ankle pain worse and cause extreme tension on ATFL which began to hurt. Both orthosis were the same and did not allow for differences in foot dynamic mechanics.

    She sustained the injury whilst wearing Saucony trail shoes (sorry don't know exact model) but they have a rigid midfoot and very little dorsal bend. I have not seen her run in these. She recently purchased some Salomon trail shoes which whilst equally rigid had more cushioning on the innersock - we observed her running on a treadmill barefoot and then in the trail shoes. We were very shocked to see that the trail shoes dramatically worsened the pronation on the right foot. I can only imagine that super soft innersole allowed her STJ to pronate 'in to' the shoe and the combination of a rigid midsole then created the need for further compensation for the FHL. Also after just 3 minutes of running in these shoes she started the toe tingling and lateral border pain (both feet).

    I realise that trail shoes are often designed for transverse plane stability but could the forefoot stiffness actually contribute to creating greater STJ pronation?

    This patient needs a trail shoe type sole for grip but probably needs more a more flexible mid sole - I've suggested a Brookes Cascadia 7 which I think will achieve this but if anyone has a better suggestion I'd be very grateful for ideas. She's bringing some in for a treadmill test next week.

    We have embarked on a proper rehab program of balance, strength, cross-fric massage and trigger point plus have redesigned an orthosis that incorporates some rearfoot varus control, 1st met cutouts and forefoot valgus posting. We are also going to test for cuboid syndrome next week.

    If anyone has any thoughts or suggestions I'd be very happy to hear from you.

    Leah :dizzy:
  2. N.Knight

    N.Knight Active Member

    Re: Trail Shoes and a patient with functional funct hallux limitus and chronic peroneal injury

    The tib post pain, where about is the pain in relation its's the tendon/muscle?

    Did the tib post pain start post inversion injury? How often are the inversion injuries is the LLD playing a part?

    Is the pain only on running?

    I am thinking if the Tib post pain is insertional is it a spring ligament injury from the inversion injury, which is aggravated by compensation for the peroneal injury?

    Orthoses I would have done what have, if they fails I would try extending the length of the lateral forefoot post. I agree on checking the cubiod and muscle strength

  3. Leah Claydon

    Leah Claydon Active Member

    Re: Trail Shoes and a patient with functional funct hallux limitus and chronic peroneal injury

    Thanks Nick.

    The pain in tib post started about 2 months after the inversion injury, so I think this is more to do with the fact that tib post is the antagonist to peroneus longus and so perhaps became aggravated after the peroneal strain.

    The pain in tib post tendon is not as far as distal attachment but is sub medial malleolus and extends approx 15 cms proximal from the medial malleolus.

    I am certain the LLD is playing a part in the inversion injuries - she is slightly unusual though because in stance she weight bears more on the longer limb. She also pronates on the shorter limb and supinates on left longer limb (Right Short Leg cerebral lateralisation).

    She is pronating on the right shorter leg and has FHL on that side but shows an obvious heel adduction. If she is in low gear propulsion the with heel adduction if she hits an camber sloping away from her midline she will have the potential to go into hyper inversion and strain her peroneals ..... thinking aloud here, hope I am making sense.

    Thanks for tip on longer lateral forefoot post.

    Anyone got any ideas about why a stiff trail shoe would create worsening STJ pronation and increased heel adduction. If a stiff midsole is designed for motion control why should it make the patient worse. I can only think that it has something to do with compensation for FHL.

    Any pearls of wisdom on this will be appreciated.

  4. Ian Linane

    Ian Linane Well-Known Member

    Re: Trail Shoes and a patient with functional funct hallux limitus and chronic peroneal injury

    Hi Leah

    Commenting on the trainers is outside my knowledge. In addition there are those here who might have BMX insight to offer. What catches my attention are:

    "10 months ago trail running sharp inversion of right ankle
    She states she often "goes over on her right ankle""
    the arising of Tibialis Posterior and neurological symptoms

    I find myself treating a number of lateral ankle issues post inversion injury and have occasionally found tib post issues can arise much later than an original inversion injury, yet can benefit from a revisit/treatment of the original injury.

    It is the combination of the initial incident and repeated incidents that leads me to comment as follows.

    One contributing reason for the symptoms might be the existence of what Mulligan hypothesises as a "positional fault" within a joint.

    If this is the case then, for me, the combined use of the following in a revisit to a case of prolonged symptoms has contributed to recovery:

    1 Mobilisation with movement (MWM's) to the inferior fibular head (this automatically
    includes active motion of the talus within the TCJ. ( a further addition to this might
    be a MWM posterior/anterior draw of the low leg over the talus using a belt but I would
    do the fibular one first)

    Maitland or Coneely mobs to the superior fib head
    Maitland cephalad/caudad mobilisation of the fibular (often neglected)

    2 Neuro-mobilisation assessment and treatment to address patterned pain symptoms.
    This may be something you can do or perhaps your physiotherapist is trained in it.

    It seems that you have some of the soft tissue stuff covered. Hope this can help.
  5. Lorcan

    Lorcan Active Member

    Re: Trail Shoes and a patient with functional funct hallux limitus and chronic peroneal injury

    Have you considered the option that the inversion injury would result in hypertonic peroneals and trigger points. This would by reciprocal inhibition cause weakening of the Tib post which would therefore be unable to resist the pronation as before.

    Also could the LLD be due to similar muscle imbalance rotating/twisting the pelvis. I was a course last week with a presenting pt with hams issues and a LLD of 1cm+ which were due to tight adductors on one side which when released with MET removed the LLD.

    Good luck.
  6. Leah Claydon

    Leah Claydon Active Member

    Dear Lorcan and Ian

    Thank you both very much for the useful and constructive posts.

    We shall be seeing the patient this week and shall look into the fibular MWMs suggested - yes, we can do these though I think I shall leave it our physio to do this as he does more of this than I do.

    As for the trigger points - yes found several severe trigger points in tib post which post treatment brought about instantaneous relief. I shall check with the physio to see if he found similar in the peroneals. I don't think we found them to be hypertonic. Her BJHMS is quite marked - she's 'uber bendy'! In spite of the LLD - there did not appear to be any pelvic or upper body rotation. We shall check again though as per you kind suggestions.

    Still musing on why a stiff trail shoe would cause increased pronation - I can only think that the rigid sole further blocked 1st ray function which caused the windlass mechanism to fail. Any ideas anyone?


  7. Griff

    Griff Moderator

    Hi Leah

    In this scenario we cannot be entirely sure that the kinematic differences you saw were as a result of the stiffness of the shoe midsole. All we can confidently state is that the magnitudes of external pronation moments seen when running whilst wearing this shoe were greater than when running barefoot. Is there anything about the design features of the shoe which may suggest to you why this would be? For example, does it have a wide bulky heel? Does the heel have a lateral flare?

  8. RobinP

    RobinP Well-Known Member

    What Ian said on the kinematics. I wouldn't be too bothered about how much pronation there is but more concerned about the timing. Is there any static lateral deviation of the subtalar joint axis. If so, then it could be active pronation to protect the lateral ankle ligaments.

    I have found this to be quite common in the "shorter limb"

    In addition, in someone who had a previously benign os navicularis that flared up 2 months after a nasty inversion injury, I would be extremely suspicious that the ossicle has been damaged in some way (high velocity/high force compression) hence the flare up of the PT tendon if it has fibres of the tib post that insert into it.

    High arched/rigid devices that go anywhere near the ossicle have a tendency to make this considerably worse. I like to use the Robert Isaacs "high and soft" approach for this. However, if there is peroneal overusage, you will have to factor in at what point in the gait cycle the peroneals are being overused and modify the forefoot posting/footwear as required.

    Having said that, I can't see the patient but your good clinical presentation gives plenty of info for members to give suggestions, any or all of which could be very successful


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