I would be interested in anyone's thoughts on the following case history:
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42 year old female (medical doctor)
55kg (122 lbs)
Keen trail runner with no previous history of injury
Med History:
- Autosomal dominant polycystic kidney disease taking anti-hypertensives
- Asthmatic mild but needs daily corticosteroid and salbutomol as required
- 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:
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