Troubling Issue

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Hi, all. This is my first post to this forum so if I get something wrong, please forgive me. I'm hoping this is the right section in which to post my issue.

A little bit about me. I received my pedorthics training (105 hours) through the Robert M. Palmer Institute of Biomechanics about 4 years ago. For the past 4 years I have been employed by Dr. Kevin Hearon, a chiropractor here in Boise Idaho. Dr. Hearon is an extremities practitioner, and his protocols were incorporated into a post-graduate educational curriculum for chiropractors, and they are certified as "CCEPs" (Certified Chiropractic Extremities Practitioner) through the Council on Extremities Adjusting. Long story short, I feel that I have received an abundance of knowledge through the practice of pedorthics and by working closely with Dr. Hearon.

Now, here's the issue we have been dealing with, I hope that some of the great minds here can help. A male patient came to us complaining of bilateral shin pain that is atypical. I say "atypical" because his symptoms do not correlate with medial tibial stress syndrome (shin splints). He had seen two other doctors. One diagnosed him with posterior tibial tendonitis and put both his legs in casts for 6 weeks. After the casts came off he felt the same. The second doc told him that he had post tib tendon dysfunction, and told him that he'd have to "live with it."

Well, the first thing that we did was to make a pair of biomechanical orthotics for him, and told him to ice it, take it easy, and gave him the usual advice for adaptation to his orthotics. But yet, while the orthotics helped a little, he is still complaining of this pain. So then we moved him to a form of electronic stimulation called "ARP" (Accelerated Recovery Performance - http://arpwave.com) to see if that would help. We've been doing that once a day for the past 15 days. Results are confusing at best - sometimes it looks like he's improving, other times he's back to where he was, or worse.

Now, everything that I see points to post tib tendon dysfunction. However, he defies they typical ortho tests. ROM is fine, he can stand on his toes and hold it just fine. In short, his PTT is strong. Inflammation is not visibly apparent, and icing doesn't seem to help anyway.

So I am personally at a loss to figure out what's going on with this guy. I'm hoping for some good feedback from you folks. Have you ever had a case like this, or have you ever seen a situation like this? What has worked for you?


Beau B. Avery

 

some more details on the clinical presentation and findings might kick start things on here

 

A bit more in the way of history might help as well. Age? activities? onset? Past medical?

 

If it is indeed shin splints, try using removal crest pads under the sulci from toes 2-5. It was not explianed well at a AAPSM seminar I attended many, many years ago when I was still a resident in beautiful Scottsdale, AZ, but one of the case report on this ailment discussed that when the speaker used crest pads it relieve the shin splints completely. I said removal such as the ones you can order from Pedifix, etc so that you can see if it would help or not. If it does help then you can incorporate it somehow into the orthotic devices. Like I said, the speaker did not know himself why it helped in his cases but my theory is that perhaps there is this proprioceptive component that relieves the excessive pull of the tendon (the German physicians make a big deal aboout proprioception and foot biomechanics all the time and how to implement them into orthotic fabrication)! It wouldn't hurt to try it and much luck to you. Oh and the seminar was iin Scottdales; not my residency training.

Dr Brooks

 

Thanks. I'll see if I can put this case in the right format.

Just FYI on how I treated him his last visit, though. To his foot orthotics I added a 3 degree medial post and added a little more posting the arch. I'm having try Z-Coils with the strongest aspect of the coil to the medial side. Hopefulyl the impact reduction and extra posting will help.

 

Maybe consider compartment syndrome?!

 

I agree Graham-
I would also like to know more clinical history and what the previous diagnoses were based on. eg: why is it atypical?