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Which is the best orthotic treatment for bilateral fibular head pain??

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ivan M., Sep 21, 2011.

  1. Ivan M.

    Ivan M. Active Member

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    Hi all!

    Last day came to my office a young woman . She wants me to evaluate the link between hypotetical biomechanical disorders on her feet and chronic fibular head pain.
    Since many years she has played squash, and other sports, but nowadays she goes running 3-4 times/week.
    She refers that pain in the fibular head appeared many months ago. The ache is important during running and for that reason she must stop activity during several minutes.There are not problems on their feet. No pain on peroneal muscles.She also refers a tendence to twist their feet during walking , but there is no history of significant ankle sprains.

    The significative findings during physical evaluation are:

    -Biceps femoralis strain
    -Limited dorsiflexion of ankle. Gastrocnemius equinus.
    -HAV Stage II
    -First metatarsal plantaflexed.
    -Windlass test negative
    -Positive supination resistance test (there´s a great resistance to generate supination moments)
    -Maximally pronated feet
    -Moderate varus tibial
    -Rearfoot varus

    In your opinion , do you consider any foot orthosis treatment?? If it was yes, which would be the best modifications during positive cast. ?? Medial heel skive and invert the positive a few degrees???
    I´m very :confused:

    I would apreciatte if you help me a bit.

  2. Craig Payne

    Craig Payne Moderator

    Start by mobilising/manipulation the ditsal and proximal tib/fib joints.

    Then do some treatment direction tests (TDT's): eg
    1) get them to hop on one leg -- is it painful? Put on some low dye tape; get them to hop again --- is it painful?

    2) does the lunge test hurt? Medially wedge the heel, get them to do the lung test again; -- is it still as painful?

    If the TDT's are all negative, stay away from orthotics, as the probability of them helping are going to be low.

    If the TDT's are positive, then go for it; as supination resistance is high, yes use a big medial heel skive.
  3. timharmey

    timharmey Active Member

    I do various mobilisations with reasonable results but was under the impression that the great and the good think it is the Devils work.I dont think they solve everything but play a part, seeing you recommend them as part of a treatment plan is cool but slightly confusing .Your thoughts? Are that they are like the curate's egg ?
  4. efuller

    efuller MVP

    Where's the STJ axis?

    Peroneal muscles may hurt in walking, but not hurt with manual muscle testing.

    When you grab the arch and attempt to supinate, observe the peroneal muscles. Peroneal muscles can provide significant resistance to supination. When attempting to dorsiflex the hallux in stance, also observe the peroneal muscles.

    How did you determine that the "feet" were maximally pronated. Maximum eversion height?

    This could be a foot that would tend toward maximum supination unless the peroneals are constantly acting. (plantar flexed 1st, rearfoot in varus) In this foot type I would blame the peroneus longus for the fibular head pain.

    Is the tibial varum so high that you can see the tibia adduct relative to the femur? The lateral collateral knee ligament attaches there. I can't come up with to many other explanations of fibular head high stress.

    If you want your orthotic to reduce stress on a structure then you have to figure out what structure is in pain.

  5. mr2pod

    mr2pod Active Member

    Is the pain unilateral, or bilateral? and are the observations unilateral or bilateral?
    You list the biceps femoralis strain as an observation, having its insertion into the fibular head could also be the cause. I would look locally at the tib-fib joints as Craig suggested, but also at the biceps femoris, and the reason why it is strained. Has it been injured? Compensation/recruiting for other weaknesses? etc
  6. David Smith

    David Smith Well-Known Member

    Eric wrote

    Spot on Eric

    and if I can just add -

    Then figure out what mechanism it is that is causing the increased force that results in excessive stress that is causing pathology and painful symptoms

    I.E. 'Is it a tension or compression stress? how can that stress come about e.g. is it forces applied from axial compression is it bending moments and what direction would those moments be in? With regard to your biomechanical assessment: What is the most likely scenario to propose that would explain your findings?

    Which of those observation, or others that have been suggested, would be the most likely to lead to a biomechanical function that would lead the the excessive stress on the structure or tissue you have defined as the one that is in pain?

    There are many and various structures on and around the fibula head that could be causing pain but the actual osseous head seems the least likely unless there is a compression syndrome (which is more realistically pathology of the joint tissues) or a fracture or a non mechanical aetiology.

    What intervention or treatment plan (not necessarily orthoses) will be the most effective to address the problem? I.E. reduce tissue stress and resolve pain.

    Regards Dave smith
    Last edited: Sep 22, 2011
  7. Ivan M.

    Ivan M. Active Member

    Thanks Craig,
    I´ll to do those tests as soon as she comes back to the office. Then I´ll report the results.

    By the way, I will be very pleased to meet you during the Clinical Tests´ Seminar which is going to hold at the Spanish National Congress of Podiatry.

  8. Ian Linane

    Ian Linane Well-Known Member

    I think Craig is probably right in terms of hands on treatment.

    Addressing physiological movement/inhibition at the joints is a simple and quick method of intervention and can buy interesting results at times. May buy enough relief until you go down an orthotic route (if need be).

    I have certainly found inferior/superior fibular head mobilisation helpful in these instances. However it is worth bearing in mind that this same fibular bone moves up and down so if the posterior/anterior mobs of both fibular heads only buy some improvement, try superior inferior mobs on it

    A further addition may be mobilisation of the Talus and/or Calcaneum on the Talus.

    Mulligan tends to argue for possible positional faults that can occur in these areas post any ankle sprain injuries and so its worth checking if there has been any injury there however many years ago! There may still be unresolved issues there.
  9. Ivan M.

    Ivan M. Active Member

    Hi Eric
    The STJA is medially deviated

    She didn´t refer any pain along peroneal muscle in walking or during activity

    OK.I´ll observe that during the next examination.;)

    Yes, I determine that her feet were maximally pronated with the maximum evesion height. Moreover, when I told her to do it, she tended to turn her knees in a valgus position.

    No. Has a low-mild tibial varum
    Absolutely yes. I want to reduce stress on fibular heads.

  10. Ivan M.

    Ivan M. Active Member

    The pain and observations are bilateral.
    Biceps femoralis hasn´t been injured.
  11. TedJed

    TedJed Active Member

    As Craig & Ian have identified, connective tissue (CT) restrictions can impede normal range & quality of motion of the fibula. PHx of ankle sprain is often connected with fibula dysfunction due to a shifted/displaced talus.

    Releasing CT restrictions would play a useful role in helping the orthotic therapy be more effective if it is not having to 'fight' against CT restrictions.

  12. TedJed

    TedJed Active Member

    Hey Tim,

    If anyone claims any treatment option 'solves everything' then I think they could probably be grouped in with snake oil salespeople.


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