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I have a 14 year old young sportsman patient with heel pain suffered over past two years - history/ symptoms/exam point to Severs disease. He has an externally rotated neutral hip position, genu valgum and a bilateral inverted forefoot position leading to excessive foot pronation when standing relaxed and in gait. Normally I would expect a good result by treating him with orthotic therapy to reduce the excessive pronation.
However he 'in toes' significantly when walking (a position that appears to result from an internal tibial torsion) and this increases when running. Fortunately he does not trip himself over.
My dilemma is that if I reduce overpronation with orthoses I expect this will increase foot adduction and emphasise the in toeing. Has anyone has a similar problem with a patient and successfully treated them with orthoses?
I too have seen a few similar cases, and I also fear putting youngsters in orthoses who already intoe may exaccerbate this (although i haven't read any evidence to prove this), as theoretically there foot would be less abducted in the forefoot. In reality, i don't know if this happens as much as we may think. I do see some kids who intoe slightly greater with orthoses (once again, just what i see, no evidence that i have read), however i think this is largly a matter of treating the problem at hand.
As the hips are already in an external position, external hip strengthening and/or internal stretching will not be of great benefit. At 14, he still theoretically does have some torsional development below the knee with some external malleolar rotation still likely. This is largely variable but good to keep in mind.
Severs, in absence of biomechanical problems can be treated with ice/stretch/heel lifts and limitation of activity.
In cases like this, if orthotics are required, despite the theoretical increase in forefoot adduction, i would generally pursue them. At 14 he is no doubt right into his sport and keen to get on with it. Sometimes, if the child is aware of the intoeing, its good to sit them down and point out a few of their potential heros who have intoed gait eg andre agassi. Often in this light, some kids tend to not be as worried!
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I am again being lazy here (as i have with a few posts) and not hunting down the research article...don't even know if i have it. But i do know there is some researching suggesting that gait plates do not decrease the degree of intoeing. The only effect they had in this research was decreasing frequency of tripping, but in this young man this does not seem to be apparent. It showed there was no change in intoeing with or without gait plates
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Thank you Dawesy and Mark Egan for what appears to be sound advice. I have put patient in touch with a good physio for stretching - he has tight gastrocs and hamstrings, recommended resting from hectic sports schedule initially and initiated icing and started him with some semi flexible othotics to partially reduce his pronation. Have not incorporated gait plates - I have not encountered anyone who has had much success with them. Will let you know result.
I have had several young fellows like this including my own son who suffered on and off for three years, and had suitable orthotic therapy (with inverted foot position) I read an article on the net about the use of acupuncture for Severs and promptly sent him off to a sports physio who also is an acupuncturist. He needled him in the post tib and medial gastroc which he said were very tight ( he had been continually stretching his calves for some months) and within a week of the treatment the heel pain was gone and has not returned to date (some six months, he's 13 so I wouldn't have expected the growth plate would have fused in that time), I have since then sent on three other of my more difficult(to respond) patients all with the same excellent, immediate results.
He needled him in the post tib and medial gastroc which he said were very tight ( he had been continually stretching his calves for some months) and within a week of the treatment the heel pain was gone
Are you 100% sure it was severs? There are well documented trigger points in post tib and gastocs that refer pain to the heel ..... accupuncture is very effective for trigger points.
No, with him I wasn't absolutely sure, as the focal area of pain changed a bit over time however there was a complete absence of any other evidence pinpointing a different diagnosis.
The other cases were very much 'sever's- like' though.
It may well be that a "gait alteration" as a result of the pain from the severs initiated the triggers points in leg muscles, which refered pain (which may have replaced or become superimposed on the severs pain)
I have seen this a number of times in allegedly "resistant" plantar fasciitis .... the orthoses "worked real well", but the pain was still present. It appeared as though the orthoses worked on the plantar fascitis, but the "altered function" (even though it was allegedly better function) resulted in trigger points developing in the intrinsic musculature --- accupunture of those resulted in rapid resolution.