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I have noticed alot of lig lax patients in my clinic over the passed little while, other than providing orthotics to improve foot function, should I be thinking of anything else?
Is it worth refering onto physio for strengthing exercises.(if so can anyone suggest which ones)
I have noticed alot of lig lax patients in my clinic over the passed little while, other than providing orthotics to improve foot function, should I be thinking of anything else?
Is it worth refering onto physio for strengthing exercises.(if so can anyone suggest which ones)
cheers scott
If its loose, tape, brace, strengthen and avoid provocative tensile activities such as stretching and mobilising. If its tight and stiff and not impinging, stretch and mobilise the bejesus out of it.
Not hard is it. Would have been easier to hear and understand this in my 1st uni year, instead of my 10th.
Strengthening exercises? Just go for the ones where the agonist activity reduces tension in the targeted passive structures. Stronger, more toned hamstrings and gastrocs for instance will assist a pathological genu recurvatum that has a lax posterior knee capsule for instance. Just apply the logic to any structure, anywhere in the body. Beware though, strengthening aint the universal panacea that every (wo)man and his dog make out it to be.
Ron
The Following User Says Thank You to Atlas For This Useful Post:
one patient that I am most worried about is a 10 year old football playing girl who is walking on her navicular.
pain when walking (most days) under the arch area, but no pain when playing football (3xweekly).
I am thinking along the lines that this is not a muscular problem but more of a bony pressure injury point.
cheers scott
I like Ron's common-sense recommendations and think these are good, basic ways to address joint issues.
Ligamentous laxity is, from a biomechanical perspective, a decrease in tensile stiffness of the ligaments that connect the joints of the foot and rest of the body. As such, for a given elongation of the ligament, the ligament that is "lax" will exert less tensile force on its origin and insertion than will a normal ligament. As a result of this decrease in ligamentous tensile stiffness, the joint bound together by "lax" ligaments will allow increased rotation and translation motions for a given force applied to the segments of that joint than will a joint bound together by normal ligaments.
The most common form of ligamentous laxity is a syndrome that has various names such as "generalized familial ligamentous laxity syndrome", "generalized joint hypermobility", "generalized ligamentous laxity", or "hypermobility syndrome". This syndrome is differentiated from other genetic diseases with associated "ligamentous laxity" such as Ehlers-Danlos syndrome, Marfan syndrome and osteogenesis-imperfecta.
For your 10 year old female football player, a good pair of foot orthoses is probably all that is needed to make her asymptomatic. Navicular tuberosity pain at this age is relatively common and may be due to either an accessory navicular or insertional tendinitis of the posterior tibial tendon. In soccer specifically, these children may have pain when striking the ball with this area of the foot. If soccer is causing pain, I make certain that the child is icing the foot after practice and games, wears some form of foot orthosis in their soccer boots, and use "doughnut pads" around their prominent navicular to avoid injury from blunt force to the navicular tuberosity while playing.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I am slightly puzzled why she has no pain during football but does experience pain with everday walking?
I was thinking the football boots may be offering her more support
thank you scott
Scott,
Yes, the more common presentation of navicular tuberosity pain in children is increased pain with running than walking. Check the shoes...that will probably explain a lot.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I see alot of ligament laxity, and in your case would struggle as to whether to place the patient in rigid orthotics which can have medial and lateral flares-works well, OR
Soft EVA orthotics for the 'bony' pain at navicular. Perhaps rigid orthotics with a cushion layer- must watch "too much bulk" issue in daily shoes worn. How is her Posterior Tibialis tendon functioning, hence strengthening of tendons/stretching antagonistic peroneals and even Tendo Achilles if necessary, may be warranted also.
Agree with Atlas that if ligaments are the issue-leave muscles alone! In this case though, you may need to ascertain this 1st.-ie girl playing football only.
I like Ron's common-sense recommendations and think these are good, basic ways to address joint issues.
Ligamentous laxity is, from a biomechanical perspective, a decrease in tensile stiffness of the ligaments that connect the joints of the foot and rest of the body. As such, for a given elongation of the ligament, the ligament that is "lax" will exert less tensile force on its origin and insertion than will a normal ligament. As a result of this decrease in ligamentous tensile stiffness, the joint bound together by "lax" ligaments will allow increased rotation and translation motions for a given force applied to the segments of that joint than will a joint bound together by normal ligaments.
The most common form of ligamentous laxity is a syndrome that has various names such as "generalized familial ligamentous laxity syndrome", "generalized joint hypermobility", "generalized ligamentous laxity", or "hypermobility syndrome". This syndrome is differentiated from other genetic diseases with associated "ligamentous laxity" such as Ehlers-Danlos syndrome, Marfan syndrome and osteogenesis-imperfecta.
For your 10 year old female football player, a good pair of foot orthoses is probably all that is needed to make her asymptomatic. Navicular tuberosity pain at this age is relatively common and may be due to either an accessory navicular or insertional tendinitis of the posterior tibial tendon. In soccer specifically, these children may have pain when striking the ball with this area of the foot. If soccer is causing pain, I make certain that the child is icing the foot after practice and games, wears some form of foot orthosis in their soccer boots, and use "doughnut pads" around their prominent navicular to avoid injury from blunt force to the navicular tuberosity while playing.
I read some of the posts in the podiatry forum and wondered how rigid an orthotic a young foot will tolerate from your experience.
I assessed a 10 year old girl while here in Mumbai, and may cast her before i return to the uk in a couple of days, but am not sure if she will tolerate a rigis device.
She's maximally pronated, but not in pain, just very unstable, with the talus looking subluxed! I believe she has had some achilles lengthening surgery, but not bone surgery, as i think she was born with T.E.V.
I think there was also some neurological problem, but the parents assured me that she had undergone lots of tests for everything, and they said she was just a slow learner! she looked like a typical cerebral palsy child to me, but they said not! She was very slight build and weak, with generalised ligamentous laxity, and has only recently been able to walk with some boots that brace her lower leg slightly, but dont adress her foot position!
Would Ehlers-Danlos syndrome, Marfan syndrome or osteogenesis-imperfecta cause similar effects or a cerebral palsy kind of appearance??
Would you recommend forcing the foot near to 'neutral' to cast it as it is completely 'flat' even non-weight bearing! so may be tricky!
Thanks in advance
Regards
Podiatrist
UK
I read some of the posts in the podiatry forum and wondered how rigid an orthotic a young foot will tolerate from your experience.
I assessed a 10 year old girl while here in Mumbai, and may cast her before i return to the uk in a couple of days, but am not sure if she will tolerate a rigis device.
She's maximally pronated, but not in pain, just very unstable, with the talus looking subluxed! I believe she has had some achilles lengthening surgery, but not bone surgery, as i think she was born with T.E.V.
I think there was also some neurological problem, but the parents assured me that she had undergone lots of tests for everything, and they said she was just a slow learner! she looked like a typical cerebral palsy child to me, but they said not! She was very slight build and weak, with generalised ligamentous laxity, and has only recently been able to walk with some boots that brace her lower leg slightly, but dont adress her foot position!
Would Ehlers-Danlos syndrome, Marfan syndrome or osteogenesis-imperfecta cause similar effects or a cerebral palsy kind of appearance??
Would you recommend forcing the foot near to 'neutral' to cast it as it is completely 'flat' even non-weight bearing! so may be tricky!
Thanks in advance
Regards
I have noticed alot of lig lax patients in my clinic over the passed little while, other than providing orthotics to improve foot function, should I be thinking of anything else?
Is it worth refering onto physio for strengthing exercises.(if so can anyone suggest which ones)
cheers scott
Check hamstrings - often even with lig-lax and pes planus I've found tight posterior muscle groups.
I prescribe stretches for these, rather than refer to physiotherapy.
Also, exercises to strengthen core muscle groups.
This is not backed up by any evidence at all, but I have noticed that the paed patients I've got who have a trampoline in the back garden and use it regularly achieve better core stability/strength than a lot of the others. I suspect its because jumping on one of those things is a lot more fun than doing the exercises and "something is better than nothing" when it comes to activities that involve these muscle groups. Probably gymnastics and/or dance would achieve a similar result.
You can't put severe flatfeet into subtalar joint (STJ) neutral position with foot orthoses by themselves from my experience since their STJ axes are too medial to do so. Using a "rigid" orthosis is not the problem, as long as it is designed well. In the asymptomatic child, you must also realize that it may be better to try to not overcorrect, cause pain, and then not have the child want to wear the devices at all. In these situations I may use a 6 mm medial heel skive, rearfoot posts, 20 mm deep heel cup, 4 mm polypropylene orthosis with some medial arch height, but not so much that medial arch blistering/pain occur. Putting the child into high top shoes will help also.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
You can't put severe flatfeet into subtalar joint (STJ) neutral position with foot orthoses by themselves from my experience since their STJ axes are too medial to do so. Using a "rigid" orthosis is not the problem, as long as it is designed well. In the asymptomatic child, you must also realize that it may be better to try to not overcorrect, cause pain, and then not have the child want to wear the devices at all. In these situations I may use a 6 mm medial heel skive, rearfoot posts, 20 mm deep heel cup, 4 mm polypropylene orthosis with some medial arch height, but not so much that medial arch blistering/pain occur. Putting the child into high top shoes will help also.
Thanks. I'm going back to Mumbai in a couple of weeks.
Regards
Martyn
Ligament Laxity
Linear Mode
