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Help please

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podiatrystudent, May 11, 2007.

  1. podiatrystudent

    podiatrystudent Welcome New Poster


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    Hi to all,
    I was hoping Kevin Kirby might be able to help, but anyone really - I'm doing a case study on a 21 year old male patient with pain in the lateral right ankle, recurrent ankle sprains, previous diagnosis of Grade II ankle sprain (ATFL damage), peroneal weakness, NCSP of 4 degrees inverted and RCSP of 2 degrees inverted, lunge test result of 65mm, FPI of -3 for left foot, and -5 for right foot... I was hoping someone might be able to direct me to literature that will help me decide on the best orthotic treatment for such a patient... so far i have only found 2 articles (one by Guskiewicz and Perrin, and another by Orteza et al... surely there is more information out there on orthotic treatment for a patient such as this... I was thinking something along the lines of modified root, with cuboid notch? or maybe mod root with kirby skive? help! im a bit lost... but would you support the inversion to some degree or enhance pronation... (ok im a student, i may be completely on the wrong track here..)
    Thankyou!!
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    This is a frontal plane issue of the ankle.

    Hence any varus deformity of the hindfoot will place the already attenuated ATFL at more risk of injury and promote instability.

    If, as you say, there is a varus attitude of the hindfoot in RCSP, due to some kind of cavo-varus deformity or similar - introduce any form of valgus wedging/correction of the hindfoot/forefoot and it will help. Do a Coleman block test to help figure this out.

    Recurrent instability and sprains despite this approach with wedging/foot orthoses +/- ankle bracing = delayed primary repair of lateral ankle ligament/s (eg modified Bronstrom).

    Forget about all the numbers and look at the bigger picture. :cool:

    LL
     
  3. Scorpio622

    Scorpio622 Active Member

    It is important to differentiate lateral ankle ligamentous pain from sinus tarsi pain. Lamont recommends using a pencil eraser to palpate the ATFL vs sinus tarsi since a finger may press on both structures.

    When in doubt I give a diagnostic injection of lidocaine into the sinus and perform a provocative test to see if the pain decreased.

    In my experience orthotics have a much better success rate with sinus tarsi issues and less with lateral ligamentous pain, although they may help the peroneals provided they are posted correctly.
     
  4. Please help, what is a coleman block test?
     
  5. Scorpio622

    Scorpio622 Active Member

    Try Google.
     
  6. Stanley

    Stanley Well-Known Member

    Have the patient stand on the injured leg and bend the knee. Now have them pronate and then supinate.
    Pronation pain is related to "jamming" of the sinus tarsi which I call sinus tarsitis. The treatment of this is orthotics to back off from the end range of pronation. Make sure you look for the tight gastocnemius and treat this (via manipulation, heel lift, exercises, treating of the short leg, etc.) Local care consists of steroid injections, manipulate the lateral talus, and myofascial release of the cervicis ligament.
    Supination pain is suggestive of a sprain of the ankle or subtalar joint. Check your anatomy, and you will see that the ATF ligament does not cross the sinus tarsi. Treatment consists of immobilization initially, and then cortisone injuections for the sinus tarsi syndrome, strengthening exercises for the muscles that support the ankle and STJ. Orthoses would have to prevent supination via cuboid support and sub 2-5 raise. Myofascial release is indicated in the effected ligaments.

    Regards,

    Stanley
     
  7. Podiatrystudent:

    This is a difficult case to help you with given the information you provided. Sinus tarsi pain (i.e. sinus tarsi syndrome, sinus tarsitis) is most commonly caused by two distinct mechanisms: 1) A maximally pronated foot where the increased interosseous compression force within the sinus tarsi caused by the lateral process of the talus banging against the floor of the sinus tarsi of the calcaneus with each step causes irritation within the sinus tarsi. This phenomenon was first described in the medical literature in 1989 (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989).
    2) A foot that has had significant inversion ankle sprains where there is post-traumatic scarring within the sinus tarsi.

    Both types of feet will have almost no pain with passive STJ pronation and both types of feet will have increased pain with passive STJ supination (contrary to what another contributor wrote).

    Treatment revolves around trying to increase the space within the sinus tarsi so that the foot is not maximally pronated, so that the interosseous compression force within the sinus tarsi is reduced and/or the sinus tarsi scar tissue irritation is kept to a minimum.

    Now, back to you. Is the patient maximally pronated at the STJ in RCSP? Perform a maximum pronation test (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992) and tell me. Second, what is gait function like? Is the patient supinating in late midstance, stable in late midstance or pronating in late midstance?
     
  8. Footsies

    Footsies Active Member

    Kevin, would you be able to explain the maximum pronation test?
     
  9. Stanley

    Stanley Well-Known Member

    I used to teach about this as two conditions, the jamming of the subtalar joint I called Sinus tarsitis which was to distinguish it from Sinus tarsi syndrome (injury to the cervicis ligament) in 1982.

    The impinging of the subtalar joint was first described in 1960 (contrary to what another contributor wrote):Brown, J. E.: The sinus tarsi syndrome. Clin. Orthop. 18,. 231-233 (1960).

    The pain on pronation is seen with more than just mild passive force. That is why other contributors will not find it. If you were to use the patient's body weight to put additional force on the subtalar joint, then you would find the pain secondary to pronation. As I wrote, "Have the patient stand on the injured leg and bend the knee. Now have them pronate and then supinate." I should have also told you that I ask the patient which direction hurts the most.

    Nonetheless, do the tests yourself, and let me know what you find.

    Regards,

    Stanley
     
  10. Stanley:

    I did not mean that I was the first to describe sinus tarsi syndrome since I realize this was described for some time before my 1989 paper. What I meant was that the mechanics behind sinus tarsi syndrome, with medially deviated STJ axes causing increased magnitudes of interosseous compression force within the sinus tarsi that leads to sinus tarsi syndrome, had not previously been described in the literature until my 1989 paper.

    Thanks for providing the reference on sinus tarsi syndrom for us.
     
  11. Here is the original text from the book chapter where both the maximum pronation test and supination resistance test were first described 15 years ago (I wrote the Chapter along with Don Green in October 1990).

    Below is the original photo of me demonstrating the maximum pronation test for one of my pediatric patients.
     

    Attached Files:

  12. Mart

    Mart Well-Known Member

  13. bsdavid

    bsdavid Member

    Hi Kevin,

    If you do find that a child's STJ is in a maximally pronated position in relaxed stance, with a 'hard' supination resistance test (with a very similar foot type to above) what type of device would you recommend in an orthoses? I have a three year old patient with the most pronated STJ I have observed and am wondering if I should just be focusing on rearfoot correction rather than midfoot to avoid interfering with the windlass and musculature in such a young age.

    TIA
     
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