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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!!
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.
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.
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.
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!!
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?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
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).
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin, would you be able to explain the maximum pronation test?
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).
Quote:
Two of the most important tests in the physical examination of the pes valgus deformity are next performed with the child again in their relaxed stance position. The first of these tests, the maximum pronation test, is a maneuver designed to determine whether the foot is standing in the maximally pronated subtalar joint position. While in their relaxed stance position, ask the child to try to lift up the lateral sides of their forefeet, but instructing them that they may not flex their knees to do so.
If the maximum pronation test is done correctly, the child will use their peroneus brevis muscle to attempt to pronate their subtalar joint, and if the subtalar joint is not already maximally pronated, the calcaneus will evert further. The physician should observe for heel motion from behind the patient. Any further calcaneal eversion of less than two degrees during the test signifies that the child is standing in their maximally pronated position. Sometimes it is helpful for the physician to actually use their own feet or their hands placed on the ground in front of the child to demonstrate exactly how to perform this maneuver.
It is important in both children and adults to determine whether or not a foot in the relaxed stance position is maximally pronated. If the child's foot is not maximally pronated at the subtalar joint then there is much less chance of that foot having significant pathology in the future since the pronation moments acting on that subtalar joint are being partially counterbalanced by subtalar joint supination moments which are acting to prevent its maximal pronation.
If, however, the subtalar joint is maximally pronated during relaxed stance, then this indicates that the pronation moments acting on that subtalar joint are much greater than the subtalar joint supination moments. The overwhelming pronation moment acting on the standing foot therefore causes the subtalar joint to hit its end range of pronation range of motion, and a maximally pronated subtalar joint results. The level of severity of these excessive pronation moments acting on the subtalar joint can be estimated by the next test, the supination resistance test.
The supination resistance test is actually a clinical test which has been used for many years but has never had its true significance defined. The supination resistance test is performed again while the patient is in their angle and base of gait in relaxed stance. The child must be instructed during the test to not assist the doctor in any fashion by even the slightest extrinsic muscular contraction or by any lower extremity movement or the test will be invalid.
The test involves simple application of a superiorly directed lifting force from the physician's fingertips to the area of the patient's medial longitudinal arch just plantar to the medial half of the navicular bone. Basically, the supination resistance test involves determining the amount of lifting force which the physician's fingertips must apply to cause supination motion at the subtalar joint.
If there is a great deal of pronation moment acting on the child's foot then it will take a large amount of manual lifting force under the navicular to produce any subtalar joint supination motion. If there is relatively little pronation moment acting across the subtalar joint then it will take a very small amount of lifting force to produce supination. Heavier children will obviously require more lifting force under the navicular to produce supination than lighter children. However, the actual weight of the individual has less effect on the degree of lifting force needed to produce supination than the location of the subtalar joint axis.
In a normal foot during standing, the subtalar joint axis is in its normal lateral location in relation to the medial navicular bone. Therefore, supination of the subtalar joint becomes relatively easy with lifting force under the navicular since there is a relatively long lever arm for the lifting force to produce supination moment on the subtalar joint axis and supination motion results with little lifting force.
If, however, the subtalar joint axis is medially deviated, such as in children with pes valgus deformity, then the much shorter lever arm will necessitate a much greater lifting force under the medial navicular to produce even small increases in supination moment across the subtalar joint axis. As a result, the more severe pes valgus deformities are very hard to supinate with digital lifting pressure under the medial navicular.
As is obvious from this discussion, the feet which have the most medially deviated subtalar joint axes will also be the feet which have the greatest amounts of pronation moments acting on them and will also be the feet which are the hardest to supinate in the supination resistance test. In addition, these feet are easily identifiable since the talar head is positioned well medial to the calcaneus and rest of the foot during standing.
When the foot is found to be maximally pronated in the maximum pronation test, the supination resistance test should next be employed to determine the severity of the pronation moments acting on the foot during standing. If the examiner finds that the lifting force under the navicular is approaching a magnitude which equals about half the patient's body weight and that the lifting force is not producing any subtalar joint supination motion, then it can be assumed that the subtalar joint axis is directly over or medial to the physician's fingertips. This observation indicates both an extremely medially deviated subtalar joint axis and extreme pronation moments acting on the subtalar joint during weightbearing activities.
If, however, it takes less than five pounds of digital lifting force to cause subtalar joint supination motion during the supination resistance test then this finding indicates that the foot has a less medially deviated subtalar joint axis, has a less medially located talar head and has less overall pronation moment acting on it.
Like any clinical test, the supination resistance test requires practice and observation on numerous patients in order for it to become a useful test within the physician's clinical armamentarium. The test, however, is so useful in regards to establishing a valid comparison between the patient's own two feet and from one flatfoot to the next that, once learned, it becomes the one clinical test which most reliably unmasks many of the "unseen" pathologic internal forces acting within the feet of children with pes valgus deformity. (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.)
Below is the original photo of me demonstrating the maximum pronation test for one of my pediatric patients.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Also checkout the following link for more info on supination resistance testing and it's implications and correlations with other variables investigated by Craig Payne and others including Kevin Kirby
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