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G'day fellow podiatrist & health professionals,

Let me introduce myself. I am a podiatrist that been practicing for just under 2 years hence pretty much everyweek to some extent is still a learning experience

I would like to seek some opinion from everyone who may have an idea or two regarding my questions on orthotics.

I recently prescribed a custom device polypro (milled-not heated) to a 75 yo patient with RA feet. She suffers from constant pain during weight bearing.
I've decided to prescribed an accomodative device hence the casting technique was semi weight bearing. The idea for the device is not corrective but accomodative to have a more even plantar pressure distribution.

She has bilateral MTJ collapse with very broad and flat foot type. Supination resistance is high.

After wearing the device for 8 weeks she is gradually getting adductor pain on the inside of her thigh muscle whenever she wears the device.

The device is posted to 0 degrees at the rearfoot.
Structurally she has mild tib varum


My questions is what may have cause the adductor pain?
All i could think of would be the MLA area may be too much for her to tolerate but it is casted semi wb hence the MLA profile is not prominent.

Thanks in advance for any opinions and suggestions of what may have caused it and any ideas on orthotic modification.

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Gday

I would like to ask in general terms if anyone has ever treated a patient with foot orthosis that have subsequently gone on to elicit Adductor pain? I have never heard of this, especially as you are not dealing with a runner/sports person by the sounds of things. Is it possible that as you fixed her foot pain, and Im assuming you did as you never mentioned it as an issue on follow up, she probably increased her activity levels subsequently and maybe u are looking at an overuse injury.....bearing in mind the threshhold for overuse in an 75 y/o women with chronic arthritic foot pain is not likely to eb too great (where was pain?, what type?, what Athritic changes are present in foot?what were u treating?).

Did the patient have much transverse plane motion at the hips in gait? What other gait findings did you note. How was JROM in foot?

Perhaps we need the expertise of a pod arena Veteran to unwravel this one........ Dr Kirby, Stanley, Luck lis franc, Donna, Dr Danenberg, any1????????

Sorry I couldnt have been of more help

MrT

If it was definately muscular, I am not sure of the mechanism. However there are many pathologies in the region that may present with symptom in the same region... hip joint degeneration... referred pain from the baack to name a couple.
Perhaps if you have great results with the orthoses, but this negative side effect, it may be worth having a practitioner with experience with that region to assess...
Nor me...

__________________
Craig Tanner
Podiatrist
ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR
http://www.aspetar.com/

Adductor pain in the thigh is unusual with foot orthoses. When faced with similar situations where I don't know which direction to go with the orthosis, I have found that either inverting or everting the orthosis with adhesive felt on the plantar aspect of the orthosis on a trial basis to be the most helpful for the patient and for my own understanding of the mechanics of the clinical situation. My guess from the limited information provided is that the orthosis should be everted slightly (i.e. medial arch of orthosis should be lowered or made more compliant).

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin

Rather than lower the medial arch could you ot grind a 45 degree angle on the medial side of the extrinsic post to allow the foot to evert more??

chris

I will normally grind both the plantar aspect of the anterior edge and the plantar aspect of the rearfoot post of the orthosis to "decrease the varus correction" so that there will be less medial longitudinal arch height of the orthosis. Other variations which accomplish similar mechanical adjustments to foot orthoses include 1) adding adhesive felt to the plantar aspect of the lateral 1/3rd of the orthosis (from the rearfoot post to anterior edge) and 2) grinding the medial longitudinal arch height from dorsal (or plantar) to not only decrease the arch height but also to increase the compliance 9i.e. decrease the stiffness) of the medial arch of the orthosis.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks for all the feedback.....

MrT
Yes basically the device fixed her foot pain. She was experiencing diffuse pain over her midtarsal joint bilaterally during weight bearing.
She also suffers from hip initially but no adductor pain.
Basically the foot is ok now with the device but the proximal structures i.e adductors are playing up.

Craig T
I'll try to modify the orthotics a bit first and if there is no favourable changes probably a referral would be the next step as you suggested.

Dr Kirby
Yes...what you suggested would help. I''ll attempt to evert the device a bit more by adding valgus felt or/and grind down the shell to reduce stiffness.......

Will post the outcome........in the coming weeks.......

Thanks again for the all the ideas

I have often found that adductor pain can be couple with fibula restriction - I'm not certain, but perhaps it can be reasoned that with less transverse plane motion available in the lower leg the hip takes over (sartorius involvement?) Is the patient able to internally rotate the foot well? (...seated with the knee flexed)

Perhaps some gentle mobilisation of the fibula could release things enough for the adductors to settle down. Has worked for me in the past.

Just a thought! Let me know what you think.