Navicular pain induced with 6 weeks of orthotic wear

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Recently consulted a 12 year old athletic female who complained of bilateral knee pain. A standard 4 degree inverted modified root device was prescibed. Orthotic review at 4 weeks revealed resolution of all knee pathology. 2 weeks later the patient presented with an acute localised swelling, erythema and pain overlying the navicular of the left foot after sporting and dancing activites. Ice massage and rest resolved the acute inflammation but any activity reproduced the original symptoms. Modifications to the left orthotic included adjustment of the anterior edge, first ray cut out and a 3mm heel lift. Bone scans were ordered and results are pending. Differential diagnosis' included navicular apophysitis and stress fracture. Is there any other acute pathology that could have been induced via the orthotics? And do you think the orthoses have a direct correlation to her symptomology?

 

Could be an Os Tibiale Externum, and probably coincidental. I am sure other members have other potential diagnoses.

 

Maybe activity levels increased following resolution of knee symptoms and the navicular pain is more a result of that actvity increase.

 

I wouldn't suspect Kohler's disease (apophysitis) in a patient aged 12, I thought the average age for this condition is 5 years old

I don't really have any extra suggestions to what has already been said, maybe bursitis if the patient is pronating over the medial edge of the orthosis. There's not a lot of history to go on here

What was the actual cause of the knee pain originally (Osgood Schlatter's? Patellofemoral?)?
Are the modifications to the orthoses bilateral, and were they made as a response to the navicular pain?
Does the patient have pain during standing and walking, or only with running and jumping and dancing?
How long before the onset of pain? Is it there first step in the morning?
Does the patient recall a recent trip/fall/incident that may have contributed to the pain?
How can you reproduce the pain?

Some more info might make it easier to make more suggestions

Regards

Donna

 

Take a look at the arch height of the device realtive to the arch height of the foot when the patient is standing. A really high arched device can cause the patient to overuse their posterior tibial muscle and possible results are pain at the insertion site.

Eric

 

Hi efuller,

I am a bit confused here, because in Kevin Kirby's "Thought Experiment #3" http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1841 , it was calculated that Post tib would be doing less work with the STJ axis located more centrally/laterally...which I would assume is what the Root orthotic would effectively do to the STJ axis...

We would also be assuming that the patient in question here has a medially deviated STJ axis to start with.

So if the post tib is doing less work, wouldn't it be less likely to have insertional pain than without an orthotic?

Donna

 

thanks for all your input. one point....I understood an apophysitis to be caused by an increased tractional force of a large tendon on an attatchment/physis which hasnt fully united casuing inflammation and pain ie severs or osgood schlatters, which is a different condition all together to a true AVN such as kohlers disease

 

As mechanical therapists, we are adding or subtracting forces, we are increasing/decreasing compression/tension in tissues. We are changing things. That is why we can improve conditions. But it is also why have the potential to make things worse.

 

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Hey,

Couple of questions.

Were the devices custom made?CAD or Plaster

What material was used for the shell and post?

Were the devices correctly pitched on the sagittal plane to sit flat in the shoe?

Was the rearfoot excessively everted,or stj medially deviated?

Was navicular prominant plantarly?

Was the device skived medially,how much arch fill was ordered?

I'm guessing from years of manufacturing my own orthotics that there has not been enought rearfoot correction offered by the device.

deep heel cup,medial skive 3mm up,+4 degree rearfoot post etc

I used to find that with out these measures the patient would continue to pronate into midstance,and particuarly in a mobile foot there would be gross plantarflexion of the navicular causing it to press into the medial arch of the orthotic shell.

Clinicians very often reduce the shell in the arch area,this doesnt usually help!

Try adding a medial skive to the medial aspect of the heelcup using chiropody felt,this should cause supinatory force and reduce the stj pronation.

If you flanged the device,try a navicular pocket using 3mm poron.

You could also increase the varus wedging on the hindfoot or add a reverse mortons extension to stabilise the M.T.J on the rearfoot.

If I was you I would recast and reassess your needs.

Good luck

scott

 

Hi Donna,

It is important to understand how an orthosis causes supination. I beleive it can work in more than one way. The medial heel skive or a device with an inverted heel cup will sift the center of pressure under the foot and decrease pronation moment (= increase supination moment).

Another way that orthoses work to cause supination is to have the patient increase the activity of their posterior tibial muscle. I call this the pointy object under the arch theory of orthoses. If the arch is so high that it is uncomfortable to stand on the patient will use their posterior tibial muscle to increase comfort. Have you ever seen a patient walk down the hall barefoot and walk just like they were wearing their orthoses.? There are other observations that support this idea as well.

This is one of the problems I had with the Root teachings. How does an orthosis casted in neutral position cause supination of the STJ? The piece of plastic under the foot has to alter the forces acting on the foot somehow. It can include a behavioral change.

 

Hi efuller,

Yes I understand what you mean now ... thanks for explaining it

Regards

Donna