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I can see this degenerating into an esoteric discussion about what a hypermobile foot is (I don't know )
When people use the term hypermobile do they mean:
1. The foot moves a lot more than it should (ie the standard definition of hypermobility - large range of motion)
or
2. The foot moves when it shouldn't move (a definition unique to podiatry for some reason)
If the definition is (1), then I do not see what the problem is. What is wrong with a large range of motion? If the windlass works and the muscles are capable of stabilising the osseus segments, then whats the problem?? There is a problem if the osseous segments can not be stabilised by the musculature, the windlass and the osseous locking mechanisms --> this is what the second definition above is and should NOT be really be called hypermobility (I am puzzled why podiatry has adopted this definition ) ....
Sorry Yehuda, I have not helped your patient, but maybe you could be specific as to what he problem actualy is?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
When you say "symptomatic", what do you mean? What are the actual symptoms? What examination was performed? What type of padding &/or tape did you try before prescribing orthoses? What other factors are involved here? What other shoes have been tried? Is the patient a small/light person, is that why they can't wear a "stronger" motion control shoe than Mizuno Nirvanas? Sorry, but it is very hard to comment with such limited information
What are the actual symptoms? post. tib. tendonitis and ITBS
What examination was performed? gait analysis and biomechanical examination !
What type of padding &/or tape did you try before prescribing orthoses? SC felt inlay (see kevins drawing elsewhere )
What other factors are involved here? High arched foot very flexible
What other shoes have been tried? saucony MC5 (felt like wearing bricks) Asics kayano (not as much control as the nirvana, but have more cushioning could be assoc with preious tendonitis of the AT)
Is the patient a small/light person, is that why they can't wear a "stronger" motion control shoe than Mizuno Nirvanas? Male 180 cm 65 kg
Sorry, but it is very hard to comment with such limited information Hope this helps
Yehuda
Last edited by yehuda : 10th April 2006 at 03:06 AM.
Have you tried sending to physio for soft tissue work? I think it's worth a try if orthoses + footwear + ice/NSAIDs are not working 100%.
What's the patient's relaxed stance position like? And is it a medially deviated STJ axis which needs more control ie deep heel cup, Kirby medial skive, lateral flange; or is it a more laterally located STJ axis that needs less pronation control, could the orthoses possibly be too controlling in this case?
Umm sorry I couldn't be of more help here, maybe someone more senior could help?
Although the term hypermobile has been phased out of the podiatry literature in favour of reduced stiffness I think I know what you are describing.
A hypermobile foot to me is a foot which a)has poor stability,poor ligamentous and muscular control and exhibits excessive movement at a joint at the wrong time.
Really this foot pronates at early midstance,mla flattens,forefoot splays,1st becomes incompetent,pronation continues into propulsive phase.
What is really important here is that you focus on the pathology related to the function,what structures or tissues are being affected.
Your prescription will depend on this.
If I want max control in a running shoe I would include a deep heel cup 18-20mm if poss,2-4mm medial heel skive,minimum cast dressing,and if the pronation continues into propulsion an extrinsic varus post to sulcus can help.
Also make sure that the material isnt deforming on load,you might want to add a korex mla filler to stiffen the arch of the device.
A stability shoe is probably your best bet.
Let me know the biomechanical status,and what the patient is complaining of and i'll try and help furthur.
Hypermobile is grossly inaccurate and fails to describe truely what the foot is doing.
Although the term hypermobile has been phased out of the podiatry literature in favour of reduced stiffness I think I know what you are describing.
A hypermobile foot to me is a foot which a)has poor stability,poor ligamentous and muscular control and exhibits excessive movement at a joint at the wrong time.
Really this foot pronates at early midstance,mla flattens,forefoot splays,1st becomes incompetent,pronation continues into propulsive phase.
Scott.
You hit the nail on the head, As I have said Motion control shoes are like running in bricks and for anything over 16 km are very heavy The orthotics I gave are 20 deg blake inv with 4 deg ext rf added (He has had 5mm kirby skive previously but the blakes give better control (sorry kevin )
And is it a medially deviated STJ axis which needs more control ie deep heel cup, Kirby medial skive, lateral flange; or is it a more laterally located STJ axis that needs less pronation control, could the orthoses possibly be too controlling in this case?
Donna,
I have been following your progress with Kevin's thought experiments and have been impressed with your learning. But ask yourself this, after what you have gleaned about rotational equilibrium theory and tissue stress, do you think a patient with post. tib tendonitis is likely to have a more laterally located STJ axis?
Don't mean to be a meany because I am impressed with the way you stuck your neck out :)
__________________ Science is the antidote to the poison of enthusiasm and superstition
I have been following your progress with Kevin's thought experiments and have been impressed with your learning. But ask yourself this, after what you have gleaned about rotational equilibrium theory and tissue stress, do you think a patient with post. tib tendonitis is likely to have a more laterally located STJ axis?
Don't mean to be a meany because I am impressed with the way you stuck your neck out :)
On reflection, I would ask myself this: can someone have both a medially deviated and laterally deviated axis- answer yes.
See, I ain't no meany, Donna you could in fact be right, but not necessarilly for the right reasons, a bit like Root et al.
__________________ Science is the antidote to the poison of enthusiasm and superstition
Yes now that I think about it, it is not very likely to be a laterally deviated STJ axis, but I guess I have seen a few different theories thrown around of late that may have befuddled my thinking...
There was a post by efuller:
Quote:
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.
I guess at this stage I find it very hard to comment on other people's cases when only provided with minimal info on the patient, but as you said I am sticking my neck out...sometimes I just wish my neck wasn't so long
You hit the nail on the head, As I have said Motion control shoes are like running in bricks and for anything over 16 km are very heavy The orthotics I gave are 20 deg blake inv with 4 deg ext rf added (He has had 5mm kirby skive previously but the blakes give better control (sorry kevin )
If you are not getting enough "pronation control" from your 5 mm medial heel skive foot orthosis, then maybe you a not using the medial heel skive correctly along with other necessary modifications to improve pronation control. I always use the medial heel skive along with an inverted balancing position and a minimal medial arch filler of the positive cast (to increase medial longitudinal arch height of the orthosis), with a deep heel cup and a rigid rearfoot post. With these modifications, there are few reasons why a 20 degree inverted Blake orthosis should give more pronation control than this type of orthosis.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Saying a foot is hypermobile is ambiguous and lacks meaning. This is much the same problem with saying that the first ray is hypermobile. In other words, can you give a good, precise definition of what a "hypermobile foot" is??
Does hypermobile mean:
1. There is excessive range of motion of the foot and ankle joints in non-weightbearing examination?
2. There is excessive flattening of medial longitudinal arch during weightbearing activities?
3. There is excessive rearfoot eversion during weightbearing activities?
Then, the next question to answer is what does the word "excessive" mean in questions #1-3.
Next to hypermobile, another one of my least favorite words in podiatry is "hyperpronation"....whatever that means.
I'm not trying to be nitpicky of you, Yehuda, since many others have made the same error because most podiatric clinicians are not very exact in their terminology. I just needed to chime in to agree with Craig on this matter.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
How do you describe in your patient notes the differing degrees of "decreased stiffness" of joints?
Is there a scale that you use to assess this?
I would be very interested to know this as I am trying hard to rid myself of using the term hypermobility - it's a bad habit
How do you describe in your patient notes the differing degrees of "decreased stiffness" of joints?
Is there a scale that you use to assess this?
I would be very interested to know this as I am trying hard to rid myself of using the term hypermobility - it's a bad habit
Regards
Donna
"Decreased stiffness" is not necessarily synonomous with "hypermobility". Hypermobility is a problem as a term because there is no definition which is accurate or unambiguous. "Stiffness" has a very precise biomechanical definition which can be mathematically quantified and studied. Can the same be said for "hypermobility"? Can the same be said for "hyperpronation"? Did Dr. Jay give a definition for "hyperpronation" in his presentation?...if he did I would like to see it. I believe that "hyperpronation" is a word coined on the east coast of the United States. It was never used during my education at CCPM.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I'd never heard the term "hyperpronation" used before seeing this online presentation ("This course is approved by the Australasian Podiatry Council for inclusion as Type 2 activities when submitting accredited podiatrist program log-sheets").... So on completing this online course you receive a computer generated certificate that says you have been updated on your knowledge of Conservative Control of Hyperpronation.
It doesn't clearly define hyperpronation or the symptoms - for example the slide on hyperpronation symptoms lists symptoms such as "heel pain", "calf pain", "arch pain".
My main concern is that when these Continuing Education resources are including such vague terms as "hyperpronation", podiatrists are going to continue to use these incorrect terms. We are supposed to be updating our knowledge, inlcuding keeping up to date with the correct terminology, so how can we do this when current CE resources use outdated terms?
Saying a foot is hypermobile is ambiguous and lacks meaning. This is much the same problem with saying that the first ray is hypermobile. In other words, can you give a good, precise definition of what a "hypermobile foot" is??
Does hypermobile mean:
1. There is excessive range of motion of the foot and ankle joints in non-weightbearing examination?
2. There is excessive flattening of medial longitudinal arch during weightbearing activities?
3. There is excessive rearfoot eversion during weightbearing activities?
Then, the next question to answer is what does the word "excessive" mean in questions #1-3.
When I used the term (Honest I will never use it again ) I meant 1,2 +3 and understood excessive to mean more than I normally see in patients doing a similar activity.
The reason why I found the Inverted orthotic to work better in this case was due to comfort reasons , I found for myself as a runner when wearing orthoses with minimal arch filler it hurt like a ^%&^$"%$£% and ended up taking my orthotics out after 2km
Last edited by Admin : 10th April 2006 at 11:04 PM.
Reason: fixed faulty quote
Donna
precisely why so many of the CE items for accreditation are such rubbish that they aren't worthy of your valuble time. Time that would be better spent at conference such as craigs upcoming "orthoses update" or biomechanics bootcamps. At least at these you will be spending your time learning and expanding your knowledge with current data and information. Rather than rehashing University teachings of 10 years ago. I know trhis may ruffle a few feathers but unfortunately some people in our profession can't/ won't keep up! This is not a personal attack on any individuals just venting some frustrations. This is also a compliment to craig and all others who post on this site to help themselves and others advance their knowledge in the right direction. Thats my rant for the week
I think we would all prefer to learn from someone like CP who has done credible research , rather than from an online presentation that advertises prefab orthotics and uses incorrect terminology
I agree with your frustration regarding the CE Online...don't get me started on listing the things that bug me in that one... :p
Regards
Donna :)
Last edited by Admin : 11th April 2006 at 04:04 AM.
Reason: link added to seminar
What are the actual symptoms? post. tib. tendonitis and ITBS
What examination was performed? gait analysis and biomechanical examination !
What type of padding &/or tape did you try before prescribing orthoses? SC felt inlay (see kevins drawing elsewhere )
What other factors are involved here? High arched foot very flexible
What other shoes have been tried? saucony MC5 (felt like wearing bricks) Asics kayano (not as much control as the nirvana, but have more cushioning could be assoc with preious tendonitis of the AT)
Is the patient a small/light person, is that why they can't wear a "stronger" motion control shoe than Mizuno Nirvanas? Male 180 cm 65 kg
Sorry, but it is very hard to comment with such limited information Hope this helps
Yehuda
High arched and foot very flexible.
Is it high arched non weight bearing and then has a low arch upon weight bearing. I'd suggest the term flexible cavus foot for this situation. However, this begs the question of whether we should be describing the arch height of the foot weightbearing or non weightbearing. Which of the two is more important?
Another possible scenario is that there is a high arched foot with late stance phase pronation. I've also heard this described as flexible.
A third scenario is that in gait you see enough dorsiflexion of the forefoot on the rearfoot so that plantar surface is convex. I would suggest the term low dorsiflexion stiffness for this situation.
I hate to add more to this debate, but I see loads and loads of:
a) Tib post dysfunction
b) Runners
c) Hypermobile patients
Firstly, if you are using the term hyermobile, you need to know the extent (there are nationally used scales for hypermobility). This isn't the same as hypermobile when previously applied to the first ray, rather it is actually, technically, a Rheumatological condition.
Secondly, this whole debate has focused on what we are trying to do with the gait from the persepective of the foot and as Podiatrists.
Tib post 'problems' in hypermobile runners need to be dealt with as part of a muti-disciplinary approach every time. So my treatment plan, to get this patient further would be to:
1) Tib post strengthening exercises (heel raises against the wall) whilst wearing the orthoses.
2) Physio for: a) Core stability training
b) Proprioceptive training
c) Strengthening / stretching regime
d) U/S etc
3) Video gait analysis if not already done.
4) Plantar pressure (in-shoe) if available.
5) NSAIDs if viable and painkillers to be tied in with a RICE regime.
6) If no resolution - MRI tib post.
7) Dare I say it - non-weight-bearing exercise until it calms down? A good way to get patients to do this is to tell them that tib post ruptures v.easily and that would mean an enormous gap in their running career anyway, so it's worth it!
I'm afraid this whole discussion confirms the worst of Podiatry in some ways in that we sometimes seem to forget that there's a body at the top of those feet! This may have been why we got such a blasting in Runners World recently!
Conincidentally, all the runners I see are treated MDT (Physio, Sports Massage, GP/Surgeon, Pharmacology, Diagnositcs, Trainers and Orthoses if needed) and the results are fab (I need to audit yet, so can't get figures). If I was treating as Podiatry alone, I'd have problems!
Just my view, but I think it would help with this patient!
The hypermobile foot and running
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