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Hi all

Any thoughts regarding this interesting patient would be most appreciated;

62 year old female, overweight patient, referred by Neurologist following a follow up from spinal fusion (L3/L4). She complians of pain down her legs from behind and in her hips and was diagnosed with Sciatica. There was no comment on any hip investigation or findings yet. The neuro has put her on tegratol and triptiline and has asked for a biomech exam. Findings as follows;

Bilateral Pes Cavus with hypermobility! Especially at the STJ. Her feet show atypical (for Pes Cavus) callus formations of central PMA and medial hallux, bilat.
Gait analysis showed adduction left and abduction right with pronation. The left has a semirigid first ray. She complains of no symptoms in her feet. Hip range of motion is limited and painful on passive and active request. Knees similarly but less so.
Her legs go through much torsion during ambulation and hip pain can be differentially diagnosed, clinically as degerative due to gait abnormality.

Besides hip and knee xrays, any suggestions as to the type of orthotics to be used here. I could make gait plates to achieve abduction in her left and adduction in her right, but I also want to palliate the impact on her knees and hip, and correct torsional forces through her tib and femur.

Thanks in advance for any advice

Regards

Brandon Maggen

Is there a limitation of ankle joint dorsiflexion? If so this will have to be taken into account when prescribing orthotics

Looks to me like there's leg length discrepancy with shorter left leg in this patient.

I agree with leesan. Rule out LLD first

sounds like the rigid first ray may be creating a blockage in sagittal plane motion - possibly explaining why there is medial hallux callousing (from a medial D1 toe-off). Have you looked at her tibial torsion? Perhaps that will explain why she is intoeing on the left and out toeing on the right. Are the hip ranges of motion symmetrical i.e. is internal limited more than external on left and right or are there differences (usually these ROM's are compensations for underlying osseous torsions).
I dont usually use gait plates after people have finished growing unless there is a neurological problem (e.g. UMN lesion). I would be checking limb length via CT scanogram if you suspect it and perhaps blocking MPJ ROM if it is painful and severely limited.

Hi Leesan,

Just wondered how you came to this conclusion with the given information?

Thanks

Ian

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When there's a difference bet the rt n left foot as in this case - toe-in left foot (likely supinated) and toe-out right (pronated) - I think LLD. Usually the supinated foot belongs to the shorter leg and the pronated, the longer. The presence of sciatical symptoms is a clue. Best wishes.

Leesan,

We've had similar conversations many times on this forum and I think its now generally accepted that in the case of a structural LLD it can be either foot which is in a more pronated position, and not just the longer leg as we were historically led to believe. The most common compensation seen on a longer leg is an increase in knee flexion.

See here for more

Ian

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Leesan:

Limb length discrepancy would be very low on my differential diagnosis list for causes of asymmetrical angle of gait. In addition, many times the longer leg is more supinated than the shorter leg, contrary to popular podiatric myth. I find that very few angle of gait asymmetries are caused by limb length discrepancy, contrary to your suggestion.

__________________
Sincerely,

Kevin

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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
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Hi All

Thank you for the replies.

Initially there was thought to be a LLD which was ruled out by the Neuro.
On follow-up however I checked, measuring from the ASIS to the plantar medial aspect of heel. I did this 5 times and found indeed a LLD R < L by 2cm.

Since the neuro had initially ruled LLD out, I called him to discuss my findings and his method of clinical measurement.
He was a bit surprised (perhaps because he missed it or measured incorrectly or both) and I suggested if he feels it necessary, to order a radiological investigation.

In the mean time, I am making her gait plates for each foot, taking into account each foots' requirments and adding a 1cm heel raise to the R.
I will follow her up and assess and modify regularly.
I am most keen to see how this will affect (positively) her sciatica and hip pain.

Thanks all, again.

Regards

Brandon

It seems to me that you have not actually delineated, diagnosed and defined the mechanism of the problem yet, but have already decided how to treat it?....can you explain what you are thinking?
regards Phill