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have recently graduated and biomechanics is not my strong point!

I recently saw a gentlemen in my clinic who presented with pain in his right leg. one of his main hobbies was judo however he stopped this over 4 years ago as he was suffering from lower back pain. to keep his activity levels up he started running and has completed three marathons over the last three years. However not long after he started running he developed anterior knee pain. He went to a local podiatrist who advised him that he over pronated probably due to the fact he has flat feet. the podiatrist then gave him insoles (valgus dome with a 4degree medial hell wedge) These insoles did help with knee problem and he went on to enjoy two years of pain free running.

However when i saw this gentleman he was complaining of pain in the dorsal aspect of his right foot (he has no knee pain) The pain radiates from around the styloid process dorsaly across the cuboid to his lateral maleoli. He describes the pain as a dull ache which gets worse after activity and lessens after rest

He recently had an xray which showed multiple fractures to his right 1st metatrsal (the result of years of judo) the xray also showed arthritic changes in the 1st mpj which has left him with a severe hallux rigidus.
apart from this range of motion in the ankle joint and stjt is good. the patient does over pronate and appears to have a functional rearfoot varus and suffers from very tight calf muscles.

what can I do. could he be rolling over his insoles? should i encorperate a forefoot wedge into his insoles. Any advice would be gratefully recieved

sorry for the poor patient history

thanx ross

Hi there

Pain travelling from the styloid process, dorsally over the cuboid, towards the lateral malleolus...

My DDx:

• cuboid stress fracture
• sinus tarsi syndrome
• subtalar joint pathology
• calcaneo-cuboid joint pathology
• 4/5th MT-cuboid joint pathology
• sural nerve entrapment
• peroneus brevis tendon pathology

, of course there could be many more weird and wonderful things.

You should attempt to try and specifically locate any point of reproducible pain, and that will help narrow the possibilities. Is it worst along a joint line, a tendon, a specific bone. Get weight-bearing x-rays and assess the lateral column for any faulting or DJD.

Consider the nature, location, aggrevating factors, etc to help distinguish between nerve pain, and joint pain for instance. Get back to basics in your assessment and history to try and figure out which tissues are being affected. Hone in on your surface anatomy.

It sounds like the previous therapy was rather 'humble', so trail some functional taping to check the effectiveness of better stability through the hindfoot and midfoot.

Let me know how you go,

LL

Hi Ross,

Lucky has been really comprehensive, so I only have one consideration.

It seemed to me from what you say that he is still wearing the orthoses from two years ago. There is a great liklihood that they have deformed or become very unstable. They could at this stage have even initiated the process that has caused the present symptoms.

I'd replace them straight away with some temporary devices with any appropriate wedging, whilst meanwhile following Lucky's advice on investigating more exactly what structures are involved as you will also probably have to treat the currently unhappy tissue.

Cheers
Shane

I think your proposed forefoot changes have merit.

As LL suggested, try to reproduce the pain in the clinic room. My gut feeling is that passive forefoot supination will do this, but try different handling to ensure that it just 'aint' direct palpation pressure that it reproducing it.

Once you have worked out what clinically reproduces the dorsal foot pain, this will give you a solid foundation to go about orthotic modification etc.

IMO, Gardner's rule makes complete sense. Although it has not been scientifically supported, it can direct the novice practitioner as well as this site does.

Ross

There could be many thing which cause the symptoms you mention, as others have said, and it may be useful to pin point the origin.

My thoughts are this : He has/had tight calf muscles, you said tight calf muscles but good ankle RoM? recheck ankle RoM is there ankle equinus or excessive stiffness to GRF. Previously (pre orthoses) perhaps he compensated by pronating the STJ. He had orthoses fitted but were there any heel lifts fitted and 1st ray c/o. Has any modifications been made for the hallux rigidus? If not he may be compensating for saggital plane progression blockage by tending to flex the MTJ about the cuboid.
I would think about new orthoses with heel lifts, cuboid lift and 1st ray c/o plus a rocker device either on the orthosis or as part of the shoe (which is usually more convenient). There are running shoes with rocker soles available I believe.

All the best Dave Smith

thanx for advice and taking the time to get back to me. you have given me alot to consider.

thanx ross