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Hello All,
I have a question about a patient I saw recently. He is a very active 82 y.o. who likes to "walk fast" as he described it, and has vague ankle/ heel pain. Ankle ROM was normal, muscle testing normal. Eversion was restricted, but he presents with tibial varum and rearfoot varum (RCSP). There appears to be a functional equinus. There was a palpable indentation above the insertion point of the left Achilles tendon. There was no pain on palpation or neuro testing of either ankle.
He also presented with X rays that clearly showed calcaneal spurs at the origin of the plantar fascia and the insertion of the Achilles, along with medial wall calcification of the posterior tibial arteries. He states these no longer trouble him ( X ray May 2010)
During gait the rearfoot appeared to stay inverted throughout gait, no excessive pronation of mid/forefoot noted ( but this may be due to my lack of experience as a new grad whose weak point is biomechanics!)
My initial treatment was to tape the left ankle (neutral PF/DF with slight eversion), lateral felt wedges under the rearfoot, stretches of the triceps surae. He is due to return in a fortnight.
I'd appreciate any suggestions as to whether lateral wedging is the way to go, or what sort of orthotic to use. I'm used to excessive pronation/ rearfoot eversion, but not the opposite!
Thanks, Kara.

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If you want to use the tissue stress aproach to treatment, you have to identify the injured anatomical structure. Then you choose your treatment based on your diagnosis.

If the person has limited eversion, and they are sitting at their end of range of motion, lateral wedging is not going to make them evert any farther.

Have them stand and ask them to try and evert without moving their leg. With this test you can see if they are at the end of their range of motion and if trying to go farther in that direction increases pain.

Sometimes sinus tarsi pain can present as a vague ankle pain and it also can be caused by maximal pronation of the STJ. In the maximally pronated position of the STJ the lateral process of the talus is compressed into the floor of the sinus tarsi.

Eric

I would consider Root's 1/3, 2/3 theory and medially wedge closer to theoretical 'neutral' position, which means posting so that there is still some eversion available in gait. If you try this, let me know how it goes, cheers,
Kate

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My location

If you want to use the Wellness Biomechanics and Functional Foot Typing approach, this patient has a "strongly characterized" Rigid Rearfoot Foot Type (you fail to mention the forefoot).
This, as pointed out on another thread is actually the most common foot type and not the "pronated" STJ Foot (the Flexible Rearfoot) Type in my system.

Although the others offered you diagnostic and clinical information, they offered you little in terms of care because they need to know a location of tissue stress before treating.

This 82 year old needs immediate care and relief.

There is sagital plane stress into his foot that would respond very well to heel lifts or vertical rearfoot wedging.
In addition, a forgiving thermoplastic orthotic, casted using rearfoot vaulting technique (or a MASS Cast) will decompensate the rearfoot on the sagittal and frontal planes where he needs it as he has no frontal plane correctability (the plane you were taught to treat).

I would add a shock absorbing topcover of possiblty memory foam or some deformable laminate you have available in order to reduce shock up into the foot and superstructure.

The last ancillary thing I would consider is an inexpensive pair of compression stockings (15-20 gauge) to reduce concentric muscle firing.

I would set my goals high at increasing this patients walkability, stride length and quality of life.

I would encourage him to use shoes with a + heel height as I wean away the lifts and add an aggressive physical therapy program to augment achieving your goals.

FYI:
all of his symptoms and x-ray findings are consistent with the Rigid Rearfoot Type and

my only diagnostic suggestion is that the rigid rearfoot usually is associated with reduced sagital plane ankle motion and so I believe there to be some functional equinus in your patient and I suggest you retest for ankle ROM.

Why set my goals for this patient at elimination of pain (as in tissue stress) when you can educate, instruct and monitor to a higher quality of life at 82.

Good Luck

Dr Sha

Dennis, so you have no problem giving advice on an orthotic without knowing whether the pain is intermittant claudication or mechanically related. A diagnosis and explanation of the cause of the pain is a good idea before you proceed with treatment.

Well, you did say to recheck ankle motion, but the poster did say that ankle range of motion was normal. I don't think you can know the pain is related to sagittal plane stress or not from the information given.


???? Where did you get that? How do stockings effect muscle firing. Is concentric firing bad?

Elimination of pain is a higher quality of life. I don't see why that shouldn't be one of your goals. Most of my patients come seeking relief of pain and not necessarily looking for enlightenment. (Even in Berkeley)

Eric

Wow, this is getting to be the treat using my favorite paradigm thread. Inverting the patient, as opposed to everting them, may help them, but not because they are closer to neutral. Hardly anyone stands in neutral so that is no way to determine who has pathology and who does not.

Eric

Kara:

I apologize for the personal nature of Dr. Fuller's reply which has nothing to do with your request for advice on care and an orthotic for your patient.

We all realize that any advice is being given with an understanding that there is missing information and we have never seen the patient. Eric's ego is mired in detracting my advice rather than give you any.

We can also assume that this was not a trick question and that your patient is not claudicating and in need of stat stenting. Eric, this is actually an insult to Kara in order to reduce the power of my advice.

I view my patients, biomechanics differently from Eric. Prevention, performance enhancement, quality of life upgrading (Wellness) in addition to pain and suffering relief.
Eric reduces biomechanics to "get pain and come to me".
Eric, What if FFTing identifies tissue stress at a subclinical level and prevents it from harvesting through the pain threshold (where would you be then?).
That is why I added my advice to Eric's in an attempt to assist Kara.

Kara, was this a contest or a request for some distant advice.

Please keep an open mind in considering all advice.
If you have questions about mine, please contact me personally as I do not wish to divert this thread any further with my participation.

Dr Sha

Hi Kara, biomechanics can be daunting!
If you conclude it is a biomechanical problem without using too much jargon I would cast this client and put him in an orthotic with a flexible polypropelene shell. ie 2.5 mm thick. (if he is overweight) line the ILA with an EVA for a little more strength but to also maintain some flexiblity.
Don't add any extrinsic heel posts as I wouldn't be looking for further heel inversion or eversion. You can at the review add an extrinsic post if you feel a neutral rearfoot position isn't doing the job. Some orthotic labs ask for arch height so you get good contact with the shell to the foot and I find in a case like this good support to the foot from his orthotic maybe all he needs to alleviate his symptoms (as well as the stretches) I would add a foam top cover.


Ask how the strapping went and even if shoes make a difference and this will help determine if it is biomechanical. A night boot can help with the equinus. Mention to him from the start that this maybe required if the stretches aren't enough. I get them to wear it nightly for 6 weeks.

Despite all the theory with experience you will get a feel for what is going to work. The best way and in my early years sometimes it was a painful way is to just get them back. But this should get you started. Good luck

Thank you all for your advice - certainly food for thought. My thoughts were that he is already inverted past neutral, so would it be beneficial to invert him further? (Or, as I trialled, evert the rearfoot to a more neutral position?) There were no signs of any arthritic changes in the foot joints on X ray, the limited eversion felt more muscular. There was still eversion, just not 1/3 : 2/3.
I shall do more testing next visit & see if the taping/ padding was successful. Will let you know, any more advice on what to check would be greatly appreciated!
Kara

Kara.

Before we go any furthur here I strongly suggest that you identify the tissue or structure that is pathological. (sorry Eric if I'm rehashing your post.)

Ask yourself the following questions.

1) exactly where does it hurt and what kind of pain is it. burning, stabbing etc

2) what is in that area i.e insertion of tendon, ligament, joint

3) what is the function of that structure/tissue

4) what would help reduce the strain on that structure/tissue

"Ankle/heel pain"- could be 1 of 50 problems. With different treatment stategies.

Scott

I really appreciate you attempting to take the high road Dennis. However, my advice was that we need more information before we can tell her what to do with her orthotic.

I apologize for Dennis getting personal as well. I was questioning as to whether generic advice would be good without having seen the patient. Functional foot typing appears to be generic advice regardless of the pathology the patient is having.


Dennis, I have been asking you numerous times to explain why you think functional foot typing is related to pathology. In functional foot typing you talked about looking at differentiating feet based on the supination end of range of motion among other things. Why does supination end of range of motion have any bearing on pathology. Dennis, this is not a personal attack. This is an attack on an idea that you have proposed. Please keep the two separate.

My advice to Kara is not to use any formulas to create an orthotic, but rather to design the orthotic for pain the patient is having. It is possible to have too much of a good thing. For example if her patient was standing relaxed, inverted, with additional range of motion in the direction of eversion then a valgus wedge could be the right thing. This would tend to be an over supinated foot with a laterally positioned STJ axis. Most feet stand within 1-2 degrees of maximal pronation. A more laterally positioned STJ axis foot will stand more inverted than that. This foot was classically considered a rigid forefoot valgus foot. This foot should be treated differently (needs forefoot valgus or rearfoot valgus wedgining).

Classically a foot with a rearfoot varus could be at its end of range of motion and still have its heel bisection inverted to the ground. This foot should be treated differently than the rigid forefoot valgus foot. If the foot in its maximally pronated position in stance has very little load on the medial forefoot (because there is no more eversion range of motion available, then the foot needs a forefoot varus wedge to more evenly distribute the weight across the forefoot. (You can also differentiate these foot types by looking at the wear pattern in the shoe.)

Non weight bearing observations at the end of range of motion of supination will have less relevance to pathology than looking at the foot where it actually functions.

Eric

Thanks all, px returned and said pain is resolved ( also on anti inflammatories).
Thanks for your input, I am sure I will be able to put it to use down the track!
Cheers,
Kara

Hi Kara,

Glad to hear your Pt seems to be improving.
Kara as stated earlier in the post by two different pods you need to come up with a diagnoses, you need to know what is hurting in order to know how to fix it.

now im not going to get into the debate about who is correct or not, as you are a new grad you are going to come accross these type of pt's a lot, so although this one may have resolved unfortunately the next one may not.
With an inverted foot type in RCSP you need to do what Eric suggested, you should never try and pronate a foot more than it can as this will cause problems/ pain further up the chain knee or hip or worse, also using a Mass type device has the potential to restrict pronation even more, by causing a greater supinatory moment.

One of the things I used to tell students both in the UK and here in sydney when they come for their clinical placments, is with Biomech you need to know your anatomy, if you dont know what is hurting it is impossible to fully treat with any paradigm, whether orthoses or exercise etc..
Sorry if this sounds patronising, not my intention.

hope this helps

Col.