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Hi,
I have never posted on here before although often use this site as it's an excellent source of information. I am hoping for some advice/thoughts please?

I have recently been asked to treat a Hockey athlete for what the physiotherapist has diagnosed as 'shin splints'. He is 22 years old, slim and a strong athlete. He complains of pain on the medial aspect of the distal 1/3rd of each tibia. He has struggled with this on/off for a few years although the symptoms have become increasingly bad, limiting his training since June 2010. He is currenly been advised not to train.
I often find it difficult to make a clear diagnosis on a patient with these symptoms i.e. PTTD, MTSS, compartment syndrome. The physiotherapists and doctor are now considering pressure testing for compartment syndrome.

He has bilateral mild cavus feet and marked tibial varum, the rearfoot of inverted at initial contact with little rearfoot movement following heel contact. There is no significant coxa-valga/vara and the femoral neck angle appears normal.

The patient's previous podiatrist suppleid custom foot orthotics, 3mm polyprom with 4mm lateral heel posts. The patient explained that he did not notice any improvement with these orthotics.

I understand the reasoning for correcting the rearfoot with lateral heel posting and also wondered if perhaps the medial compartment required further stretching? However, as this method did not work my thoughts were that the loss of shock absorption and the marked tibial varum increase stress on tib. post. and increase the strain and bowing of the medial/anterior aspect of the tibia.
I supplied him with 2mm custom carbon fibre orthotics with medial heel posting. Initially his symptoms improved for 1 month although following a weeks intense training the symptoms have returned.
5 days ago I adjusted his orthotics and increased the medial posting. The athlete is comfortable wearing them walking although has yet to train in them.

The physio's and doctor are now considering pressure testing as they believe consercative treatment has failed although I wonder if my train of thought is in the completely wrong direction or if anybody has any thoughts on how to help??

Your feedback is greatly appreciated.

Thanks,

Mhairi F.

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Welcome to the arena Mhairi,

Is the nature and presentation of the athletes pain suggestive of a chronic compartment syndrome? (i.e. Can he train through the pain? Does he report feelings of a vice around his leg?) In my opinion compartment pressure testing should not be requested just because conservative treatment has failed. You can usually justify the request for pressure testing based on the clinical presentation of the symptoms.

MTSS + marked tibial varum. It's all about the bending moments of the tibia. if you haven't already I recommend you read this thread which covers it all in considerable detail and should help with your orthoses prescription decision making: Medial Tibial Stress Syndrome

It will then also make sense why your athletes previous prescription (lateral posting) did not help at all. It's not uncommon for some of these athletes to require fairly substantial full length medial wedging to get full symptom resolution.

All the best

IG

Hi Mhairi.

Maybe suggest an MRI to find the exact source of pain -

Boney - stress reaction/fracture, muscle

Sounds like the medial posting for the heel worked well, what about forefoot posting - maybe add a forefoot Varus post.

Here a great thread for you to read.

http://www.podiatry-arena.com/podiat...ead.php?t=1898


Re pressure testing depends on what you think the cause of the pain is. there are 2 camps of thought here.


ie increased bending moments on the tibia not going to give information of any use

Muscle/compartment issues causing symptoms at medial tibia.

I would add icing 25 min 1-2 daily and triceps surea stretching to the program

Hope that helps

__________________
Mike Weber.



Crazy Mary

Something about great minds and same thoughts again Ian.

__________________
Mike Weber.



Crazy Mary

Hi Ian,

Thank you for the speedy reply.

Yes I completely agree that pressure testing should not be recommended at this stage as I am sure the orthotics can off load the site better and I don't believe his symptoms are that of compartment syndrome. He can train through the pain although has been advised not to.

Thank you again for the link, I'll have a read just now.

I think my main concern was that by increasing the medial would I increase the chance of developing a lateral ankle injury? I expect not although I'm being cautious.
thanks
Mhairi F

I think there is always that possibility. Just make sure you councel the athlete well.

Are they marked impression from the foot in his shoe? Callus location?

There are two reasons for an inverted heel in stance. One is that foot is at it's end of range of motion in the direction of eversion and is still inverted to the ground. The other reason is that there is a laterally positioned STJ axis and the foot has achieved equilibrium where the STJ is significantly inverted from it's maximally pronated position. Are you familiar with the coleman block test? Are you familiar with testing for maximum eversion height?

If the patient cannot evert their lateral forefoot off of the ground then a plausible explanation for the inverted heel and medial tibial stress is very high loads on the lateral forefoot. If this is the case then, as suggested above, a forefoot varus wedge in addition to the rearfoot varus post. If the patient has a lot of eversion range of motion then this woulb definitely increase his risk of inversion injuries or peroneal tendonitis.

Eric

Hello Friel Mhrairi,

Your query below caught my eye. I don't engage much these days in discussion as I feel at quite a distance from how the mainstream practice. Probably, the gulf is getting wider. Nevertheless, some deperados out there may find something from another perspective.

As you describe his foot function and location of symptoms I'd expect to be able to palpate tenderness by pressing into the soft tissue just behind the medial edge of the tibia. It cannot be much other than FDL m. With the problem being so long standing I'd also expect tenderness to be palpable at many points along that edge of the tibia as well = bone stress with active trigger points in FDL.
As part of a package of treatment dry needling the triggers and other acupuncure techniques will give considerable benefit. Only anecdote but I have had success with far longer duration cases while increasing their level of activity.

So not treating the cause yet, which is quite probably the biomechanics.
From your description I would be expecting the problem to be coming as Eric said from overloading of the lateral forefoot, with possibly the beginnings of retracted lesser toes. My first mechanical focus would be on providing elevation for the lateral border possibly extending into a reverse morton's or a valgus wedged extension. I would be leaving the rearfoot alone as you already have a laterally unstable foot. I would also be very careful not to cause any supinatory moments into the midfoot through the medial arch.

Whilst it is not uncommon to get some short term improvement from medially wedging an already laterally unstable foot (by changing function enough to alter forces in the tissue) you are very likely to cause long term harm. I've seen this happen many times. To speak simply, these feet do not have any issues with excess eversion/pronation at any stage of gait in any segment of the foot and to apply any medial wedging at any stage is illogical to me (despite any theories that have been put up to support it). Any medial wedging applied at best will still interfere/cancel out the lateral stabilty you may be trying to impart.

This will still be a difficult case due to its chronicity. If I had him settled in 8-12 weeks I'd be very happy.

My comments are just on the face of what has been presented and hopefully succint.

All the best
Shane

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Shane Toohey