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Saturday, April 16, 2016

Question from fellow podiatrist

Hi Dr Blake,

I had a patient who presented today with pain in the anterior as well as anteromedial aspect of both knees, hamstring pain bilateral, ITB pain on left side and numbness on soles of both feet. The patient has had the knee pain for over 30 years due to a fall during sporting activities. Severity is about a 7/10 and standing / walking makes the knee pain worse.

Patient only has hypertension and takes medication for it.

On examination, there was limited knee flexion, hip internal rotation, MTJ ROM, 1st MPJ bilaterally.

STJ axis was severely medially deviated for the right foot where the line of the axis exits through the mid arch area.
The STJ axis was medially deviated for left foot, however it was less severe with line of axis exits below the 1st metatarsal head.

Supination resistance was very hard for right foot(where I could not even move it) and hard for left foot.

The patient RCSP was 8 deg inverted (right) and 6 deg inverted (left)

Jack's test was moderate for both feet with no arch increase / windlass mechanism activation.

Did not do a gait assessment as patient uses a walker and he finds it difficult and painful to walk.

My diagnosis was patellofemoral pain syndrome with medial plica irritation bilaterally as I was able to reproduce the symptoms on palpation bilaterally. The patient also had tarsal tunnel as the Tinel's sign was positive bilaterally. I have also ordered knee x-rays.

My thoughts are that the excessive pronation is causing compression on the tibial nerve as well as increasing the stress on the patellofemoral joint. Besides that, the tight and weak quads, tight hamstrings may also be causing patella maltracking as well as irritation of the medial plica as the quads have to work harder during gait.

In terms of treatment, I have advised patient on footwear and icing. I have also learnt some tool assisted massage which I can use for the tight quads and hamstring since I think the patient is not able to do quad and hamstring stretches as he is using a walker. I am also thinking of supine straight leg lifts as part of the tx plan to strengthen the quads.

As far as orthoses prescription go, I am a bit lost. Do I just use an accommodative device
or use a Fettig modification on an inverted type device?

Have you had cases like this where the STJ axis is medially deviated but the RCSP in inverted and also where the STJ axis is laterally deviated but the RCSP is everted? What kind of orthoses prescription do you use for these cases?

I find this case to be challenging and your thoughts would be greatly appreciated.


Dr Blake's response: Thank you so very much for the question. First of all the deviation of the subtalar joint is only one part of an evaluation. Medial deviation is a sign that the foot has a tendency to pronation, whereas lateral deviation is a sign of the tendency to supinate. However, other forces can override this, especially sagittal and tranverse plane external forces. I suspect his external hip position is pulling his whole foot laterally, and the rigid nature of his knees and feet can not alter that. That being said, this is a typical presentation of an elderly patent who needs accommodative orthotics with valgus wedging added to the ortho after dispense. The soft based full width orthotic devices will give him great shock absorption and added stability. After dispense, correct any lateral instability (aka supination) with some form of valgus wedge. And you are correct to work on the tight and weak muscles to ease his walking. Hope this helps. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.