Friday's Patient Problem of the Week:Supination and ankle problems

Good Evening Dr. Blake 

    I am a 33 year old  young man living in Los Angeles CA. I have been having ankle inflammation in my right ankle which started about 1 year and 7 months ago. It was a pretty simple episode that I got ankle cramp and I manipulated my ankle with my finger and got inflamed for over 8 months.

Dr Blake's comment: Inflammation in the ankle in somehow who stands like you do is very very common. It normally is a combination of muscle fatigue and mechanical stresses (flat feet, high arches, loose ligaments, tight muscles, etc). Typically, you place yourself into some logical problem of rest, bracing, anti-inflammatory, and stretching and strengthening. The rest part is activity modification where you try to sit more at work, or at least get a soft mat to stand on, and use weekends (days off) to recover. 

   During this time,  I was trying to not put pressure on my right ankle so I was putting my body pressure on the left foot. The inflammation was not going down with taking lots of Ibuprofen 800 mg twice to 3 times daily. I was having burning sensation and warmth feeling around my ankle all the way down towards my heel.

Dr Blake's comment:Burning can be from a lot of causes---neurological coming from local or as high as your spine, vascular with poor circulation, and inflammatory with marked swelling. Unless there is more swelling than you describe, this burning may be from some stress on the nerves, however could be from swelling deep within the ankle joint.

    I have high uric acid level which is approximately around 9.2 or little less over the past 12 years, and while suffering from burning and discomfort,  my ankle would get a warmth feeling when I was wearing shoes. I saw couple of podiatrists where one gave me lidocaine injection to increase blood flow to reduce the inflammation, but it did not help me. 

Dr Blake's comment: Nothing in the history you give sounds like gout, although there is mild versions of it. Typical Gout is red, hot, and swollen area, where you worry that there could be an infection in your workup. The high uric acid blood test could have just been a red herring. 

   Over the phase of 1 year I received 3 cortisone shots in my right ankle that it finally helped with the inflammation going down. When my ankle was inflamed, I was experiencing tingling sensation around my ankle which the tingling would be less when I was laying down on my bed.

 Dr Blake's comment: So, your tingling was probably from deep swelling putting stress on the tarsal tunnel nerves. Nerve pain is so debilitating, and your body goes quickly into a self preservation mode to relieve it. However, this preservation mode normally produces way too much muscle atrophy and severe weakness settles in. 

   After about 1 year my left foot started burning around the ankle and I have changed many shoes but I would feel the burning getting worse as I wore every shoes. My wife noticed that I walked not straight and she brought it up to me every time I walked. After reading and doing a lot of research online, I came to conclusion that I have severe supination and I still have a little inflammation on the right ankle with the burning sensation and tingling.

Dr Blake's comment: Best to send me a photo of you standing, barefoot and in shoes, from the back of the heels. The photo should be from 2-3 feet behind you in good lighting. This will help me understand the severity of your severe supination. Supination, with the lateral instability it causes your ankle, could explain all of your symptoms. That would be nice. 

http://youtu.be/bc2PRrtwemM



http://youtu.be/hxsNaBXT_ug

    I have been seeing physical therapy for couple of sessions and they have gave me stretches and some work out but I need your help Dr. Blake. Please respond back and try to eliminate my pain and suffering that I am having for the past 1 year and 7 months. My job is a Pharmacist and I stand on my feet over 8 hours. Please please get back to me to find a solution to my suffering. I would really appreciate your concern and attention Dr. Blake if you can make my wishes of walking normal without any pain. GOD may bless you and your family for helping a young married man gain back his strength and be pain free.

my cell phone number is XXXXXXXXX  please contact me if you have to and please help me with all my suffering.

Dr Blake's response:

     Thank you so very much for your email. I have tried to give it some attention. I am glad you are going to the Physical Therapist since they can be my eyes in my attempt to help some. 

The questions I would have from them:

1. Are you excessively supinating and, if so, can they design an inserts that completely eliminates that stress?

2. Do they think you have inflammatory pain or neuropathic pain? Neuropathic pain is true suffering. Ask them to teach you neural flossing and test for low back involvement. 

http://youtu.be/Xs8Cl39LXQg

3. Can they give you an Air Cast Ankle Brace for more stability but not a lot of compression?

http://www.betterbraces.com/aircast-sport-stirrup-1

4. If it is neurological, you should have a doc involved that can give you oral meds, topical medications, and be able to order MRIs, EMGs, etc as indicated. All your pain can be coming from the low back because it is so hard to stand in spine neutral constantly in your job.

http://youtu.be/E0E60NpOSHg



5. Ask the  physical therapist if an ergonomic evaluation of your work place can be done to make sure you know all the tricks at keeping your ankles and back healthy and minimally stressed. 

I sure hope this helps you some. 

Correcting for Over Supination in Orthotic Design

Shoe Wedging to Stop Supination

Supination following heel strike is one of the most deadly biomechanical problems. The shoe industry is starting to pay attention with a range of mor stable neutral shoes which will work with orthotic devices to stabilize that problem. However, almost weekly I need to do in-office shoe wedging to eliminate this problem even in the face of good orthotics and shoes. When we strike the ground walking or running, our legs must internally rotate from the feet, ankles, knees, hips and pelvis to absorb the shock. This internal rotation of the entire lower extremity allows the foot to pronate, and the foot to adapt to the ground. If our foot supinates at this time, forcing external rotation of the foot and ankle, problems arise in many ways. The foot can no longer adapt to the ground well and sprains can occur. The shock wave of heel strike will intensify potentially causing bone and joint problems. The peroneals and iliotibial band must work overtime at stabilizing the lateral/outside of the foot/ankle/knee/hip and strains occur. 

So, when I watch someone walk and run, I look for over-supination at heel strike. I see if simply the shoe needs changing from stability to neutral. I teach the patient how to perform lateral power lacing. I evaluate any shoe inserts/orthotics to see if I can adjust for anti-supination. And, I may also wedge their midsole as shown in the photos below to see if this helps eliminate supination at heel strike, and ease their symptoms. 

Lateral (baby toe side) of the midsole is opened with a scalpel. This process can be easily done by some shoe repair stores.

In this case, a 1/4 inch wedge of grinding rubber from JMS Plastics is placed into the opening. Both sides of the midsole and both sides of the wedge are initially glued with Barge Cement and let to dry for 10 minutes.

All excess wedge material is cut and ground off and SuperGlue is used to seal any gaps that did not seal completely.

The final product is shown. This patient Vince has chronic medial knee joint compartment disease, and this wedging has allowed him to avoid knee replacement successfully for the last 15 years by eliminating the excessive supination which was causing the medial knee compartment to compress abnormally with every step.

So, when evaluating individuals with various injuries, watching them walk and/or run, can give you great clues to treatment. Gait evaluation should be done in most non-acute injuries to see if gait changes may help. This is one example of this process in action. 

Biomechanics for the Podiatrist: Thou Shall Not Varus

  Blogging on Friday is Biomechanics for the Podiatrist    


The phase "Thou shall not Varus" is a bunionectomy phase for students and beginner surgeons to avoid over correction of a bunion. In this article, I would like to discuss a simple fix for patients who bring in shoes that over supinate them. This is also called under pronation, lateral instability or Varus Instability. After the foot is placed over 3-4 degrees of varus positioning, that foot can destabilize quickly and become laterally unstable. The YouTube video below describes this common problem most commonly observed as the patient walks away from you. 


     Lateral Instability or Excessive Varus Positioning can be helped in the office with simple shoe wedging at the time that the problem is noted. The following photos explain the process.

A scalpel is used to cut into the lateral side of the midsole normally from the heel to the metatarsal heads.

Then Barge Cement is used to glue the 2 sides of the opening and the 2 sides of the wedging material.

Here the 1/4 inch wedges, and they may be any thickness, are standing up with both sides glued and the glue is drying.

Here is a closer look at the wedge which is skived and the curved end to be placed into the distal end of the opening.

Once the glue has dried, the opening is forced wide, and the wedge is stuffed into the midsole as deep as possible.

Here is the side view of the wedge in place, the sides ground smooth, and super glue (or knock-off) used to seal any loose attachments.

Another view of this wedge from the back.

     One of my Golden Rules of Foot: Thou Shalt Not Varus. Over Supination has been blamed as a cause or aggravating factor in more than 17 injury pain syndromes, including peroneal tendinitis, ilio-tibial band syndrome, ankle sprains, stress fractures, knee and hip joint arthralgias, low back pain, etc. Patients who are too varus positioned as functionally unstable. Personally, I believe over pronation should get a little less press and over supination more. Definitely, this simple in office shoe wedging technique will help 1000s of your patients.

Samuel Merritt University Lecture on Gait Evaluation 9/18/11

        First of all, why do we perform gait evaluation on patients???

What are we looking at when we watch someone walk or run?

Where do we start? How about the Head and work our way down?

A Basic Checklist to use while watching someone walk or run follows.

[ ] Head Tilt

[ ] Shoulder Drop

[ ] Asymmetrical Arm Swing

[ ] Limb Dominance

[ ] One Hip Higher and Low Back Structure

[ ] Asymmetrical Hip Motion

[ ] Asymmetrical Knee Motion

[ ] Smoothness of Weight Transfer

[ ] Signs of Poor Shock Absorption

[ ] Heel Lift Issues

[ ] Apropulsive Push Off

[ ] Digital Clawing

[ ] Angle of Gait Asymmetry

[ ] Angle of Gait Position

[ ] Summary Right Side

[ ] Summary Left Side

http://www.drblakeshealingsole.com/2011/09/checklist-basic-gait-evaluation.html

And Here is Tiffany again who introduced me, our star podiatry student, walking barefoot. Again let us start at the Head.

What were our gait findings?

• Slight Head Tilt to the Right
• Little Dominance or Drift to the Left
• Slight Left Shoulder Drop
• Left Arm Swing Greater
• Outwing to Left Hip
• Leads with Left Hip
• Increased Internal Patellar Rotation
• Excessive Supination following Heel Contact left greater than right
• Digital Clawing

Here Tiffany is demonstrating excessive supination on the left side following Heel Strike and dangerous Varus Thrust at the Knee.

Now Tiffany herself will discuss the components of the Orthotic Device designed to prevent this contact phase supination following heel strike.

Here Tiffany demonstrates the elimination of the excessive supination with the above mentioned orthotic corrections.

This short video demonstrates Limb Dominance seen primarily in Short Leg Syndrome with body lean to the long side (80%) and to the short side (20%);

So, let's review the findings in gait evaluation which will give you an excellent idea if their movement can be correlated to their symptoms. But, this time, I will start at the feet and work our way upwards. The Green Areas symbolize normal motion or position.

Supinators: Various Gait Videos

    The video demonstrates excessive supination left side worse than the right clearly demonstrated by Tiffany. This is the first of a series of videos on supination and what orthotic modifications are utilized to treat it. Here also the varus thrust at the knee is shown  in the left knee, a potentially disabling force. As the tibia moves on the femur after heel contact in a varus direction, at a time when the knee should be flexing and tibia becoming more valgus, the medial knee joint compartment gets beat up.





This second video shows Tiffany with orthotic devices to prevent supination. A separate video showed the components of this orthotic device. The supination seen in the first video is eliminated after heel strike, and the varus thrust greatly reduced at the knee. There are patients who have foot pronation whom also exhibit varus thrust at the knee.




Tiffany here is seen without the Denton Modification (one of the simple orthotic modifications used to prevent excessive supination). Without the Denton Modification (and there is a separate video on its manufacture), Tiffany definitely supinates more following heel contact.


The components of gait evaluation are demonstrated by Tiffany Hoh, 3rd Year Podiatric Medical Student at Samuel Merritt University in Oakland, California. The findings include:

• Little Head Tilt to Right
• Little Dominance or Drift to the Left
• Slight Left Shoulder Drop
• Left Arm Swing Greater
• Outwing to Left Hip
• Leads with Left Hip
• Increased Internal Patellar Rotation
• Excessive Supination following heel contact left greater than right
• Digital Clawing (toe gripping)

Here Liz is seen excessive supinating with a running gait pattern. Excessive Supination is also called under pronation or lateral instability.

Supinators: How to Make a Denton Modification

This short video describes how to make a Denton Modification to control the forces of supination. It was created by Dr Jane Denton, Podiatrist, and can be used on custom made and some over the counter orthotics.

Supinators: Orthotic Modifications to Help Control Supination Motion

Tiffany Hoh, 3rd Year Podiatric Medical Student at Samuel Merritt University, discusses for Dr Rich Blake's Blog the components of orthotic devices that help prevent excessive supination. These include:

• Root Balanced Orthotic Device
• Zero Degree Extrinsic Reafoot Post
• High Lateral Heel Cup
• Lateral Phalange
• Denton Modification
• Valgus Wedge
• Reverse Morton's Extension
• Forefoot Valgus Extension

Supinators: Gait Evaluation Video

This short video shows the damaging motion of over supination (aka under pronation or lateral instability). Focus on Tiffany's left foot in particular following approximately every other heel strike where the heel rolls to the outside. Then focus later on her left knee motion demonstrating the varus thrust which can accompany over supination causing medial knee compartment compression forces and possible injury. This is the first of 5 videos entitled "Supinators". The entire series will show the correction of this problem with orthotic devices with the particular modifications needed and the introduction of the Denton Modification. See the link below to the possible injuries associated with over supination.

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-13.html

Podiatry Video Quiz #5: Which foot insert shows more supination tendencies?

This short video demonstrates the findings seen in over supination.

Basics of Gait Evaluation (Part II): Excessive Supination with Short Leg and Uneven Arm Swing

The Gait Findings noted:

• Head to the Right
• Body Lean to the Left
• Slight Left Shoulder Drop
• Increased Left Arm Swing over Right
• Left Hip Outward
• Internal Patellar Rotation 
• Excessive Supination Left greater than Right
• Digital clawing or gripping

Simple Shoe Modification for Supinators

The 2 photos below show a 1/4 inch wedge placed into the heel midsole to re-level a shoe that is beginning to break down due to over supination (the motion of spraining your ankle). This can be accomplished by a local shoe repair shop although bring in the photos. Many of my patients are in great shoes, but they just do not have enough stability in this area. This rolling out motion of the heel is also called lateral instability. The shoe wedge gives a strong resistance to that motion. If done correctly, you should never feel like you then roll your feet inward (the opposite motion of over pronation). You want to resist supination, but not become a pronator.

Good Running Shoe for Supinators: Consider Saucony Triumph 8

Here is a view of the Saucony Triumph 8 from the side. The shoe is a neutral shoe, which for supinators can be too soft and unstable, but this one seems to work well. As the video says it has some good qualities that make it stable. One of my patients EB brought this shoe to my attention. It works very well for her and she is a significant supinator.

Here is EB in the Saucony Triumph 8 left shoe from the back view. You can see how vertical it holds her foot, although she has an insert to stop some of her supination.

     Running shoe stores can tend to use to many generalizations and one of them which has always bothered me is that supinators need neutral cushioned shoes. Many supinators, with orthotic devices to correct some or all of that supination, due the best in stability shoes. I am always fighting these neutral shoes when trying to stablize an unstable foot. So, I hope this Saucony Triumph 8 stands the test of time.

Supinators: Wedges for the Shoes (Email correspondence)

This post emphasizes the problems supinators have in getting appropriate treatment. Here Ramin goes to great lengths to help his relative. With 10-15% of the population supinators, these heroics should not have to happen.

12-1-10 Phone Call from a great son-in-law looking for help obtaining a wedge to help with over supination for his mother-in-law. Advised to email specifics.

Dear Dr. Blake,


Hi. Thank you very much for returning my call. I appreciate it and I apologize that I was unable to answer when you called; my schedule has been filled with a lot of meetings the past couple of days....

Basically, the type of shoe insert that my mother-in-law needs is similar to the attached photo that I found in a sports journal article, and also is similar to what you have on your website (http://www.drblakeshealingsole.com/2010/06/help-for-supinators-lateral-shoe.html) except that the one on your website goes in on the outside of the shoe and what she needs is an insole that gets inserted into her shoes. The reason is that her legs have become bow shaped (like parentheses) and she has pain in her knees; her doctor has suggested the use of this type of insole so that over time the pain is lessened and the bones begin reshaping and move inward.

If I'm not mistaken, this is called a Lateral Foot Wedge (correct?), that according to her doctor would be about 1 cm at the thickest side at the outer edge of the foot where the little toe is, and gradually thins out as one moves toward the big toe. My mother-in-law lives overseas and I'm flying to go visit her and the family on December 10th, so I'm hoping to have something in hand before then to take with me.

Some more information in case it helps:

Her shoe size: European size is 37, which corresponds to 6.5 American size.

Type of shoes she wears: For going outside, she wears Dr. Scholl's medical shoes (flat bottom with a bit higher ledge than regular shoes). For inside (where she spends most of her time) she wears plastic home slippers with flat bottom that are closed in front (it'd be great if the insoles would work for these considering that the back side of these is open, I believe).

I'll give you a call later to get your invaluable advice. Also, since you mentioned that you can make one of these for her, can you please let know how much it'll cost for a pair?

Thank you enormously and best wishes,

Ramin .
 
 


12-3-10 Email from me back to the great son-in-law

Finishing inserts now how do I get them to you rich

Email from the great son-in-law

Wow, that's amazing! Thanks so much for your expert and invaluable help. If possible, please send the inserts to my address:

12-7-10 Email
Hi. Thanks very much for your follow up.Yes, I did receive them yesterday. I'm flying out on Friday and will take them with me. My wife and I will be back in early January and I'll definitely get in touch after we get back.


My mother-in-law sent her regards and asked me to thank you enormously for your help and kindness.

Wishing you and your family a great holiday season and a happy new year,

Ramin
 
Editor's Note: Poor Supinators get a bad deal since the shoe world never addresses their issues. They need a good support group. These wedges I made should help her. I made 2 pairs, one to send back if there was some problems that I could adjust and mail back. See the links below to other supination posts.
 
http://www.drblakeshealingsole.com/2010/06/help-for-supinators-lateral-shoe.html
 
http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guideline-18.html
 
http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-13.html
 
http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-9.html
 
http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-8.html
 
http://www.drblakeshealingsole.com/2010/04/quick-tip-4-monthly-shoe-check-for.html
 

Supinators: Help with Lateral Shoe Wedging

     There is really no great shoe for people whom overly supinate (roll their feet to the outside like spraining their ankles). One way that podiatrists, pedorthists, and shoe repair people handle this problem is with lateral (or valgus) shoe wedging. The wedging can be placed on the outersole or into the midsole as demonstrated by these photos. With excessive supination (aka lateral instability) accounting for 17 known symptoms, including ilio-tibial band strain, low back pain, ankle sprains or strains, cuboid syndrome, etc., this common wedging process can greatly diminish symptoms caused by this motion.

     The photo above demonstrates the initial cut with an eleven or ten blade half way up the midfoot and half way through the shoe from lateral to medial. The cut goes from the ball of the foot to the back of the heel.

Once the scalpel has made the cut, barge cement is applied to the inside of the shoe.

     Depending on the size of the wedge needed, grinding rubber (I purchase from JMS Plastics) is beveled and then both sides are glued and left standing to dry. Here 1/4" wedges are being made for multiple shoes. The front end of the wedge (placed into the front part of the shoe) is slightly rounded before skiving to ease in the shoe placement.

     Here is a closer view of the shoe wedge with the beveled part that will be placed into the shoe first (go in the deepest) and the rounded front part.

Here is the wedge being shoved (yes, shoved!!) not so gently into the shoe as deep as possible.

     Here is the shoe wedge from the side view after initial sanding to make presentable.

     Here is the finish product of a 1/4" valgus or lateral midsole wedge to fight excessive supination tendencies. Super Glue or one of its knockoffs is normally used here to seal any gaps. It takes time working with the Barge Cement to know how long to wait before applying the wedge. The patient should never feel that the shoe now overly pronates them. If so, there is too much wedge. Normally when this happens, this wedge is removed and a new one one half that thickness is then applied.