Hi Twirly/ Bel
Start with the easy ones I say
.
I'm certain that if you take DH, RI, DS and DTT you would have 4 different approaches to the whole thing. Then you need to add in whether you consider more proximal issues to be involved and not just the foot which may make you take biomech' assess' much further. Interestingly there would be varied amounts of time spent in a biomech assess by all the above as well.
Therefore, to try and make this more
"visual" for visual learners, I am posting the following as an "in context" example. There may be many other things about the following situation I might consider but the following is enough for now anyway. Hope you can follow it.
Case StudyFemale, late 40's, diagnosed by GP with right foot heel pain he classed as PF.
History of broken Fib on the left in last three years; leg in plaster; then took 12 months after healing for pt to weight bear fully on the left. Right foot now has heel pain that seemed to come on after weight loss and new exercise routine (not vigorous). Certainly largely over weight.
Some discomfort to the right lateral ankle with some swelling. Wakes her up at night and feels she has to click the foot by rotation in order to free it up before she can go back to sleep. Feels she drifts to the right in gait.
Assuming relevant histories are taken, that you have noted pts posture and shod foot function as they walk from the door to the chair, the following are some of the things that may go through my mind:
1. Is the issue really PF? Whatever it is, is there a compensatory gait from previous injury?
2. The diagnosis could be inaccurate? So check. Simple step is to palpate the PF and determine what you think. This is important as some of the symptoms of PF could also be applied to other issues. Surprise, the origin of the PF is clear of symptoms on palpation. Continue on along the PF applying pressure to the length of medial, then central, then lateral bands, then along the slips into the base of the proximal phalanges. What are your findings as these will inform some of your intervention. Still no signs. OK, then maximally evert the heel and try again. Still no signs, add in a pronated MTJ and try again, still no signs, further add in dorsiflexion of the toes. Still no signs.
3. What options have we left? Well there could be trigger point issues in the gastroc’ or soleus (as well as very tight posterior compartment group) but we leave them out for now, similarly at this point possible neurological components, and look at some of the muscles around the origin of the PF. Take Abductor Hallucis for example. Palpate along its length. Aaah pain.
So we may now have the source of pain even, possibly, a diagnosis but now we are left with a possible contributing joint active mechanical contributor to find.
4 Observei) The lady in stance. Note the basic alignment of the feet. Neither have particularly lowered medial arches but the left is slightly lower than the right and this seems to be in the area of the MTJ rather than the STJ.
Why?
Well in this case if we look closely at the right foot we can note from the shape it suggests it is more laterally loaded than the left and if we look from the rear we note that the calcaneum is at vertical, where as the left is slightly everted. There are upper body issues that may also imply this foot situation or vice versa.
ii) Briefly watch her walk. Observe for any of the drift that she has suggested happens. Why, yes! both at heel strike and foot flat she has a tendency for marked ankle wobble and drift to the right and uses the upper body to compensate to keep herself centred. Then at early heel lift she seems to exhibit a sudden and fast pronation at the MTJ, the ankle wobbling all over the place again.
OK what foot structures might be over working to maintain stability and are they generating tissue stress? Could this be what has affected Abductor hallucis?
5. NWB check the amount of available eversion, from STJ neutral and compare it against the possible amount of FF supinatus you see. (Is there enough bend/rotation - see another post of mine - at the STJ bilaterally?) Hmm, there is a right heel in slight varus when the foot is in neutral. it moves minimally from there to vertical and no further (not enough bendy at the STJ for the amount of ff supinatus I am seeing). Consistent with the heel positioning you saw in WB.
6. What now.Structurally, WB in gait, I now want to alter the type of instability I am seeing in the right foot. That is, I want to reduce the level of wobble and to do this one option I might take is to produce an orthosis prescription that has the left foot with a vertical heel and 2deg intrinsic varus post and a right device that has a vertical heel with a 2deg intrinsic valgus post. This valgus post is there to create a pronation moment. That is, a reaction force that in this case serves to resist the tendency for the right foot to want to go over laterally. You can apply this post on the front of the device or in more extreeeeem cases use a lateral heel skive to achieve a similar thing. In both devices I am wanting the apex of the arch to be around the navicular area. (just a fetish I have)
Net result has been a less unstable gait (less wobbly) especially on the right, more confident and controlled gait, likely less tissue stress going through the foot as it is less wobbly. Plenty of soft tissue massage and maybe some wobble cushion wok to improve ankle function and proprioception.
Although this sounds protracted as a written piece, all the above assessments can be achieved in 10 minutes (excluding the casting and soft tissue work).
Hope this contextual example approach has worked. Clearly it is but an example.
Maybe others can do similar with their responses. I know we'll all be different with our approaches and it is worth bearing in mind that even with agreed protocols, in reality ( taking into account more proximal issues) each case should move you outside of the protocol somewhat as each is unique (just my opinion).
Cheers
Ian