We would like to welcome you to our Open Day at the DLT warehouse, offices and showrooms in Huddersfield.
Free entry and open to all with special offers and discounts on the day. Our famous Yorkshire hospitality will be on display with plenty of food and drink for you to enjoy.
• 10% Discounts on the day
• Deals on equipment
• Want to view a particular product?
Email JulianBall@dltchiropody.co.uk and he will arrange this for you.
The day will run from 10am to 4pm on Saturday 8th June. We are running two workshops:
• An introduction to using Radial Extracorporeal Shockwave Therapy which is a safe and effective treatment for chronic muscle and tendon pain. Times 11am – 12pm & 1pm – 2pm.
• Heat Moulding ICB Orthotics – ICB Orthotics are very versatile and can be custom fitted by heat moulding to the patients foot.
Times 10am – 11am & 12pm – 1pm.
To guarantee a place please use the booking form here but there will be many spaces on the day.
A Dorsiflexed 1st Ray (Metatarsal) also known as metatarsus Primus describes a deformity in which the 1st Ray /Metatarsal lies in a dorsiflex position relative to the lesser metatarsals.
The first ray is made up from the first metatarsal and the medial cuneiform. The ray facilitates movement in all three planes however predominantly produces the frontal and sagittal plane movements of dorsiflexion coupled with inversion and plantarflexion with eversion. This is due to its axis being 45° to both of these planes.
The biomechanics of this condition and the compensatory mechanisms and the resultant limitations need to be considered to understand both the function issues and the possible treatment that will need to be proposed for this condition.
The first ray (metatarsal) normally sits parallel to the plane of the lesser rays with equal amounts of dorsiflexion and plantarflexion usually 5mm up and 5mm down to allow the required plantarflexion to enable 65° to 75 °of MPJ dorsiflexion during the propulsive phase.
A Dorsiflexed 1st Ray is an osseus deformity where the lesser metatarsals sits lower to the bisection of the 1st Metatarsal when the foot is in the STJN position.
The condition may be congenital or acquired and is often referred to as ‘metatarsus primus elevatus’ or simply the prime metatarsal is elevated in reference to the lesser.
It should not be confused with Forefoot Supinatus as once the foot is placed in STJN the shaft can, with a supinatus, be plantarflexed. However, we should understand that the dorsiflexed 1st can be both fixed and or mobile in nature.
Because the 1st metatarsal is dorsiflexed it encourages the foot to collapse medially inhibiting the phalange from propelling over the 1st MTPJ, jamming occurs and a reduction in the ROM of the joint may be experienced.
The result of this jamming will be a stiffening of the joint and often the patient will develop an adductory twist in gait to reduce the load on the 1stMTPJ, as this occurs callosity will develop on the medial aspect of the hallux.
The distal phalanx of the hallux can also be forced into dorsiflexion as a toe off compensation, causing a hole to wear on top of the shoe and thickening of the nail from the constant trauma on the dorsal toe.
Clinical assessment of Metatarsal Phalangea Elevatus ( MPE) involves the evaluation of the sagittal plane position of the joint. The patient is evaluated in a non-weight bearing supine position with the subtalar joint in its neutral position (use the ICB AAM method) for Neutral.
As previously stated Metatarsus primus elevatus can be described as being congenital or acquired and can be further classified as a rigid, semi rigid, mobile or hypermobile deformity. A normal range of motion usually indicates a congenital deformity whilst an acquired.
MPE is characterised by an abnormal range of motion. This may be due to tibialis anterior contracture or associated with a forefoot supinatus.
The main issue is that the elevated metatarsal encour-ages the foot to function similar to a forefoot varus and excessive pronation is a key element as the foot collapses medially to allow normal ground contact in the toe off phase. Treatment will be a Morton’s ramp extension.
The purpose of the treatment is to allow a more normal ‘toe off’ to occur in the gait cycle by filling the gap under the 1st MTPJ whilst supporting the proximal hallux and thereby allowing earlier loading to occur.
To create the Mortons ramp to lift the proximal hallux this can be achieved by using a ICB 4° Forefoot addition (acts like a Morton’s ramp Image 9) to support the hallux and allow it to propel over the 1st metatarsal joint during toe off stage of gait.
A Full Length orthotic can also be used to create a Morton’s extension, use the forefoot addition to provide the required lift. See image 10 add the addition and mould to the foot in Neutral. First mark out the Morton’s extension ramp shape , cut and use a hand grinder to smooth the distal edges.
Orthotic therapy is not an exact science, so be prepared to adjust the orthotic for the patient by adding or subtracting as needed.
General REFERENCES
1. Merriman, L.M. and Tollafield, D.R. (1995) Assessment of the Lower Limb. Churchill Livingstone, Singapore Figure 2: Evaluation of first ray position(Merriman and Tollafield, 1995)
2. Root M L, Orien W P, Weed J H., 1977 Normal and Abnormal Function of the Foot. Clinical Biomechanics Vol 2, Los Angeles
3.Merriman’s assessment of the Lower Limb 3rd Ed. Churchill Livingstone
The knee joint is the largest joint in the human body consisting of two articulations: one between the femur and tibia, and one between the femur and patella. It is commonly described as a ‘hinge joint’, being a combination of a hinge and pivot-joint, which permits flexion and extension as well as a slight internal and external rotation.
The knee joint consists of an articulation between four bones: the femur, tibia, fibula and patella, and comprises of four compartments. These are the medial and lateral tibiofemoral compartments, the patellofemoral compartment and the superior tibiofibular joint. The components of each of these compartments can suffer from repetitive strain, injury or disease.
There are many reasons for experiencing knee pain such as, sprained ligaments, meniscus (cartilage) tears, tendonitis, and excessive supination and excessive pronation. The knee is a complex joint, and it can experience pain due to an exaggerated Q angle of the upper leg, for example.
Some of the conditions that can affect the anterior knee compartment are conditions such as :
Patellofemoral pain syndrome
Chondromalacia Patella
Osgood-Schlatter’s disease
Sinding Larsen Johansson syndrome
Knee bursitis/Hoffa’s disease
Generally in this article we will be dealing with non-trauma induced pain or biomechanically induced pain which is often described as idiopathic in nature.
Often when the subject is discussed terms such as ‘Retro Patella pain’, ‘Patella Femoral Dysfunction’, ‘Medial Compartment Syndrome’, ‘Chondromalacia Patella’ or ‘Iliotibial Band Friction Syndrome’ – these conditions are descriptions of knee pain (or pain centres) and do not indicate causative factor/s contributing to the experience of the pain.
Generally pain can be experienced Medial, Lateral or Anterior aspects and it is recommended that the Symptomatic treatment approach is adopted which, treats the pain and then progressively treats the underlying causative factors.
Understanding the dynamics of the knee joint is important in understanding why certain foot mechanic issues can impact upon the knee compartment. The knee is one of the most important joints in our body, playing an essential role in movement related to carrying the body weight horizontally (in running and walking) and in a vertical direction (jumping and absorbing ground reaction impact). The ligaments surrounding the knee joint offer stability by limiting medial and lateral movements, and together with several menisci and bursae, protect the articular capsule.
There is an allowance in the knee joint for a small amount of medial and lateral movement of between 3°-5°. Movement in excess of this puts the patient at risk of experiencing medial collateral ligament and lateral collateral ligament damage.
Both excess pronation and excess supination can have a deleterious effect on the medial and lateral collateral ligaments as outlined by Michaud 1 in which he states that for every 1˚ of pronation and or supination, the tibia internally or externally rotates 1˚, which in turn impacts on the knee joint, as it bears the stress generated by the tibial rotation.
When both excessive internal and excessive external rotation are experienced together excessive movement of the patella ligament occurs and pain can be experienced anteriorly.
Tiberio(2) notes that malalignment factors such as, excessive rotation of the lower leg which accompanies subtalar joint pronation has been cited as a major contributor to patellofemoral dysfunction.
There appears to be a direct link to knee pain from foot mechanics issues and therefore identifying and treating basic lower limb biomechanics appears to have a beneficial affect for patients.
Controlling both pronation and addressing any issues with forefoot will be a determining factor in addressing anterior knee pain.
The medial collateral ligament (MCL) connects the femur to the tibia, whilst the lateral collateral ligament (LCL) connects the femur to the fibula and both work to stabilise the knee by bracing and protecting the sideways movement.
The lateral collateral ligament is placed under stress by lateral biomechanical factors such as supination, internal lateral rotation of the tibial shaft and the impact of an untreated forefoot valgus deformity.
Patients that present with a high forefoot valgus FFTVL in excess of 10° will supinate their foot from heel strike to toe off which will stress the lateral knee compartment.
Excessive pronation will cause internal tibial rotation producing stress on the medial collateral ligament.
Idiopathic anterior knee pain however, is often results from a combination of both pronation and supination in which the anterior patella attachment is aggravated by the Lateral to medial movement in the gait cycle.
A Forefoot Valgus less that 10° will allow the patient to heel strike lateral, the ground ‘reaction forces’ are sufficient to propel the foot into pronation at mid stance to toe off due to the lower Forefoot valgus deformity.
The movement at mid stance, in this situation, is rapid and as the supination to pronation movement occurs the patella tendon moves lateral to medial placing additional stress on the tendon.
Stabilising the foundation and reducing excessive movement around the sub talar joint ( STJ) is essential, a reduction in tibial rotation will have beneficial effects on collateral stress at the knee compartment.
A key point in the orthotic therapy to treat knee pain is that the orthotic is correctly fitted and aligned to the bisection of the calcaneus and the alignment of the tibia or tibial varum angle. Failure to adequately address this issue will result in the patient continuing to exhibit the same foundational instability or allow the patient to, in the case of pronation, to ‘collapse the arch onto the orthotic’ due to the poor rearfoot correction.
Patients often ask if sports tape can be used to treat a condition, in place of customised foot orthotics. Sometimes this arises out of financial considerations, and other times because they do not understand the specific roll that a taping procedure plays when treating lower limb biomechanical dysfunction.
Practitioners can incorporate taping therapy into their treatment regimes to help patients who may be unsure of the value of orthotic therapy, and so identify whether orthotic therapy will be of benefit. Sports taping techniques can be incorporated in conjunction with orthotic therapy for a period of time to provide optimum results for the patient.
There are numerous conditions for which a taping procedure can be beneficial such as, Plantar Fasciitis, Osgood Schlatter condition and knee pain (Chrondromalacia Patella syndrome).
Plantar Fasciitis ( heel spur syndrome) is a classic case where the use of a low dye strapping technique is particularly effective as a temporary treatment to ‘mimic’ the realignment and support provided by an orthotic device. ‘Low dye’ taping seeks to control the foot and lift the longitudinal arch at the susentacula tali area, to limit excessive calcaneal eversion. The mechanism used controls the rearfoot, lifts the arch, shortens the foot structure, which in turn reduces the elongation of the plantar fascia and tension at the calcaneal attachment.
This method of treatment is very effective, however, the sport tape must be replaced within 3-4 days, some patients have allergic reactions to the zinc oxide tape. Low dye taping is especially effective for long term foot pain sufferers, such as Severs Disease and patients with Achilles Pain, when used in conjunction with an orthotic device.
Note in figure 1 (below) how the tape is crossed over in a ‘figure of eight’. Watch the video below for the Low Dye Strapping technique.
Osgood Schlatter Condition is one which responds very quickly to a combination of orthotics (to treat the excessive pronation) and strapping (to reduce tension on the patella tendon). The complicating issue with Osgood Schlatter is external tibial torsion, which should be treated by a practitioner who uses ‘gait plate’ orthotic therapy to correct the torsion. Growth spurts combined with excess pronation, a highly active child and external tibial torsion are all contributing factors.
Strapping may be used exclusively to treat to Osgood Schlatter (see fig. 2 ). However the condition and associated pain often appears to ‘flare up’ and so controlling the patients’ biomechanics is essential for effective treatment.
Medial knee pain due to excessive pronation can be assisted using orthotic therapy and the McConnell strapping techniques to stabilise the patella. Internal tibial rotation is associated with excessive pronation, resulting in medial displacement of the patello-femoral path and encouraging lateral displacement of the patella (knee cap). See Fig 3 below This is a common problem and elicits pain and around the medial aspect of the patella, especially with excess loading activities such as running.
Internal tibial rotation is also responsible for creating medial collateral strain of the ligamentous structures that wrap around the medial aspect of the knee and lower leg (Cosgarea, 2002).
Excessive pronation causes excessive strain to the medial co-lateral ligament. As a factor of this condition the VMOs weaken and the ITBs tighten, causing external rotation of the femur as a compensation. The patella begins to track on the lateral aspect of the femoral condyle, crepitation and grating feeling is experienced on flexion to extension.
As mentioned strapping using the McConnell technique and strengthening the VMOs is a good treatment regime, however, it will NOT correct the cause of the problem, only assist in pain relief.
Anecdotal studies have supported that in clinical practice, patellar tape provides a useful treatment technique, clinical and research evidence supports relief of pain associated with PFPS (patella femoral pain syndrome)1 The condition and pain will generally recur constantly until the knee has degenerated or become OA (osteoarthritic) – at which time surgical intervention may be needed.
A basic requirement to reduce rotational stress on the knee is control and correction of the STJ (Subtalar Joint) and MTJ (Midtarsal Joint) pronation and this can be achieved with an orthotic device that corrects rearfoot pronation.
The most effective biomechanical treatment for medial knee pain, involves the following 3 steps:
1. McConnell Technique – to control lateral/medial patella displacement.
2. Low Dye Strapping – to mimic orthotic treatment. However, low dye is only a temporary treatment.
3. Orthotics to stabilise the structure and limit excess pronation. The orthotics should be moulded to the patient’s NCSP (Neutral Calcaneal Stance Position) Otherwise described as Ideal position.
This action will control STJ and MTJ pronation – making it more effective in producing long term results for the patient.
REFERENCES :
1. Patellar taping: is clinical success supported by scientific evidence K. Crossley*, S. M. Cowan*, K. L. Bennell*, J. McConnell. Manual Therapy (2000) 5(3), 142-150
COSGAREA, A.J., BROWNE, J.A., KIM, T.K. & MCFARLANE, E.G. (2002) Evaluation and Management of the Unstable Pa-tella, The Physician and Sports Medicine, 30, 10
One of the most profound changes to affect the study of foot function was the theory proposed by Root etal (Root 1964, Root et al 1971) which outlined the concept of a measurable neutral position about which the foot was supposed to function.1
There has been much conjecture about the relevance of Neutral Calcaneal Stance position (NCSP), other-wise described as a patients unique Ideal position. However, still today the ‘Root Theory’ has stood the test of time albeit with alternate theories and modifications to ensure that the process works in a clinical setting.
The Foot Posture Index (FPI) 2 is useful in establishing several methodology’s to manipulate the weight bearing foot into a posture that can be considered functionally neutral and quantify the frontal plane position of the foot.3
For clinicians the challenge is to find a fast, effective method of establishing the patients position in which, they are neither excessively pronated or excessively supinated otherwise defined as NCSP or Ideal as opposed to a resting Calcaneal Stance position RCSP. Using of the FPI in a clinical setting could be quite cumbersome as the 6 steps need to be correlated with each other and the time taken could be excessive and highly inefficient.
Most practitioners using orthotic therapy around the world have de-faulted to the Talo navicular method which, at times, made finding congruency difficult due to a lateral osseous exostosis on the talar head often being present Equal ness or congruency is not instance easy to establish.
Therefore a method which can use the FPI and additional method combining together to overcome any anatomical variances such as the ICB Anterior Line Method (ICBAAM) is of particular benefit.
The ICB AAM uses the Talo Navicular reference points aligning the tibia with the 2nd MTPJ by drawing an anterior line.
The Talo Navicular method uses talar head congruency to establish the neutral position.
FIG 1
The TN Reference points can be established by placing the foot in a dorsiflexed position4
It may be useful in some cases to move the foot into inversion and eversion while palpating for the talar head This way both eversion and inversion can be clearly identified.
In the resting position the Anterior line will deviate medially indicating that pronation is evident and Laterally if the foot is supinating.
TN reference points are exposed when the foot is dorsiflexed with the heel on the ground.
At rest the tibial varum alignment aligns with the 1stMTPJ on a excessively pronated foot.
The Rearfoot position can also assist in establishing neutral in conjunction with ICB AAM.
There is a direct correlation between rearfoot alignment and anterior alignment position.
When finding the tibial varum angle the practitioner is conceptualising where the Tibia sits within the soft tissue and the same process is undertaken when bisecting the calcaneus.
The ICB Anterior Alignment Method is especially useful when moulding and fitting orthotics as it provides reference points that can be clearly identified when wearing shoes and socks.
Using the ICB Anterior Alignment Method ICB AAM to establish neutral is also useful when taking a foam box casts for custom made orthotics.
NB: every patients neutral may be different, use the established parameters to identify the patients ideal position. and compare with their resting position.
REFERENCES:
1. Merrimans Assessment of the lower Limb 3rd ed p289
2. Development and validation of a novel rating system for scoring standing foot posture: The Foot Posture Index An-thony C. Redmond a,b,*, Jack Crosbie c , Robert A. Ouvrier b 10 May 2005
3. Merrimans Assessment of the lower Limb 3rd ed p290
4. The Orthotic Solution p 29
Michaud T.C., 1993 Foot Orthoses and Other Forms of Conserva-tive Foot Care. Williams and Wilkins, Baltimore, pp.93-105.
Root M L, Orien W P, Weed J H., 1977 Normal and Abnormal Func-tion of the Foot. Clinical Biomechanics Vol 2, Los Angeles
Valmassy, R.L.. Pathomechanics of Lower Extremity Function. Clinical Biomechanics of the Lower Extremity. Mosby, St Louis.
Generally rearfoot supination, inverted position of the calcanaeus relative to subtalar joint neutral or ideal positioning, is not that common and different professions describe it with different terminology eg. Rearfoot valgus is also a term to describe a weight bear-ing/compensated position of the rearfoot. ‘Closed kinetic chain supination consists of calcaneal inversion with talar head abduction and dorsiflexion.’1 it is the collective term for plantarflexion, inversion and adduction of the foot apparatus.2 which is happening around the Sub Talar Joint.
It is correct to say that supination is a fundamental action in the gait cycle and a necessary element, however, in this newsletter we are considering excessive supination or the problematic ‘supinated foot’ structure. Supination of the foot occurs at heel strike to mid stance and then again at toe off and so addressing extended supination and its consequences is important, albeit that the supinated foot occurs in only approximately 8-9% of the population.
Often the supinated foot will present with high arch3 or a more rigid foot structures and upon assessment may exhibit a forefoot valgus deformity.
Patients suffering this biomechanical anomaly will usually wear the lateral aspect of their shoes and experience lateral side joint pain resulting from excessive stress placed on the joints due to the excessive lateral pressure as seen in the Image opposite .
Examining the wear pattern on the patients shoes is a valuable assessment tool as it can indicate the way the body addresses the biomechanical anomaly within the gait cycle, pressure points and wear a tear patterns are often evident.
Note: the Lateral wear pattern, in this instance a pattern under the 1st MTPJ indicating a plantarflexed 1st condition.
Unilateral supination may be a compensation to structural leg length discrepancy in which the SHORT leg develops a supinated or excessively inverted position to raise the pelvic alignment, in this instance assessing structural leg length is important.
Use a methodology that you are familiar and comfortable with to assist in assessing structural Leg Length.
When assessing for ideal or neutral position using the ICB AAM method the foot may need to be everted or moved medially (pronated) to align the 3 reference points of the anterior line.
Anterior view Supinated with ICB AAM line
When a Forefoot Valgus deformity is present the use of a fore-foot wedge addition, will encourage the straightening of the reference lines to enable the practitioner to place the foot into subtalar joint neutral/ideal (STJN).
Most of the ‘off the shelf’ styled or premade orthotics are designed to be anti pronating devices, when treating a supinator these devices will need to be adjusted and modified to suit the supinating patient. Rearfoot supination, if mobile, may be treated with a lateral eversion wedge/ addition, however, mid foot and forefoot inversion (supination) can be treated with forefoot post-ing and lateral eversion ramps.
Often uncompensated (rigid) rearfoot supinators will exhibit a plantar flexed 1st MTPJ as compensation, seeking to enable the 1st MTPJ to make ground contact for toe off phase of gait and will require a 1st MTPJ cut away of deflection to accommodate the plantarflexed 1st.
Supinators will not require rigid or firm EVA styled products, rather mid density or softer materials are best and the orthotic device should be moulded well into the arch.
Generally a curved last shoe is designed for the supinated styled foot. Pronators will require a straight or semi curved last shoe.
Stabilising the forefoot will reduce the inclination to excessively invert or supinate the foot thereby reducing inversion sprain condition.
ICB recommends DUAL Density Sports or Blue mid density styles moulded well into the patients arch.
REFERENCE :
1.Ronald L Valmassy Clinical biomechanics of the lower ex-tremities 1996 p 12
2.Merriman’s Assessment of the lower limb 3rd Ed 2009 p228
3.Katherine E Morrison, MS, ATC and Thomas W Kaminski, PhD, ATC, FACSM Foot Characteristics in Association With Inversion Ankle Injury J Athl Train. 2007 Jan-Mar; 42(1): 135–142
Leg length inequality and the pathogenesis or the origin of the condition, is and will always be, a controversial subject. There is not enough space to conduct a debate on the treatment, origin and possible associated compensatory mechanisms that may arise when we examine the topic. Also a wide variance of opinion exists on the significance of structural leg length and the various methods for measurement.
Many texts define minor structural leg length discrepancy as, less than 2 cm of difference. Other studies have suggested that, 40-70% of the population have at least some degree of LLD1, larger differences also appear in .001% (1:1000)of the population. From ICB’s perspective in dealing with Lower Limb Biomechanics, a 2cm structural difference is, rather than being minor, quite a significant amount and should be treated mechanically.
Leg length discrepancy or anisomelia, meaning a difference in length between paired legs, can broadly be categorised into two types:
1. Structural leg length difference, a difference in the long bone measurement of the leg. Its root cause can be illness, hereditary or trauma-related. The etiological factors involved in the causative process can be numerous such as: Idiopathic developmental abnormalities, fracture, trauma to the epiphyseal endplate prior to skeletal maturity, degenerative disorders, Perthes disease, cancer or neoplastic changes and Infections to name a few.
2. Functional differences can be more difficult to identify and treat as the etiological factors can be difficult to diagnose, e.g: body compensation associated with trauma, shortening of soft tissues, joint contractures, ligamentous laxity, axial misalignments, foot biomechanics, such as, unilateral excessive pronation, pelvic rotation and pelvic flare to name a few.
Often structural short leg syndrome is a commonly un-recognised condition that often goes untreated. It can be argued that even small discrepancies of only 4mm, if uncorrected, may over time set off a chain reaction of symptomology throughout the body.
There are 3 types of short leg issues that have been attributed as causative factors: inherited biomechanics, postural habits and or trauma:
1. Structural Short Leg: when the measurement from the head of the femur to the lateral or medial Malleolus measures shorter on one side than the other.
2. Functional Short Leg: when the measurement from the 2 same reference points are equal on both sides, but there still appears to be a short leg – usually due to a twist in the pelvis.
3. Combination of Structural and Functional Short Leg.
Symptoms Common symptoms may include:
• Neck and shoulder pain
• Back ache & Hip pain
• Foot pain, Ankle pain, Knee pain.
Muscular, Vascular and Neurological systems may also be affected. Osteoarthritis in the joints, and Scoliosis (including idiopathic’) are classic indicators of a leg length discrepancy and or twist in the pelvis.
Biomechanical Aetiology
Anecdotal observation indicates that 80% of compensations is excessive long leg pronation. If the pelvis does not level as a result of the excessive pronation, the pelvis may twist or drop to one side – causing either a scoliosis or prolapse of the vertebral discs. Unilateral tightness in the gluteal muscles may occur with posterior pelvic tilt and rotation, which in the case of a functional short leg has the effect of rotating the pelvis posteriorly-effectively causing increased rotation of the spine at L1 to L5. A tendency to repeatedly pull (overstretch) the same muscles even though it has been given sufficient time to heal may occur.
A unilateral bunion is often associated with a leg length discrepancy. As the body excessively pronates to provide long leg compensation (to level the pelvis), this predisposes the longer leg to the formation of a HAV or bunion 2. Thus when bilateral HAV is evident and there is unequal Bunion growth, it can be deduced that a longer leg may be evident.
Assessment
Although some Physicians still use measurement methods such as Knee height and tape measure. Current research indicates that newer manual techniques and radiographic analysis are preferred over the old tape measure method.
There are many ways to measure leg length, 2 of the most reliable methods are:
1. CT Scanogram: a radiographic technique that measures the actual length of the tibia and fibula bones. Point of failure in this method could be the inability of the radiologist to match the measurement reference points, however, this is not usually an issue.
2. Supine medial malleoli asymmetry (manual) (Fig : 4): A technique which is becoming more common and certainly more popular is a process that osteopath Gary Fryer at RMIT University Melbourne 20053 known as The Palpation for Supine Medial Malleoli Asymmetry Technique. This method is we believe, quick to perform and has demonstrated both a high intra-examiner and inter-examiner reliability. The trial concluded that Intra-examiner and inter-examiner reliability was almost perfect following subject selection for malleoli asymmetry, suggesting that clinicians can reliably detect medial malleoli asymmetries of greater than approximately 4 mm difference. The patient is placed in the supine position.
The Practitioner balances the hips and pelvis, then marking the inferior aspect of the medial malleolus with a pen. Align the malleoli and rub together to compare the pen line markings, checking for discrepancy between the two lines.
Treatment
In the case of a structural leg length discrepancy, a heel lift alone to the short leg may not provide the solution for the patient, as the long leg will continue to pronate and cause upper body imbalance and compensations. Correction to the longitudinal arch of both feet and their biomechanics by prescribing an orthotic device is essential.
The orthotic device will ensure the correction and realignment of the feet, and the addition of a heel lift on the shorter leg will prevent jamming in the hip of the longer leg, and prevent upper body compensations and resultant pain.
Generally 80-85% of compensatory action will be excessive long leg pronation, other compensations may occur such as : Long leg knee flexion, short leg supination, genu recurvatum or knee hyperextension as a means to adjust the pelvic alignment.
References
1. Woerman AL, Binder-MacLeod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J. OrthopSports Phys Ther 1984;5:230-8.
2. Neale’s disorder of the foot 8th edition 2010 p103
3. Gary Fryer 2005 : Factors affecting the intra-examiner and inter-examiner reliability of palpation for supine medial malleoli asymmetry.
Knee pain is a common condition experienced by people of all ages, and levels of activity. Knee pain is a problem that can be experienced due to many contributing factors, Including: increased Q-angle, genu-valgum and genuvarum, muscle tightening through the gastrocnemius, iliotibial band and VMOs, hyper-extension of the knee and tibial rotation and torsion, bakers cyst, connective tissue disorders such as lupus .
When discussing knee pain, terms such as ‘Retro Patella pain’, ‘Patella Femoral Dysfunction’, ‘Medial Compartment Syndrome’ or ‘Ilio Tibial Band Friction Syndrome’, come to mind. However, from ICB’s experience, these conditions are simply descriptions of knee pain. Knee can be affected by trauma, foot mechanics or issues at the hip. Trauma issues are not discussed in this article , rather we focus on the other two areas, both of which can affect the operation of the knee.
If the patient’s pain is idiopathic (i.e.. no known cause or trauma), excessive pronation and excessive supination may constitute the underlying cause of the problem – as outlined by Michaud, 1997 1. Michaud states that for every 1˚ of pronation the tibia internally rotates 1˚, which in turn impacts on the knee joint, as it takes the stress that is generated by the tibial rotation.
Tibial rotation describes the rotation of the tibial shaft and is different to tibial torsion. Tibial Torsion is a twisting in the osseous structure of the tibial shaft. Internal Tibial rotation is associated with excessive pronation, medially displacing the patello femoral path and encouraging lateral displacement of the patella. Internal Tibial Rotation is a common problem and elicits pain under and around the medial aspect of the patella – especially with excess loading activities such as running and jumping.
Internal tibial rotation is able to con-tribute to medial collateral strain on the ligament structures that wrap around the medial aspect of the knee and lower leg (Cosgarea, 2002)
To treat pain associated with internal tibial rotation, give VMO strengthening exercises , knee strapping, and other strengthening exercises – all of these are valuable treatment options, however, these methods, no matter how beneficial, only treat the symptoms. Controlling and stabilising the foundation is a key to successful treatment of medial knee pain.
CAUSES OF MEDIAL KNEE PAIN
A major cause of medial knee pain is excessive pronation which causes the medial collateral ligament to elongate resulting in the weakening of the VMOs and the ITBs tightening. A con-sequence of this action is external rotation of the femur as compensation. As the ITB and piriformis muscles compensate to reduce medial rotation, the patella begins to track on the lateral aspect of the femoral condyle and a grinding and crackling is felt on the flexion to extension.
Strapping, using the McConnell technique and strengthening VMOs is a good treatment method, however it will not correct the problem – strapping will only assist in pain relief, and the condition will constantly re-occur until the knee has degenerated or become Osteo-Arthritic, and may eventually require surgical intervention.
A basic requirement to reduce rotational stress on the knee is STJ and MTJ control and correction.
BIOMECHANICAL TREATMENT
• McConnell strapping technique to control lateral/medial patella displacement, in conjunction with low dye strap-ping to mimic the support and control of an orthotic de-vice. Low dye strapping, however, is only a temporary treatment.
Low Dye taping to imitate wearing orthotics.
• ICB Orthotics moulded to the patient’s Ideal/NCSP (Neutral Calcaneal Stance Position) to control abnormal STJ and MTJ pronation, by aligning the calcaneus with the lower 1/3 of the tibia and limiting the joint to its original function as a hinge joint.
Rearfoot correction using ICB Orthotic with intrinsic 5° Rearfoot varus.
• Strengthening VMO exercises whilst correcting the feet with orthotics, and stretching the ITBs.
• Mobilisation of the knee joint may also be useful.
• Acupuncture can be performed at the point of pain to aid pain relief.
• Runners may require increased rearfoot varus wedgeing to compensate for the higher tibial varum angle at heel strike, during the running cycle.
REFERENCES: 1 MICHAUD, T.C. (1997) Foot Orthoses and Other Forms of Conservative Foot Care, p10 General References COSGAREA, A.J., BROWNE, J.A., KIM, T.K. & MCFARLANE, E.G. (2002) Evaluation and Management of the Unstable Patella, The Physician and Sports Medicine, 30, 10
MCCONNELL, J., & COOK, J. (2001) Anterior Knee Pain, Clinical Sports Medicine, 2nd Edition, [http://www.clinicalsportsmedicine.com/ chapters/24a.htm]
PETERSON, L., & RENSTROM, P. (1986) Sports Injuries: Their Prevention and Treatment, Sydney: Methuen Australia
Osgood–Schlatter disease or syndrome, also known as Apophysitis of the Tibial Tubercle, is an irritation of the patellar ligament at the tibial tuberosity occurring at the tendon-bone junction of the patellar tendon and the tibial tuberosity.1
The condition is named after Robert Bayley Osgood (1873-1956), an American Orthopedic surgeon and Carl B. Schlatter, (1864-1934), a Swiss surgeon who described the condition independently in 1903.
Watch the video below about Osgood–Schlatter disease below.
General medical opinion is that Osgood Schlatter Disease, is caused by repetitive stress or tension on the growth plate of the upper tibia (the apophysis), which can be complicated by growth spurts and biomechanical deformities or anomalies. In general medical circles it is often called ‘growing pains’ and is similar in bio-mechanical dysfunction to Severs Condition, however occurring in this instant at the tibial tuberosity being characterised by inflammation of the patella tendon and surrounding soft tissues at the point where the tendon attaches to the tibia.
This condition appears to afflict children who are growing fast and often have external Tibial Torsion condition combined with Internal Tibial Rotation associated with excessive pronation.
Osgood-Schlatter’s Disease, is we believe, caused by repetitive stress or tension on the growth plate of the upper tibia (the apophysis), which can be complicated by growth spurt syndrome and biomechanical deformities or anomalies. The cause is similar in biomechanical operation to Sever’s Disease, except that it occurs at the tibial tuberosity and characterised by inflammation of the patella tendon and surrounding soft tissues at the point where the tendon attaches to the tibia.
As stated, it is usually young people who suffer with this disease – experiencing pain just below the knee joint and patella which usually worsens with activity. It is also associated with an avulsion injury (stretching the tendon so much that it tears away from the tibia and in extreme cases takes a fragment of bone with it – See Figure 2).
A bony bump may appear on the up-per edge of the tibia (below the knee cap) that may be particularly painful when external pressure is applied. It has been misdiagnosed in the past in Australia as “surfer’s knee” (a myth that only surfboard riders suffered from the condition). The hinge motion of the knee is not actually affected.
Most commonly Osgood Schlatters Disease affects active young people, particularly boys between the ages of 10 and 16 who play games or sports that include frequent running and jumping.
In a retrospective study of adolescent athletes actively participating in sports showed a frequency of 21% reporting the syndrome compared with only 4.5% of age-matched non-athletic controls2. Bilateral symptoms are observed in 20–30% of patients indicating that there is a higher incident of unilateral occurrence lead-ing one to deduce that in the unilateral cases, structural leg length or other unilateral biomechanical anomalies may be a contributing factor.
Symptoms of Osgood Schlatters Disease include:
• Pain over the tibial tubercle
• Swelling over the tibial tubercle
• Weakness in the quad muscle group
• Increased pain & swelling with activity
• A visible lump at the base of the knee cap
• Pain to the touch over the affected area.
Often the pain may last only a few months or may recur until the child stops growing.
Not a lot has been written about the effect of the combination of a growth spurt combined with both pronation or supination, and internal and external tibial torsion. However, children appear to experience more pain and resultant damage to the attachment when these factors occur in combination.
The pain (and resultant effects) become more noticeable during activities that require running, jumping or going up or down stairs and is most common in young athletes who play football, soccer, basketball, netball or who are involved in gymnastics and ballet.
Contributing Factors whilst the Child is still growing
1. Excessive Pronation: As the foot pronates internal tibial rotation occurs. The body’s mechanism of compensation causes the ITB’s and abductor muscles to tighten in the opposite direction causing the patella to laterally and superiorly displace, hence causing a tractional pull on the tibial tuberosity.
2. Supination & Pronation:
Because of the anterior position of the tibial tuberosity, when the foot supinates due to a FFT valgus deformity less than 10 degrees in the swing phase of gait, the foot lands laterally then the ground reaction forces (on the lateral side) propel the foot into pronation with the same effect above.
3. Internal Tibial Torsion:
Internal tibial torsion will cause the foot to rotate the tibial condyle medially. The ITB’s and gluteals then tighten and come into action as an external rotator of the femur as the compensatory mechanism causing external rotation above the knee and internal rotation below the knee.
The two rotation actions have an effect on the patella and its tendon attachment also causing the tibial tuberosity to stretch and pull.
4. External Tibial Torsion: This causes the foot to externally rotate in the swing phase of gait, the iliopsoas and adductor muscle groups combined to provide compensation at the late swing phase, causing the foot to straighten and land laterally (same effect as 2). Then the ground reaction forces cause the foot to pronate with the help of the psoas pull resulting again in internal rotation above the knee and external tibial torsion position increases tractional forces on the patella and its attachment.
Treatment
• Orthotics moulded to the patient’s Ideal/Neutral Calcaneal Stance Position to realign and hence reduce the effect of tibial rotation.
• Combine orthotic therapy with strapping: use an Osgood Schlatters strap (see below) to reduce the tension on the attachment at the growth plate whilst the child is playing sport (see Figure 3).
Stretching may exacerbate the tearing – alternatively use deep friction massage to help in pain relief.
• R.I.C.E Active children may experience shortening of the muscles whilst growing, which coupled with biomechanical anomalies = predisposition to Osgood Schlatter.
Contraindications It is important to differentiate from malignancy, infection, fracture, tendonitis and Sindling-Larsen-Johansson Disease. Initially the diagnosis is based on clinical signs and symptoms including: pain, heat, tenderness and local swelling with prominence at the tibial tuberosity. X-ray is required to establish the extent of the condition.
Steroid injections are discouraged as this may cause weakening of the infra-patellar ligament, scaring and fat necrosis.
REFERENCES
1 Nowinski RJ, Mehlman CT (1998). “Hyphenated history: Osgood-Schlatter disease”. Am J. Orthop. 27 (8): 584–5. PMID 9732084.
2 Kujala UM, Kvist M, Heinonen O (1985). “Osgood-Schlatter’s disease in adolescent athletes. Retrospective study of incidence and duration”. Am J Sports Med 13 (4): 236–41. doi:10.1177/036354658501300404. PMID 4025675
Hallux limitus / rigidus is defined as a degenerative arthrosis of the first metatarsophalangeal joint characterised by a decrease in first metatar-sophalangeal joint range of motion and eventual absence of motion.1
* The Morton’s extension is a 3°- 4˚ ramp under the phalange to allow the patient to propel off at toe off stage of gait. To create a Morton’s extension you can use an ICB 4° Forefoot wedge. and trim.
The progressive nature of the condition was first documented by Cotterill2 and Davies-Colley3 in literature over a century ago, in which they described hallux limitus / rigidus as a progressive condition producing a severely painful and rigid big-toe joint.
Hallux Limitus is assessed as being evident when movement of the great toe (hallux) is restricted to less than the normal range of motion or flexion to 65 – 75 degrees.
Flexion in the big toe assists to maintain the correct walking gait action to perform normal functions such as stooping down, climbing up, or even standing. For these reasons this disorder can be very troubling and even disabling.
Early signs and symptoms include: • Pain and stiffness in the big toe
• Abduction of the foot in gait to reduce stress on the 1st MTPJ at toe off.
• Swelling and inflammation around the 1st MTPJ
The main contributing factor biomechanically is as follows:
1. A long 1st metatarsal shaft
2. A short 1st metatarsal shaft In the case of the long metatarsal shaft the 1st MTPJ strikes the ground early and dorsiflexes the 1st metatarsal head. As this happens it restricts the proximal phalange from propelling over the 1st MTPJ and creates an impingement of the joint. Osteoarthritic changes result in the metatarsal joint and narrowing of the joint space leading to hallux limitus or a joint with limited movement. If action is not engaged to prevent it will eventually lead to hallux rigidus or joint ceasure.
A short metatarsal shaft will adduct to the midline of the body to gain ground contact, as this happens the metatarsals will plantarflex and rotate, and the ground reaction forces will cause dorsiflexion of the 1st metatarsal head.
This, when combined with the pronation factor, will create impingement at the tarso metatarso joint and reduce the proximal hallux’s ability to propel over the joint.
The tarso-metatarsal joint will in this instance be stressed and the ability of the proximal hallux in the propulsive phase of gait to flex to its normal range of motion will be reduced as it impinges or jams the 1st MTPJ.
Often this is referred to as a Functional Hallux Limitus (FHL) as it combines with the pronation factor and ground reaction forces to limit movement. Limited flexion will usually cause 3 types of outcomes:
1.An adductory twist: this is where the calcaneus pivots medially at the propulsive phase of the gait cycle. This is in turn assisted by the external hip rotators such as piriformis, gluteals and ITB’s, and as this takes place medial ground reaction forces (GRF) put pressure on the 1st MTPJ. As the patient attempts to toe off this causes the hallux to deviate and develop me-dial callosity.
2.The distal phalanx of the hallux be-comes the alternative propulsive mechanism which is due to limited joint mobility at the 1st MTPJ, thus causing dorsiflection of the distal hallux with secondary action of nail trauma & nail thickening ( onychogryphosis). The result of this is that many patients wear through the dorsal aspect of their shoe or socks.
3. Abduction of the foot in gait to reduce the impact upon the 1st MTPJ resulting in increased medial pronatory forces.
Correctly aligned and modified orthotic device will alleviate these outcomes and allow the 1st MTPJ to function within the parameters of the structural abnormalities of the foot of the presenting patient.
Once the foot structure is realigned and maintained in the ideal / neutral position pressure is taken off the 1st MTPJ and increased flexion in the joint can be achieved.
Rx : Treatment for a long 1st metatarsal shaft- an orthotic to lift the proximal hallux and at the same time deflect the 1st MTPJ by way of a depression placed under the joint using a heat gun on a 100% EVA orthotic device – using a full length orthotic style is best (see fig. 1 below). Composite orthotic products have limited heat-ing ability and do not allow for easy deflection creation.
Rx: Treatment for a short 1st metatarsal shaft is more complicated as we need to attack the problem on a num-ber of fronts:
1. Correct the pronation factor using an orthotic device moulded to the patient’s ideal / NCSP (Neutral Calacaneal Stance Position) which will control rearfoot eversion (pronation). Generally a device with between 4˚-6˚ rearfoot varus will give the required control.
2. The orthotics should control and correct both the Subtalar and mid tarsal joint pronation together using a device that can be moulded to effectively follow the con-tour of the patients arch to reduce longitudinal arch col-lapse (which would encourage the foot to evert during the propulsive phase) whilst maintaining rearfoot con-trol.
3. Use a ‘Morton’s extension addition’* to lift and sup-port the hallux and allow the hallux to propel over the joint (see Fig. 2). The Morton’s extension lifts the 1st MTPJ to level with the lesser metatarsal joints and allow the proximal phalange to maintain its position and stops the 1st MTPJ from plantarflexing & rotating which encourages the pronation effect.
Ultrasound or other physical therapy modalities may be undertaken to provide temporary relief.
Non-steroidal anti-inflammatory drugs (NSAIDs), may be pre-scribed to help reduce pain and inflammation in the 1st MTPJ.
Supplements such as glucosamine-chondroitin sulfate and some vitamins and mineral supplements may also be helpful .
Differential Diagnosis: Check for gout, rheumatoid and Psoriatic arthritis.
REFERENCES: 1. MARCINKO DE: Medical and Surgical Therapeutics of the Foot and Ankle, pp 423-465, Williams & Wilkins,Baltimore, 1992.
2. COTTERILL JM: Stiffness of the great toe in adolescents. Br Med J 1: 1158, 1888.
3. DAVIES-COLLEY N: Contraction of the metatarsophalangeal joint of the great toe (hallux flexus). Br Med J 1: 728, 1887.
General references Camasta C A., 1996 Hallux Limitus and Hallux Rigidus. Clinics in Podiatric Medicine and Surgery. 13(3) pp. 423-445
Chapman C., 1999 Rocker Soles. Podiatry Archives @ www.mailbase.ac.uk/podiatry. January 1999
Chapman C., 1997 Looking through JAPMA. The Journal of Podiatric Medicine. 52(8) pp1113
Durrant M N, Sipert K K., 1993 Role of Soft Tissue Structures as an Etiology of Hallux Limitus. 83(4) pp173-181
Root M L, Orien W P, Weed J H., 1977 Normal and Abnormal Function of the Foot. Clinical Biomechanics Vol 2, Los Angeles
Sanner W H., 1994 Clinical Methods for Predicting the Effectivess of Functional Foot Orthoses. Clinics in Podiatric Medicine and Surgery Vol 2, number 2. pp288-291
Yale, Irving D.P.M ., EdD (Hon.), 1974, Podiatric Medicine
