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Suggestions?

Posted by josh s on 10/09/01 at 15:34 (062555)

I just got back from visiting the big pod at world famous clinic, he gave me a lot of info, but seemed more of the surgeon type than the orthotic/biomechanics master.

This is the lowdown: rearfoot varus (slightly worse on right foot), forefoot equinus (x-ray's came back from radiologist saying bilateral cavus). Insufficient range of subtalar eversion. Fairly normal forefoot to rearfoot relationship. Slight gastroc soleus equinus. (Doctor said combination of 'dropped forefoot' and calf equinus created a equinus situation.) Excessive abduction and dorsiflexion at midtarsal joint. As he described it, the lack of subtalar eversion coupled with the sagital plane block of equinus is causing early heel lift and compensatory midfoot collapse which is being countered by contraction of posterior tibial tendons. Main sympton is aching pain deep in the plantar midfoot region. Doctor mentioned that this pain is likely the posterior tibial insertion points on inferior surfaces of tarsal bones. Bilateral symptoms, but right foot definately worse- abducted in gait and stance.

He recommended shock absorbing shoes, heel lifts, continuing with current orthotics ( which have'nt helped much yet), stretching gastroc-soleus. If this does'nt work he said he'd make me some leather and cork devices which will function mainly by providing bulk support under arch.

From what I've read this sounds like flexible high arch feet with stage I posterior tibial tendon dysfunction.

Any suggestions?

Re: Suggestions?

Ed Davis, DPM on 10/10/01 at 13:27 (062657)

Josh:
I don't know much about your symptoms or history, so if you can provide more info., it would be helpful.

Your doc has made some very good points about the manner in which a forefoot cavus will increase the need for ankle dorsiflexion range of motion (I am saying basically the same thing as he said but with slightly different terminology).

I may differ on the orthotic issue though. The classical cavus orthotic tends to be a bulky device built up to 'fill in' the cavus or high arch. It can work but the bulk and weight can be both annoying and limit shoegear choices. I have seen some cavus orthotics so bulky that they would probably be confiscated as potential weapons at airport security.
The same, if not better, effect can be achieved using a thin (about 1.2 mm) graphite device, carefully contoured and crafted.
Ed

Re: Suggestions?

josh s on 10/10/01 at 21:27 (062704)

Thanks for the response Dr. Davis.

Of possible interest is the initial biomechanical assessment I received about two years ago by a young DPM in Hawaii: Fully compensated rearfoot varus, ankle equinus, mild forefoot varus, flexible flatfoot. I mentioned the flexible flatfoot opinion to the pod mentioned above and he asked if he took x-rays ( he did'nt) and apparently missed the cavus.

My experience is that if I am tired I function with a more abducted gait and roll off the medial side of hallux. Over the years I have consciously (and now habitually) contracted peroneals and tibialis posterior to prevent midfoot abduction and 'raise' the arch, could I possibly have been so 'succesful' in this strategy that I developed an anterior cavus?

It also seems to me that my first metatarsals are hypermobile in dorsiflexion, though this was not noted by pod. I assumed that this was why I tend to roll weight more across the lateral column (attempting to turn a compensated varus into an uncompensated varus) and thus avoid the pain I often feel in the talar/navicular region if I allow the midfoot collapse. Knowing of my tendency to crank up the arch muscularly, I attempted most recently to totally relax and drop the arches while being x-ray'd. No difference between this set and those taken 6 months prior. However, I noticed and pointed out to doctor that on the lateral view, it appeared that the sesamoids were floating above the ground, though I made a conscious effort to balance weight evently across the forefoot while being filmed. He said that was interesting but did'nt make a point of it. He did note some hypermobility in midfoot abduction.

It's late and I'm rambling amateur biomechanics. I'll try tomorrow for more coherant history and symptoms, thanks again.

Re: Suggestions?

Ed Davis, DPM on 10/10/01 at 21:43 (062707)

Josh:

Do you recall either doctor perhaps mentioning metatarsus adductus (inward positioning of the metatarsals--congenital)? The reason why I am bringing this up is because abduction of the foot either, often at the midfoot often occurs in attempted compensation for metatarsus adductus. A bit harder to control this foot type via orthotics.
Ed

Re: Suggestions?

josh s on 10/11/01 at 10:09 (062732)

Dr. Davis,

Neither doctor mentioned it. I think it can be ruled out as my first pod told me he had metatarsus adductus, so he probably would have caught it.

After doing some hunting for anterior equinus (cavus) info on web I found several references mentioning neurologic influences contributing to it's development. The DPM I saw this week asked alot of questions about childhood- fishing for evidence of palsy and such. The only thing I can think of that I forgot to mention to him is that I had several extreme hyperextention of lumbar spine injuries approx. 1 and 2 years prior to development of symptoms. I do have a history of occasional shakiness and tingling in my legs, particularly after alot of flexion or extension of spine, but always attributed it to tiredness or sciatica.

What about the variation of a more vertically oriented oblique midtarsal joint axis? I've read that this will cause forefoot abduction. Neither pod mentioned it, but it seems not such a commonly looked for biomechanical anomaly. The pod did remark that the superior view of mid and forefoot x-ray did'nt show a whole lot, the forefoot appeared fairly congruent to me. I'm assuming that if the above factor is present this view would show a sharp angulation at the calcaneo-cuboid joint. My mother has very similar foot structure to mine with a high varus arch, but her forefoot is so abducted that she cannot balance on one leg because she collapses medially. Strangely she has no symptoms in her feet, but recently was diagnosed with degeneration of medial menesci, with no apparent trauma.

Unfortuanately, though the doctor I consulted asked if I had any more questions, I forget to ask perhaps the most important question. It seems that the combined influence of rearfoot varus forcing pronation too late in stance (and unlocking midfoot) and the equinus factors forcing dorsiflexory and abductory(if this is the cause) compensation by midfoot makes for a perpetuating cycle. This assuming that we have the full picture. It seems important to ask: What came first, the varus or the equinus? Did the varus cause the equinus or do they simply co-exist. As a child I remember being limited in ankle dorsiflexion to the point that when I jumped from a height I had to quickly roll to the ground as I could not bend my ankles deeply enough to absorb the impact. Then again rearfoot varus appears to either be hereditary or developmental in origin. Is it possible to determine the original cause in such a case? Or is it more helpful to treat and/or accomodate the existing conditions. As most of the population appears to have relative rearfoot varus angulation, it seems that If I could attain a 'normal' ROM in dorsiflexion at ankle, that the other factors might be minimized.

I read an article by Payne and Dananberg recently describing their theory of sagittal plane blockage. They focused on fuctional hallux limitus, but I assume the compensation strategies they describe for sagittal plane blockage would be in common with equinus influences. Late midstance pronation, rolling off the outside of foot with failure to utilize high gear push off, hinging forward at the hip are compensation strategies that they describe that I've noticed in my own gait at different times.

I have a pair of retainer orthotics (so-called 'rational orthotics') by afo-lab (afo-lab.com) presently at the lab being tweaked. Prsently I'm alternating between my first pair of orthotics prescribed by the first pod I saw and a pair of dansko clogs with 1' heel height differential and a rearfoot to forefoot surface contour that seems to accomodate the anterior cavus. These clogs actually work better for me than the orthotics, though I'm not pain free. This pair of orthotics is a thin graphite type device from Langer biomech.- made from a neutral cast and posted with 4-6 deg. of rearfoot varus. They also are intrinsically posted forefoot varus. The pod who made them took the measurement for the forefoot varus from the completed negative cast. Strangely, the pod I saw most recently said I had a fairly good forefoot to rearfoot relationship. He even did the coleman block test to check for forefoot valgus or plantarflexed first ray possibility. With this in mind, I'm not especially comfortable (physically or mentally) wearing this pair (though with heel lifts they are tolerable) as I do have the dorsal exostosis that apparently indicates forceful dorsiflexion of hallux- it seems a forefoot varus orthotic would only further contribure this to this, as well as prevent hallux plantarflexion and thus a high gear push off.

Thanks for your comments about the bulk orthoses, I think I'll try to avoid them for now. Another offer my recent doctor made was to add a lateral flare to the heel of my shoes, saying it would prevent ankle inversion injury (which I do have a past history of). From what I've read this would not be a good idea for my foot type. I recall that this may be appropriate for the type of cavus foot with forefoot valgus who oversupinates but that for my rearfoot varus it would only accelerate pronation at contact. This is what confirmed my opinion that though the doctor was very helpful and thorough, he was not the orthotic specialist.

Thanks for your time Dr. Davis, since we can't take tractograph measurements over the internet I'd best quit speculating. Do you know of any biomechanics masters practicing in Minnesota?

Re: Suggestions?

Ed Davis, DPM on 10/11/01 at 16:51 (062770)

The discrepancy in the description of the forefoot to rearfoot relationship coupled with the dorsal exostosis (assuming it is on the top of the first met head) may imply that when the doctor who took the casts of your feet to make the graphite orthotics, took the casts without reducing forefoot supinatus. In other words, you may have been contracting your tibialis anterior muscle while the cast was made and that created some false forefoot varus in the cast. Howard Dananberg, who wrote the article you read, is truly the 'master' at dealing with that problem--he practices in New Hampshire. My assumption is that you need a new cast, taken with the elimination of any false forefoot varus (forefoot supinatus is a postional forefoot varus) as that will be significantly more effective. I love graphite but Langer, a respectable lab, is sort of a newcomer to graphite orthotics.

I am unfamiliar with practitioners in Minnesota. A couple of potential resources-- http://www.acfaom.org tends to have a preponderance of podiatrists attuned to biomechanics. My favorite lab for graphite devices is Northwest Podiatric Lab of Blaine, WA. Work backwards by giving them a call and see who they work with in your area. There telephone number is 800-442-7260.
Ed

Re: working backwards

josh s on 10/12/01 at 10:37 (062837)

Thanks Ed!

Working back from the lab may work. Your comments about forefoot supinatus seem right. Could this account for the appearance on lateral weight bearing x-rays of the sesamoids and 1st metatarsal heads not touching the floor surface?

Josh

Re: working backwards

Ed Davis, DPM on 10/12/01 at 14:36 (062866)

Yes.
Ed

Re: Thanks

josh s on 10/12/01 at 15:58 (062873)

Thanks!

Re: Suggestions?

josh s on 10/12/01 at 17:09 (062884)

Ed,

In looking back at your 10/11/01 response, I noticed that it is not the head of the 1st metatarsal that has the dorsal exostosis, but the base. The dorsal articulation of 1st metatarsal and medial cuneiform. Does this change your analysis. I read in Michaud's 'Foot Orthoses and other forms of conservative foot care' that both flexible or aquired plantarflexed 1st ray and dorsiflexed first ray conditions will manifest this formation.

I e-mailed Dr. Dananberg and may go see him. He's got a program designed for the out-of-state patient.

Thanks,
Josh

Re: Suggestions?

Ed Davis, DPM on 10/10/01 at 13:27 (062657)

Josh:
I don't know much about your symptoms or history, so if you can provide more info., it would be helpful.

Your doc has made some very good points about the manner in which a forefoot cavus will increase the need for ankle dorsiflexion range of motion (I am saying basically the same thing as he said but with slightly different terminology).

I may differ on the orthotic issue though. The classical cavus orthotic tends to be a bulky device built up to 'fill in' the cavus or high arch. It can work but the bulk and weight can be both annoying and limit shoegear choices. I have seen some cavus orthotics so bulky that they would probably be confiscated as potential weapons at airport security.
The same, if not better, effect can be achieved using a thin (about 1.2 mm) graphite device, carefully contoured and crafted.
Ed

Re: Suggestions?

josh s on 10/10/01 at 21:27 (062704)

Thanks for the response Dr. Davis.

Of possible interest is the initial biomechanical assessment I received about two years ago by a young DPM in Hawaii: Fully compensated rearfoot varus, ankle equinus, mild forefoot varus, flexible flatfoot. I mentioned the flexible flatfoot opinion to the pod mentioned above and he asked if he took x-rays ( he did'nt) and apparently missed the cavus.

My experience is that if I am tired I function with a more abducted gait and roll off the medial side of hallux. Over the years I have consciously (and now habitually) contracted peroneals and tibialis posterior to prevent midfoot abduction and 'raise' the arch, could I possibly have been so 'succesful' in this strategy that I developed an anterior cavus?

It also seems to me that my first metatarsals are hypermobile in dorsiflexion, though this was not noted by pod. I assumed that this was why I tend to roll weight more across the lateral column (attempting to turn a compensated varus into an uncompensated varus) and thus avoid the pain I often feel in the talar/navicular region if I allow the midfoot collapse. Knowing of my tendency to crank up the arch muscularly, I attempted most recently to totally relax and drop the arches while being x-ray'd. No difference between this set and those taken 6 months prior. However, I noticed and pointed out to doctor that on the lateral view, it appeared that the sesamoids were floating above the ground, though I made a conscious effort to balance weight evently across the forefoot while being filmed. He said that was interesting but did'nt make a point of it. He did note some hypermobility in midfoot abduction.

It's late and I'm rambling amateur biomechanics. I'll try tomorrow for more coherant history and symptoms, thanks again.

Re: Suggestions?

Ed Davis, DPM on 10/10/01 at 21:43 (062707)

Josh:

Do you recall either doctor perhaps mentioning metatarsus adductus (inward positioning of the metatarsals--congenital)? The reason why I am bringing this up is because abduction of the foot either, often at the midfoot often occurs in attempted compensation for metatarsus adductus. A bit harder to control this foot type via orthotics.
Ed

Re: Suggestions?

josh s on 10/11/01 at 10:09 (062732)

Dr. Davis,

Neither doctor mentioned it. I think it can be ruled out as my first pod told me he had metatarsus adductus, so he probably would have caught it.

After doing some hunting for anterior equinus (cavus) info on web I found several references mentioning neurologic influences contributing to it's development. The DPM I saw this week asked alot of questions about childhood- fishing for evidence of palsy and such. The only thing I can think of that I forgot to mention to him is that I had several extreme hyperextention of lumbar spine injuries approx. 1 and 2 years prior to development of symptoms. I do have a history of occasional shakiness and tingling in my legs, particularly after alot of flexion or extension of spine, but always attributed it to tiredness or sciatica.

What about the variation of a more vertically oriented oblique midtarsal joint axis? I've read that this will cause forefoot abduction. Neither pod mentioned it, but it seems not such a commonly looked for biomechanical anomaly. The pod did remark that the superior view of mid and forefoot x-ray did'nt show a whole lot, the forefoot appeared fairly congruent to me. I'm assuming that if the above factor is present this view would show a sharp angulation at the calcaneo-cuboid joint. My mother has very similar foot structure to mine with a high varus arch, but her forefoot is so abducted that she cannot balance on one leg because she collapses medially. Strangely she has no symptoms in her feet, but recently was diagnosed with degeneration of medial menesci, with no apparent trauma.

Unfortuanately, though the doctor I consulted asked if I had any more questions, I forget to ask perhaps the most important question. It seems that the combined influence of rearfoot varus forcing pronation too late in stance (and unlocking midfoot) and the equinus factors forcing dorsiflexory and abductory(if this is the cause) compensation by midfoot makes for a perpetuating cycle. This assuming that we have the full picture. It seems important to ask: What came first, the varus or the equinus? Did the varus cause the equinus or do they simply co-exist. As a child I remember being limited in ankle dorsiflexion to the point that when I jumped from a height I had to quickly roll to the ground as I could not bend my ankles deeply enough to absorb the impact. Then again rearfoot varus appears to either be hereditary or developmental in origin. Is it possible to determine the original cause in such a case? Or is it more helpful to treat and/or accomodate the existing conditions. As most of the population appears to have relative rearfoot varus angulation, it seems that If I could attain a 'normal' ROM in dorsiflexion at ankle, that the other factors might be minimized.

I read an article by Payne and Dananberg recently describing their theory of sagittal plane blockage. They focused on fuctional hallux limitus, but I assume the compensation strategies they describe for sagittal plane blockage would be in common with equinus influences. Late midstance pronation, rolling off the outside of foot with failure to utilize high gear push off, hinging forward at the hip are compensation strategies that they describe that I've noticed in my own gait at different times.

I have a pair of retainer orthotics (so-called 'rational orthotics') by afo-lab (afo-lab.com) presently at the lab being tweaked. Prsently I'm alternating between my first pair of orthotics prescribed by the first pod I saw and a pair of dansko clogs with 1' heel height differential and a rearfoot to forefoot surface contour that seems to accomodate the anterior cavus. These clogs actually work better for me than the orthotics, though I'm not pain free. This pair of orthotics is a thin graphite type device from Langer biomech.- made from a neutral cast and posted with 4-6 deg. of rearfoot varus. They also are intrinsically posted forefoot varus. The pod who made them took the measurement for the forefoot varus from the completed negative cast. Strangely, the pod I saw most recently said I had a fairly good forefoot to rearfoot relationship. He even did the coleman block test to check for forefoot valgus or plantarflexed first ray possibility. With this in mind, I'm not especially comfortable (physically or mentally) wearing this pair (though with heel lifts they are tolerable) as I do have the dorsal exostosis that apparently indicates forceful dorsiflexion of hallux- it seems a forefoot varus orthotic would only further contribure this to this, as well as prevent hallux plantarflexion and thus a high gear push off.

Thanks for your comments about the bulk orthoses, I think I'll try to avoid them for now. Another offer my recent doctor made was to add a lateral flare to the heel of my shoes, saying it would prevent ankle inversion injury (which I do have a past history of). From what I've read this would not be a good idea for my foot type. I recall that this may be appropriate for the type of cavus foot with forefoot valgus who oversupinates but that for my rearfoot varus it would only accelerate pronation at contact. This is what confirmed my opinion that though the doctor was very helpful and thorough, he was not the orthotic specialist.

Thanks for your time Dr. Davis, since we can't take tractograph measurements over the internet I'd best quit speculating. Do you know of any biomechanics masters practicing in Minnesota?

Re: Suggestions?

Ed Davis, DPM on 10/11/01 at 16:51 (062770)

The discrepancy in the description of the forefoot to rearfoot relationship coupled with the dorsal exostosis (assuming it is on the top of the first met head) may imply that when the doctor who took the casts of your feet to make the graphite orthotics, took the casts without reducing forefoot supinatus. In other words, you may have been contracting your tibialis anterior muscle while the cast was made and that created some false forefoot varus in the cast. Howard Dananberg, who wrote the article you read, is truly the 'master' at dealing with that problem--he practices in New Hampshire. My assumption is that you need a new cast, taken with the elimination of any false forefoot varus (forefoot supinatus is a postional forefoot varus) as that will be significantly more effective. I love graphite but Langer, a respectable lab, is sort of a newcomer to graphite orthotics.

I am unfamiliar with practitioners in Minnesota. A couple of potential resources-- http://www.acfaom.org tends to have a preponderance of podiatrists attuned to biomechanics. My favorite lab for graphite devices is Northwest Podiatric Lab of Blaine, WA. Work backwards by giving them a call and see who they work with in your area. There telephone number is 800-442-7260.
Ed

Re: working backwards

josh s on 10/12/01 at 10:37 (062837)

Thanks Ed!

Working back from the lab may work. Your comments about forefoot supinatus seem right. Could this account for the appearance on lateral weight bearing x-rays of the sesamoids and 1st metatarsal heads not touching the floor surface?

Josh

Re: working backwards

Ed Davis, DPM on 10/12/01 at 14:36 (062866)

Yes.
Ed

Re: Thanks

josh s on 10/12/01 at 15:58 (062873)

Thanks!

Re: Suggestions?

josh s on 10/12/01 at 17:09 (062884)

Ed,

In looking back at your 10/11/01 response, I noticed that it is not the head of the 1st metatarsal that has the dorsal exostosis, but the base. The dorsal articulation of 1st metatarsal and medial cuneiform. Does this change your analysis. I read in Michaud's 'Foot Orthoses and other forms of conservative foot care' that both flexible or aquired plantarflexed 1st ray and dorsiflexed first ray conditions will manifest this formation.

I e-mailed Dr. Dananberg and may go see him. He's got a program designed for the out-of-state patient.

Thanks,
Josh