Pertinent Roundtable Pearls On Orthotic Management
A: Howard Dananberg, DPM, notes that the muscles of the foot and lower extremity are designed to act in a phasic manner, and there is delineation between stand and swing function. When muscles act out of phase, he notes many symptoms can be present. These symptoms may include shin splints, leg cramps, low back pain, arch fatigue, plantar fasciitis and heel strain. Dr. Dananberg emphasizes that the exam should focus not only on pronation but also on joint ranges of motion and muscle strength. As he notes, it is not unusual for a stronger muscle to be symptomatic because it is taking over the effect of the weaker muscles.
Dr. Dananberg notes the existence of manual techniques for restoring motion and strength, particularly when the weakness is related to arthrogenic inhibition (weakening related to joint dysfunction, not disuse). These techniques include manipulation of the ankle, which he says can positively impact the strength of the peroneal muscles. When these muscles are weak, he notes anterior tibial overuse can develop with pain on the anterior lower leg.
When treating overuse syndromes, Dr. Spencer considers two main factors. The first is addressing the activity that caused the overuse and modifying the patient’s activity. The second is addressing the abnormal motions that contribute to the overuse syndrome.
Dr. Spencer emphasizes that one of the most important areas for an orthotic prescribed for an overuse syndrome is contouring the arch to the patient’s foot. He notes that the literature shows the arch of the orthotic is primarily involved in controlling leg rotation. As Dr. Spencer elucidates, one of the factors with overuse syndromes is leg rotation as a contributing factor to soft tissue stress, especially in the lower leg. By allowing the arch of the orthotic to closely conform to the arch of the patient’s foot, he says one can better address the leg rotation component of the pathology. Dr. Spencer adds that this will also allow any posting or other modifications designed to exert control over subtalar joint motion to work more effectively.
As Dr. Harris notes, most of the patients with hyperpronation are athletic teenagers. He says the severity of the biomechanical disorder does not necessarily correlate with clinical symptoms. As he explains, many patients show transverse plane dominant pronation with some degree of fixed forefoot varus and many also exhibit residual tibia varum.
Under these circumstances, such patients function with the calcaneus maximally everted. Dr. Harris says this severely diminishes the ability to dampen rotational movement, which is supposed to take place during running activities. He says designing an orthosis with the heel in slight varus and the forefoot accommodated will allow patients some frontal plane movement and relieve some of the stress on the lower limb.
Q: What is your treatment plan for the pediatric patient who presents with a non-compensating equinus and a resultant painful heel and tendo-Achilles?
A: Dr. Harris says for a long time, physicians have overlooked equinus in planning the management of pediatric flatfoot. He says there are several options for management of these patients. The first option is initiating physical therapy in an attempt to improve range of motion. Although this may be successful, he notes this approach requires a great deal of effort and adherence on the part of the child and the family.
Alternatively, borrowing from the principle used in managing idiopathic toe walking syndrome, Dr. Harris says serial stretching casting may improve the range of motion. However, he says this may prove to be a problem because most of these children are older. If one uses this technique, it requires either casting one side at a time or casting both limbs at the same time, which he notes can be a hardship on both the child and the family. Although there may be some short-term success with heel lifts and gel cushions, Dr. Harris says the treatment is purely palliative and has no effect on the anatomical pathology.