Whoa!  It is amazing what the human frame can withstand…

This 300 pound individual is retired from working with tow trucks from a towing company as well as a service station.   He believes working with the tow trucks, particularly jumping out of them contributed to the O.A. of the ankles.

He has osteoarthritic ankles, a rear foot varus of 15 degrees left side, 5 degrees right.  He is currently in the New Balance 1040 shoe.  He would like some new orthotics built. He Fowler tests positive on his current orthotic set up (with the foot on the ground, dorsiflex the foot at the 1st metatarsal phalangeal joint (ie big toe joint), simulating terminal stance; the orthotic should hug the arch through the range of motion; ie about 45-60 degress of great toe dorsiflexion, which he incredibly has). He is unable to one leg stand because of the O.A. on the ankles and pain.

He has bi-lat. internal tibial torsion, Left > Right and moderate tibial varum, L > R. He has very little internal rotation of the hips bi-lat. Ankle dorsiflexion is about 5 degrees bilaterally.

He is currently in an older New Balance motion control shoe. You can see how he has worn the shoes into varus. More neutral shoes hurt his feet; attempts to put his rear foot into valgus causes increased ankle pain. Exercise compliance is minimal.

WHAT WOULD YOU DO?

The Gait Guys. Teaching and educating with each post.

Some times there is not an easy answer.

A patient came in with intermittent pain in his feet, bilateral and symmetrical of approximately 1 months duration.  It is bothering him in the arches and the ends of the toes. He can akin it to no singular precipitaIng event. The discomfort is sharp at times, and he can sometimes get cramping. He has been taking good care of his feet, washing his feet as of late. There are no alleviating factors; lots of activity can sometimes cause more pain but not consistently.  It seems to happen in all different types of shoes, so shod or unshod makes no difference. He is unable to reproduce the pain or discomfort.

The feet were normal in appearance. Arches were normal to slightly cavus. He had a mild, uncompensated forefoot varus. No global redness. Mild redness noted at medial and lateral nail beds of the great toe. He had a loss of long axis extension of the metatarsophalangeal arIculaIons and talonavicular arIculaIons bi-­‐lat. No tenderness to palpation of the dorsal or plantar surfaces of the feet are noted. No difference in neurological integrity with respect to sensaIon, motor strength or deep tendon reflex on either side. Nail bed filling was normal. Feet were cool
and moist to touch.  He did have weakness of the short extensors of the great toes, somewhat of the long extensors of the remainder of the digits. Ankle dorsiflexion is 10 degrees on each side.

Gait was tandem with a slight crossover. 

Hmm. Pretty boring, eh?

This is what we thought the differential should include:

1.   Early Gouty arthropathy.  This would be rare in a bilateral situation but possible.
2.   Athlete’s foot. This usually presents with more redness or this could be a variant.
3.   Lack of arch support during the day and his feet are fatiguing.
4.   Lumbar spinal canal stenosis; note that he has no change with squatting or sitting, so this is unlikely.

This is what we recommended:

 He is going to try either TinacIn or Lotrimin on his feet for 2 weeks, twice per day applicaIons, changing his socks between, making his feet wet and moist before application. Will switch to a boot that breathes batter and is more supporIve for work (he is a mason), to see if this works well. Foot strengthening exercises for the muscular deficiencies were prescribed. If this does not alleviate the discomfort, we will consider running labs and imaging looking at the possibility of gouty arthropathy and/or stenosis.

The Gait Guys. Showing that we don’t always have all the answers, but have a pretty good idea of how to get them.

The Almighty Foot Tripod

You have heard us talk time and time again about the importance of the foot tripod. To review, it consists of the center of the calcaneus, the base of the 1st metatarsal and the base of the 5th metatarsal.  To see some of our other posts on the foot tripod, including other exercises, click here

Join Dr Ivo in this brief and informative video demonstrating an exercise that most people with an inadequate foot tripod will benefit from.

Remember Skill, Endurance and Strength. There are many nuances to this simple exercise, don’t take it lightly!

The Gait Guys: Hammering it out, daily, to give you the goods!