Pain on the outside of one leg, inside of the other. 

Whenever you see this pattern of discomfort, compensation is almost always at play and it is your job to sort it out. 

This patient presents with with right sided discomfort lateral aspect of the right fibula and in the left calf medially. Pain does not interfere with sleep.  He is a side sleeper 6 to 8 hours. His shoulders can become numb; left shoulder bothers him more than right.

PAST HISTORY: L shoulder surgery, rotator cuff with residual adhesive capsulitis. 

GAIT AND CLINICAL EVALUATION: see video. reveals an increased foot progression angle on the right side. Diminished arm swing from the right side. A definite body lean to the right upon weight bearing at midstance on that side.

He has external tibial torsion bi-lat., right greater than left with a right short leg which appears to be at least partially femoral. Bi-lat. femoral retrotorsion is present. Internal rotation approx. 4 to 6 degrees on each side. He has an uncompensated forefoot varus on the right hand side, partially compensated on the left. In standing, he pronates more on the left side through the midfoot. Ankle dorsiflexion is 5 degrees on each side. 

trigger points in the peroneus longus, gastroc (medial) and soles. 

Weak long toe extensors and short toe flexors; weak toe abductors. 

pathomechanics in the talk crural articulation b/l, superior tip/fib articulation on the right, SI joints b/l

WHAT WE THINK:  

1.    This patient has a leg length discrepancy right sided which is affecting his walking mechanics. He supinates this extremity as can be seen on video, especially at terminal stance/pre swing (ie toe off),  in an attempt to lengthen it; as a result, he has peroneal tendonitis on the right (peroneus is a plantar flexor supinator and dorsiflexor/supinator; see post here). The left medial gastroc is tender most likely due to trying to attenuate the midfoot pronation on the left (as it fires in an attempt to invert the calcaneus and create more supination). see here for gastroc info

2.    Left shoulder:  Frozen shoulder/injury may be playing into this as well as it is altering arm swing.

WHAT WE DID INITIALLY (key in mind, there is ALWAYS MORE we can do):    

  •  build intrinsic strength in his foot in attempt to work on getting the first ray down to the ground; EHB, the lift/spread/reach exercises to perform.
  • address the leg length discrepancy with a 3 mm sole lift
  • address pathomechanics with mobilization and manipulation. 
  • improve proprioception: one leg balancing work
  • needled the peroneus longus brevis as well as medial gastroc and soles. 
  • follow up in 1 week to 10 days.

Pretty straight forward, eh? Look for this pattern in your clients and patients

Pain on the outside of the leg? Could it be your orthotic? What you wear on your feet amplifies the effect of the orthotic.

This woman presented with right-sided pain on the outside of her leg after hiking approximately an hour. She noticed a prominence of the arch in her right orthotic. She hikes in a rigid Asolo boot ( see below). Remember that footwear amplifies the effect of an orthotic!

In the pictures below you can see the prominent arch. The orthotic has her “over corrected” so that she toes off in varus on that side. The rigid footwear makes the problem worse. The peroneus group is working hard (Especially the peroneus longus)  to try and get the first Ray down to the ground.

The “fix” was to soften the arch of the orthotic and grind some material out. Look at the pictures where the pen is pointing to see how some of the midsole material was taken out. Notice how I ground it somewhat medial to further soften the arch.

She felt better much better after this change and is now a “happy hiker” 🙂

Dry Needling and Proprioception. What a great combination.

Since dry needling and proprioception both have such profound effects on muscle tone, why not combine them to treat chronic ankle instability? We do all the time and here is a FREE FULL TEXT article that ties the two together nicely!

And what better to muscle to use than the peroneii? These babies help control valgus/varus motions of the foot and influence plantar and dorsiflexion AND the longus descends the 1st ray. We call that a triple win!

“This study provides evidence that the inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the end of the therapy in individuals with ankle instability. Our results may anticipate that the benefits of adding TrP-DN in the lateral peroneus muscle for the management of ankle instability are clinically relevant as large between-groups effect sizes were observed in all the outcomes.”

link to full text
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

photo from this past weekends Dry Needling Seminar: working on the dorsal interossei

Thinking on your feet. You have less than 20 minutes with this gentleman, as he has to leave to catch a plane. See how you did. 

Lateral foot pain and cowboy boots?

A 55 YO male patient presents with pain in his left foot area of the cuboid and tail of the fifth metatarsal.  He was told that he had a “locked cuboid” on this side by his chiropractor, who provided some treatment and temporary relief. There has been  no history of trauma and Most recently, he has been wearing cowboy boots and doing “a lot of walking” particularly when he was over in Europe and feels this was a precipitating factor.

Watching him walk in his cowboy boots, the rear foot and heel plate of the cowboy boot is worn into varus. Gait evaluation reveals his left foot to remain in supination (and thus in varus) throughout the entire gait cycle. 

Examination of the foot revealed loss of long axis extension at the metatarsophalangeal and interphalangeal articulations. The cuboid appeared to be moving appropriately. (to see why cuboid function is integral, see this post here. ) There was weakness in the peroneus brevis and peroneus longus musculature with reactive trigger points in the belly of each.  There is tenderness over the tail of the fifth metatarsal and the groove where the peroneal muscle travels through as well as in the peroneal tendon as it travels through here. 

So, what’s up?

This patient has peroneal tendonitis at the point around the foot as it goes around the tail of the fifth metatarsal. Discomfort is dull and achy in this area.  The cowboy boot is putting his foot in some degree of supination (plantar flexion, inversion adduction); this combined with the rear foot varus (from wear on the heel) is creating excessive load on the peroneus longus, which is trying to descend the 1st ray and create a stable medial tripod. Look at the pictures above and check out this post here

What did we do?

Temporarily, we created a valgus post on an insole for him.  This will push him onto his 1st metatarsal as he goes through  midstance into termiinal stance. He was asked to discontinue using the boot until we could get the heel resoled with a very slight valgus cant. We also treated with neuromuscular acupuncture over the peroneal group (GB 34, GB 35, GB 36 and a few Ashi points between GB34 and 35) circle the Dragon about the tail of fifth metatarsal, GB41 as well as the insertion of peroneus onto the base of the first metatarsal (approximately SP4).   We K-taped the peroneus longus to facilitate function of peroneus longus.  He was given peroneus longus (plantarflexion and eversion) and peroneus brevis (dorsiflexion and eversion) theraband exercises. 

How did you do? Easy peasy, right? If they were all only this straight forward….

 

The Gait Guys. teaching you to think on your feet and increasing your gait literacy with each and every post. 

 

And what have we here?

The above is a pedograph, a simple, effective pressure map of the foot as someone is walking across an inked grid. For more info on pedographs, click here.

Did you note the increased ink present under the great toe bilaterally? What could be causing this? If you look carefully, you will note that it is at the base of the proximal phalynx of the great toe. This could be none other than the tendon of the flexor hallucis brevis!

This bad boy arises from the medial part of the under surface of the cuoid and the adjacent 3rd cunieform, with a small slip from the tendon of the tibialis posterior. As it travels forward it splits into two parts, which are inserted into the medial and lateral sides of the base of the proximal phalanyx of the great toe. There is a sesamoid bone present in each tendon, which offers the FHB a mechanical advantage when flexing the toe.  The medial portion is blends with the abductor hallucis and the lateral portion blends with the adductor hallucis.

Had the increased printing on the pedograph been more distal, it most likely would have been due to increased action of the flexor hallucis longus.   Had it been more proximal (under the head of the 1st metatarsal) it would have been due to the peroneus longus.

Cool, eh?

Reading pedographs and making you a sharper clinician/coach/trainer/sales person is just one of the many skills we try to teach here on the blog. Keep up the great work!

The Gait Guys