Thornbers Podiatry“Promoting optimum health and performance”

Pt name: Mark Dodd

Presenting complaint: Buttock Pain, Pain around Left Tendo Achilles insertion.

Medical History: N/A

Sports History: Elite runner averages around 65+ miles per week, all road running.

Pt has recently had continual niggles with lower limb complex, is seeing osteopath for tight hip muscles, and currently complains of pain in left Achilles insertion to the heel.

Joint Examination:• Both Forefoot Varus deformity• Normal range of motion at sub-talar and mid-tarsal joint.• Ankle equinus = <90° dorsiflexion with knee extension.• Hip range of motion

Right = 30°:60° internal:external

Left = 15°:70° internal:external

The normal hip ROM is 45:45 either way. Therefore if you have more movement one way , then you are more likely to point your feet that way. You have an increase in external rotation over internal rotation which means your neutral foot position will be greatly out-toed.

• Both Limbs are symmetrical in length.• Both hamstrings 90:90 test = 55°• Both ITB and TFL are tight

Stance Examination:

The left foot is excessively pronated at the MTJ but also at the STJ. There is also a forefoot abduction.

Both heels remains upright in stance. But this changes with walking and they actually roll excessively into pronation.

Single knee bend on the left = XS internal rotation / buckling of the knee which indicated weak gluteals. The right single knee bend limb remains fairly external which is what you would expect.

The left heel is pronated more than the right and there is also a forefoot abduction. Note the difference in how many toes you can see between the left and right foot !

The right foot is still slightly pronated but not as much as the left.

Forefoot varus. The forefoot is inverted or tipping to the outside of your footAs compared with the heel which is level

Level heel

Gait

Excessive pronation at the sub-talar and mid-tarsal joint during mid-stance. During this Period the foot should be re-supinating for toe off.

GaitBoth your heels strike the ground slightly on the outside or

in varus which is normal, then due to your forefoot varus and ankle equinus, you pronate excessively during mid-stance, the left is slightly worse than the right but they both still pronate excessively. The probable reason for the left pronating more than the right can be seen with your single knee bend as the left leg rotates inwards excessively as compared to the right. This indicates that the upper portion of your body i.e. your hip musculature is not working as it should be.

The problem with running is that the forces acting on your body increase 3 fold and the angle at which you strike the ground in varus also increases. Next slide

For example with normal walking your heel will strike the ground in about 2° varus. With running this angle increases to around 7°, so your foot moves from a high varus position to a very flat pronated position due to your biomechanical problems. This has consequences on your musculature. With respect to your self you already have a very tight Calf muscles which are then further subjected to increased loads or a condition known as the whiplash effect of the Achilles tendon, in which the Achilles tendon pulls on the calcaneal attachment, this is causing your painful symptoms.

Diagnosis and treatment:

A Forefoot varus deformity along with an ankle equinus are leading to an inefficient excessively pronated gait, which in turn is causing Achilles tendonopathy at the site of the Achilles tendon – calcaneal attachment.

Treatment:

1/ provide casted orthoses.

2/ provide Achilles tendon stretches.

3/ reduce physical activity for 4 weeks.

4/ continue osteopathic related stretches.