Five years ago I was visited by a 31 year-old account executive. She was sent to me by her mom, an old patient. She’d had several significant microtraumatic musculoskeletal injuries during her young life. She’d had what was diagnosed as “tendinitis” in the sole of her right foot since teenage. She’d had kneecap region pain on the right, accompanied by a “tearing” sensation, for three years. She’d had right-sided sacroliliac pain on and off since she was 21, prompting numerous chiropractic and orthopedic/physiotherapeutic visits. She’d recurring right-sided hip (trochanteric) bursitis. She had new pain beneath the right big toe joint for 6 weeks prior to visiting me, and she noticed she was developing a bunion, rapidly, “before her eyes”, as she rather fearfully put it on the day of our visit. She’d seen a podiatrist 4 years prior who’d furnished her with several pairs of orthotics, unfortunately none had relieved her concurrent or newer symptoms.
My old mentor, Richard Schuster, DPM (at whose memorial lecture series I gave the final presentation to invited-only supereminent podiatrists from across America), once mentioned to me that people who have problems just on one side often have leg-length asymmetry. Recalling this I asked my patient to stand…yep, that right pelvic crest sure was lower than the left. But her right foot was way more pronated or arch-collapsed. When I asked her to roll her standing right arch up out of pronation, to make it even in arch height with the left, several things happened.
I’ll list them. First, her apparent leg length asymmetry now abated. So this hip-height asymmetry was not an indication for a heel lift, but perhaps rather an “arch lift” i.e., an orthotic. Second, her right sacroiliac joint, which had been displaced markedly towards the front when she stood foot relaxed, now assumed the same pitch front to back as her uninvolved sacroiliac joint. Third, her right kneecap or “Q” angle, which was thirty degrees when she stood foot-relaxed, now ameliorated to thirteen degrees when she assumed the right-sided raised arch position (11 to 16 degrees is considered a normal Q angle). Fourth, her right great toe, which was in a moderate degree of bunion angulation (hallux valgus) when she stood arch-relaxed or flat, now reduced to an angle similar to the great toe on the uninvolved or left foot.
Paying closer attention to her foot complaints, I palpated the area of the “tendinitis”. There was no tendinitis. The ligament on the big toe side of her ankle (as opposed to the pinky toe side) was tender. This is the deltoid ligament, responsible for helping hold the heel bone in correct alignment. Heel bone malalignment is a published cause of bunion formation.
At her great toe, there was tenderness just at the edge of the ball of her foot, under the bunion joint, exactly where the underside of the bunion touches the corner between the sole and the upper of the shoe. I was concerned she had a stress fracture of her sesamoid bone there (we are born with two little kneecap-like bones under our great toe joint, called “sesamoids”). My concern was assuaged after my X-ray. She was born with only one sesamoid in her great toe joint. The sesamoid which should be located at her pain site was absent, so it couldn’t be stress-fractured! The remaining sesamoid was not tender to palpation. These two little bones act like parachute guy-wires to hold the great toe straight against bunion formation. If the one on the inside is missing, there is less pull from this side to keep the big toe in proper alignment. This patient was rapidly materializing into a prime candidate for orthotics to keep her foot from pronating and to hold that arch up. But why didn’t the several pairs of orthotics provided by her previous podiatrist work? Was her calf was too inflexible to let orthotics work? Nope, it passed my test for flexibility, which I perform on nearly every patient with a mechanical issue. (I’ve been lecturing about this technique internationally for thirty three years, and it was the subject of my lecture at the aforementioned memorial lecture.) What about that deltoid ligament? Yep, it was very lax. I could readily coax her heel into a position three times more pronated than statistics say is normal for her age group. She’d brought me her bag of orthotics. None were directed towards grabbing her heel (they all had either a flat or a too-shallow heel cup), nor towards wedging it out of pronation (all her orthotics were devoid of rearfoot-varus wedges). This particular wedge is considered a sine qua non for proper orthotic construction (although I will remove and even reverse it if a particular case warrants it). And none of her orthotics even came close to the arch height required to make the right side even with the left. The orthotics were flat, left and right, and had cost her in toto about $2400.
I casted her for full arch-contact, rearfoot varus posted orthotics.
It is rare for me to tell a patient that I think they will love their orthotics. I feel slimy when I say that, because as hard as one tries to eliminate all possible unfavorable outcomes, one never knows for certain what might be around the corner to keep orthotics from working; plus I don’t like “selling” these things. I just couldn’t resist this time, and I told her this which I avoid most times.
Now, five years later, this young lady is an active, pain-free mother of a four year-old daughter. She, her mom, and little Ciera came and visited me last month. Both moms are wearing their orthotics. Ciera appears to have healthy feet, with no sign of deltoid ligament abnormality. Is this a great job or what?