Video Notes:
Offload like crazy at the start – orthotics.
Primary concern is trying to identify what force is causing the issue.
Is it compressive? That is, the tendon is being squashed by the navicular, which you generally see in the Pes Planus foot. Got to be careful when casting and prescribing the orthotic that you’re not putting too much force through the arch right at that point. So consider low arch with a skive, or moving high point of the arch toward the midfoot. Consider EVA material.
Is it eccentrically loading? So high level/high force pronation. Often in relatively neutral or cavus foot type, often with tib varum. It might not look like they pronate, but it’s more about the rate at which they pronate. Often in people who play cutting sports with a lot of lateral movements.
Or is it the Pes Planus foot with high supination resistance and tib. post is overloaded.
Or an abductory twist and medial roll off with late mid-stance pronation, causing eccentric loading of tib post, strengthening with calf raises will be particularly important.
Test with taping. If inversion sling tape pulled tight under the talonavicular joint is uncomfortable, then it’s likely a compressive issue. But if a lattice tape or a low-dye tape feels better, then these tapes aren’t causing compressive force on the tendon. In the compressive cohort of cases, you don’t have to bring their foot posture back to neutral, you just have to bring them back enough to take the pressure off the tendon.
Orthotics don’t need to be a long-term intervention for many, just a load-management tool to offload whilst they can build strength and you can improve ankle ROM and midfoot ROM through Mobilisation. Orthotics can also help to improve windlass in the abductory twist cohort.
However, the compressive load cohort, they are likely to be in orthotics forever.
3 month review since the start of intervention, start to think of getting them out of orthoses.
Consider the following tests barefoot:
– can they SL calf raise without pain and what’s the quality like?
– can they heel walk without pain?
– can they hop and land without pain? or 5 hop and lands without pain?
– lateral hops without pain?
Check how they pull up the next day.
At that point, look at their weekly activities. Looks at getting them to try to 30% of their activities without activities. Monitor pain. Anything from 3-4/10 pain and below is fine and educate them on this that it is normal when you are exposing that area to load again and strengthening it.
Try that for 5-6 weeks, then review re-test all the above tests, if all going well, drop orthoses for another 30% of activities.
In running cohort, they should be doing intervals and tempo sessions.
They may need to always have orthoses for their longer 10km+ runs, but fine for shorter distances.
Or some people might just need their orthoses for sport games due to higher intensity.
Hip complex strength is important. Think, if you are trying to engage windlass and late midstance propulsion, but they’ve got tight hip flexor, no glute activation, tight hamstrings, and can’t extend their hip, how are they going to roll off their big toe?? They are going to cheat the roll off.
A typical presentation includes:
– Poor 1st MPJ function
– Very poor Ankle ROM
– Very poor calf strength
– Poor hip strength
And the tib. post. is just the structure that gives way.
Therefore if you can improve strength in all these things, then you can start to think about taking the orthotic away, but if not, then the orthotic does effectively become a crutch for the system to cope with the poor biomechanics.
Tissue stress model – just need to get out of the plastic zone.
If they are doing their strength work, the orthoses will generally become overly aggressive, SR will decrease and they will start rolling off their devices and you can start reducing control through the device. This is a positive progression which can help motivate the client and progress them out of orthoses.
Conversely you might have a client with a rigid flat foot and they can’t tolerate an arch, so you start with low arch and then 12 months down the track they might be more mobile and you can re-cast and transition them to something with more control.
Consider Os Naviculares and Syndesmosis cases with traction. Aggravation of the syndesmosis can become inflamed between the navicular and the Os Naviculare or if its a stage 2 or 3 larger one, that will really contribute to the compression component of tib post. May in this case need surgery.
If you a have a “boggy” tendon full of fluid, and its a full tendinosis, you’re never going to fix/rehab that. They’ve probably had that for years if it’s reached by this point. Surgery?
