A sixteen-year-old female attends the clinic presenting with pain at her medial tibia and lateral thigh bilaterally with the right being worse than the left side. Pain has been present for just over four years with both herself and parents previously agreeing that it was most likely growing pains as the issues began at approximately twelve years of age. However now that the pain has increased recently and has been continuous for an extended period of time they thought it best to have the problem investigated professionally.
Previously to combat the aching at the medial tibia and lateral thigh the patient received weekly sports massage that would help for 2-3 days. Additionally, a physiotherapist has been seen who also had done very little to alleviate the patients pain.
The patient states the pain can be as high as 8/10 on the Visual Analog Scale but as low as 0/10 at times, with her most noted aggravated pain being extended time standing associated with school and work. Non-weight bearing rest was seen as the only really successful management thus far to the patient. The patient states that she has no allergies, regular medications or medical conditions and overall is considered quite fit.
The patient footwear at this time is deemed to be appropriate as she regularly wears;
1. Clarkes Daytonas – School and Work (80% of her week)
- Asics Nimbus – Gym and Activity (15% of her week)
- Barefoot mostly around the house (5% of her week)
The patient is a student in high school and works at a supermarket checkout that requires long periods of standing. Additionally, she attends the gym three times a week for a mixed cardio and resistance workout, attends taekwondo once a week and jazz dance once a week.
In the initial assessment the following significant findings were observed:
– Pain on palpation of the medial and anterior tibia as well as the insertion and mid portion of the iliotibial band bilaterally.
– The left foot showed a very restricted 1st ray range of motion in weight bearing and the right foot appeared to have an active windlass mechanism available.
– Both feet, left more so then the right, pronated through mid-stance to an end point range of motion further locking up the 1st MTPJ
– Due to restricted range of motion the left foot was shown to be Apropulsive and both feet displayed an early heel lift.
– Non weight bearing range of motion was found to be within normal limits.
– Proximally, there was visualized femoral rotation and poor glute activation/ control.
Given the patient’s presenting complaint and assessment finding a number of steps were taken in the initial appointment to reduce the patient’s biomechanical risk factors, the forces through the effected tissues and improve the tissues ability to cope with the stressors which are placed upon them.
The patient’s feet were supported through a low dye moccasin taping technique used to shorten the distance between the origin and insertion of the plantar fascia and reduce the speed and force of pronation occurring at the feet. This in part would have more proximal influence as we look to reduce the amount of medial tibial rotation occurring which has been producing some of the patient’s pain. Additionally, a group of glute activation exercises were prescribed so that deficits both distally and proximally were addressed.
First Follow-up
In her first follow up appointment the patient exclaimed how good she had felt with the taping on her feet and would like to invest in orthotics as a mid to long term option for her condition. On this statement the patient was talked through her orthotic therapy options and a decision was made regarding her prescription.
ORTHOTIC CASTING & PRESCRIPTION
The patient was cast using the Vertical Foot Alignment System, a weight-bearing process using cushions and cranks to create a negative cast of a patient’s foot, with the primary theory of casting associated with the tissue stress model.
The device created was a 3mm polypropylene device with a 400 durometer EVA heel post and 220 durometer EVA arch fill reinforcement. The top cover was full length with a cambrelle base, 1.5 mm poron and a 2mm EVA top for comfort purposes.
EXAMPLE:
Second Follow- up
The second follow up with the patient took place one week later and the primary focus of the consult was to release the deep and superficial muscles of the lower leg through dry needling techniques and soft tissue massage. A total of eight 40mm x .28mm acupuncture needles were used in various trigger points and adhesions of both lower legs. The patient reported feeling as though her muscles has “reset” post-treatment.
Third Follow -up
The third follow appointment was for dispense of her custom function orthotic device. The orthotic top cover was resized and shaped to mimic that of the patient’s most commonly worn shoes, the patient felt the orthotics were comfortable and supplying adequate support at this time. Additionally, the patient was taped with the same moccasin taping technique which had previously provided benefit and advised to remove it in approximately 48 hours.
It should be noted that since her initial appointment the patient has not experienced any notable pain or irritation.
Fourth Follow – up
The Fourth follow up appointment was due to be a review of the orthotic device and how the patients pain had changed in relation to the new device. The appointment was cancelled within 24 hours of the consultation time due to the patient believing they did not require the appointment stating: “I have not had any pain in a number of weeks now and I am back at the gym running on the treadmills…Everything is going well.”
Although not an ideal situation the patient had shown compliance in her activities and prescribed exercises, therefore the podiatrist suggested the patient book ahead in 6 months for another follow-up and make contact should anything change.
Conclusion:
The patient contacted the clinic after 2 months to inform the practitioner that everything was going quite well. There had been family circumstances which had limited her ability to attend but had had no pain since her last appointment and was attending the gym and running regularly.
The patient was discharged, with a recall put in place for 12 months’ time.
FootNotes Publishing 
Thanks for sharing . It’s a very informative article . My question is what is the time of every follow up? I read that u only mentioned tape and gluteus exercise , dry neeedling . Do you conduct every day session for exercise ?
What is your criteria to prescribe an orthosis when patient come to us with such kind of problem ?
In your article you mentioned in 2nd follow up regarding orthosis .
I hope you will help me solve my query. I will look forward to your positive response.
Hi Jaymin,
Orthotic therapy is most ethical and efficient when the stressor within the tissues can be identified as originating or partially originating from the foot.
In this can the patient was pronating to a point which saw her 1st MTPJ ROM restricted and in addition to poor ankle joint ROM was contributing to lower leg rotation.
As for exercise prescription, I try to have every patient leave with a set of exercises within their first couple of appointments.
The first phase of rehabilitation exercises is to re-establish the patients ability to activate the muscles and control the functional pattern.
From that point strength can be built and other training principles/modalities such as endurance and force production can be established.
I hope this helps