SPORTS MEDICINE PODIATRY ASSESSMENT

the sole to show wear marks on the lateral border of the heel and to curve towards the medial central forefoot. Excessive wear on the medial aspect of the heel and sole, as seen on the left trainer in Fig. 3, is associated with excessive pronation. The right trainer in Fig. 3 shows signs of wear on the lateral border, indicating excessive supination. That is, one foot is pronating and the other is supinating. This would be seen in a patient with a leg-length difference – the foot of the longer limb will try to pronate in an attempt to shorten, and the foot of the shorter limb will try to supinate in an attempt to lengthen.

TREATMENT The aim of treatment is to make the mobile foot stable or the rigid foot more mobile. The following mnemonics refer to treatment of an acute injury: n RICE: rest, ice, compression, elevation n RICER: rest, ice, compression, elevation, rehabilitation n PRICE: prevention, rest, ice, compression, elevation n PRICER: prevention, rest, ice, compression, elevation, rehabilitation n NICER: non-steroidal anti- inflammatory drugs (NSAIDs), ice, compression, elevation and rehabilitation. Treatment of the sports patient can

consist of a multitude of therapies, such as physical therapies, electrotherapy, stretches, strengthening and surgery. Mechanical therapies include immobilisation, strapping, taping and orthoses (Fig. 4). All podiatrists are able to apply any of the above therapies as indicated, but our expertise individual to our profession is that of podiatric biomechanics of the lower limb and orthoses.

Orthoses Many studies have shown an association between foot morphology

TABLE 1: LOWER-LIMB INJURIES AND ASSOCIATED ABNORMALITIES OFTEN NOTED CLINICALLY (8)

Injury Sesamoiditis

Common biomechanical abnormalities

Pronated foot Abducted gait Limited first ray range of motion Forefoot valgus/ plantarflexed first ray

Plantarfasciitis Achilles tendinopathy Peroneal tendinopathy Medial shin pain

Pronated/supinated foot Abducted gait Ankle equines

Pronated foot Ankle equines

Pronated foot at toe-off Excessive supination

Pronated foot Ankle equines Varus alignment Abducted gait

Patellar tendinopathy

Pronated foot Anterior pelvic tilt Varus alignment Abducted gait

Patellofemoral pain

Pronated foot Anterior pelvic tilt Varus alignment Abducted gait

Iliotibial band friction syndrome

Hamstring strain Metatarsal stress fracture Navicular stress fracture Fibular stress fracture

Lateral pelvic tilting Varus alignment

Anterior pelvic tilt Ankle equines

Pronated foot Supinated foot

Pronated foot Varus alignment

Supinated foot Pronated foot Varus alignment

Figure 4: Temporary pair of bespoke insoles

and related injuries (1–3). Table 1 lists some of the conditions and associated foot morphology. Many different theories and principles exist regarding podiatric biomechanics. Root and colleagues (4) attempted to view the foot as a dynamic rather than a static entity. In this theory, orthoses are designed to support the deformity and place the foot in STJ neutral, thus preventing abnormal compensation, which may predispose to injury. This treatment is based on maintaining the STJ in neutral, but in “normal” gait STJ neutral occurs only twice, momentarily. “Normal” is for the STJ to be constantly in motion about its axis, not held statically.

Sagittal plane (SP) facilitation theory is based on the principle that most of the motion in gait occurs in the sagittal plane. Danenburg (5) expresses a similar opinion in that excessive pronation is not a primary problem but a secondary compensation to a lack of SP motion. Rotational equilibrium theory by

Figure 2: Gait during running www.sportEX.net

Kirby (6) aims to balance the forces acting across the STJ in order to maintain equilibrium and to reduce excessive pronation and supination. Nigg (7) has developed his model in response to his work on how footwear and orthotics affect sensory perception, mechanoreceptors and proprioception and motor control in response to this. Elements of all of the above theories, and others leading to the

25 Figure 3: Pair of running trainers