Clinical Biomechanics Boot Camps

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Global Podiatry and lower limb related courses and seminars


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The Bauer Bump

The ‘Bauer Bump’ was a new word I only recently heard about and wrote here about it. The Bauer Bump is a haglund’s deformity that becomes painful in ice skates and Bauer are one of the most well known brands of ice skate, hence the term Bauer Bump. I had been well aware of the issue of Haglund’s deformity and that it was a problem in the rigid ice skate and had treated a number over the years (and I grew up going ice skating a lot!), I had just not come across the term, Bauer’s Bump.

After learning of the term, I did a bit of a deep dive into the ice skating and ice hockey lay literature, websites and social media to see just how commonly it was called this. It was commonly called that and there were a lot of questions on ice skating forums and social media sites from ice skater about it.

I was also impressed at the depth and extent of knowledge about the condition in the ice skate industry and what could be done to treat it. They certainly appeared to be doing a better job of looking after it than I was!! The ice skate experts have at their disposal tools that can be used to modify the shell of the skate to get pressure of the lump of the Haglund’s deformity. They are very valuable people because of that. If you have a patient with a Bauer’s bump, reach out to these skate fitters.

Severs Disease in Adults?

This is an interesting one. According to a search engine keyword tool, the phrase ‘severs disease in adults‘ is searched for up to 700 times a month! That is 700 people looking for information on Server’s disease (Calcaneal apophysitis) occurring in adults. It is impossible for Severs disease to occur in adults, so I am not so sure what they are actually looking for.

Severs disease is a disorder of the growth plate at the back of the calcaneus. That growth plate merges with the rest of the calcaneus about the mid-teenage years. There is no growth plate there after that time, so it is impossible for Severs disease to be a problem in adults.

It could be that people are searching for information if the Severs disease that children get can continue to be a problem as they become adults (it doesn’t).

It could be that they have heard that Severs disease is common in children and they want to know if it could be the cause of there heel pain as an adults (its not). Heel pain is reasonably common in adults and it has many causes. Severs disease is just not one of them.

What foot cream do you recommend?

This was a question I got from a colleague. I get a lot a questions from colleagues, but not usually on that topic. Typically the questions are something like, which prefabricated foot orthotics do you use, which is the sort of topic that I know a lot about and not about foot creams which is a topic that I do not know a lot about! I not sure any recommendation from me on that sort of topic carries any weight.

I thought about it for a bit. With regards to the question on which prefabricated foot orthotics do you recommend, I typically answer that the best one is the one that has the design features that match the foot that it is needed for to get the effects that you want. Based on that there is no one best prefabricated foot orthotic. I also often say in lectures that a good clinician will not stick to just one prefabricated foot orthotic brand; they will have a range of brands with different design features so they can use the one that gives them the design features that they need. You need to be able to mix it up to get a clinical effect.

The more I thought about the foot cream question, then the answer probably should be the same. Different skins need different creams. A good clinician probably would not stick to just one brand, but have a range of brands at there disposal so they can use or recommend the one that gives the desired clinical effect.

That was pretty much the answer that i gave the colleague along with the recommendation that my advice on this topic should not carry a lot of weight.

What do I typically use clinically anyway? I like the 2 different concentrations of the urea creams, as I just get the impression (in the absence of good evidence) that they do seem to have a clinically affect on the most people. The urea concentration of below around 20% is better to moisturize the skin and concentrations of above around 20% are better at the helping get rid of the drier skin and getting up to 40% it appears to be more useful at the harder callused skin. So I mix it up, just like the prefabricated foot orthotic brands. I am in Australia, so I use the Walker’s brand of urea cream from Briggate Medical. It comes as a 15% and 25% concentration, so can choose the one the is needed to meet the clinical needs.

Consumers can get the Walkers urea 25% foot cream and the 15% version online.

I still don’t get why they sought my advice on this topic ….

Lateral Column Support…

…or cuboid notch or cuboid pad or cuboid raise or cuboid elevation or Denton modification or Feehery modification or … it comes by many names. As well as having many names it is used for many reasons. There are lots of reasons and explanations given for what the purpose of it is and I not totally sure on any of them.

Some use it for cuboid syndrome, some use it to stop the foot sliding off the orthotic laterally, some use it to facilitate the movement of the center of pressure towards a high gear propulsion, some use it for … etc

The reason I raise this now is that it has recently been pointed out to me that things like a cuboid notch may not be placed in the right place. It got me thinking.

The cuboid does not “drop” and need to be supported in the sagittal place which is theoretically what a cuboid notch or pad does. Because the cuboid is part of the calcaneocuboid joint, as it “drops” it also everts (rotates). This could be interpreted as that if a cuboid notch or pad is indicated, then not only should it lift up the cuboid, it probably should also try to invert it. This means that our cuboid notch’s need to be moved more medially (but still on the lateral side of the foot orthotic shell), so they can try to invert the cuboid bone as well.

I know my anecdotal clinical experience has been I have had some awesome results and equally have had some absolute disasters where the cuboid notch has made the pain worse, so its mixed. I certainly do use adhesive felt padding on the foot as a treatment direction test to see if the design feature is indicated on a foot orthotic.

I now wonder if my dismal failures with this were becasue when I used the cuboid notch to lift up the cuboid, I was increasing the eversion force on the bone when I need to lift it up and increase the inversion force on the bone. All my cuboid pads are not being moved a little medially now, so lets wee what happens.

“Too many toes” or “all the toes”

I think most of us have heard of the ‘too many toes sign’. This is when there are more than a few of the toes are visible on the lateral side due to an abduction of the forefoot when standing or walking.

This image from a screen grab of video that I did of a case I talk about during the Clinical Biomechanics Boot Camp could just about be considered as the “too many toes” sign:

Below is a screen grab of the video of the other foot. I like to call that one the “all the toes” sign rather than just the “too many toes” sign as all of the toes are visible laterally.

The key point in talking about this case was that it was the right foot that was the painful one and the left one with that severe “overpronation” was not the problem one. This means that the “too many toes” sign is not something to be necessarily worried about. What you need to be worried about is the forces behind the foot posture and be worried about them if they are high.

The “too many toes” sign is not really good terminology and is just something that clinicians may say to patient as part of a conversation. It is not a diagnosis. It is probably better to use the components of the Foot Posture index to put a number on the amount of forefoot abduction rather than just say too many toes.

Inhibition of the peroneal muscles

The concept of peroneal muscle inhibition has both intrigued me and confused me, yet I do see it clinically and see the results, but the lack of objective data does trouble me. I started this discussion to get a better understanding of it. I am not sure it did.

The concept is that there is some sort of inhibition of the peroneal muscles, particularly the peroneus longus and the muscle does not work as it should. This “weakness” can lead to a range of symptoms from functional hallux limitus (and its compensations), increased risk for ankle sprains, lateral foot pain and maybe Achilles tendon pain. Muscle testing will show a significantly weaker peroneus longus. Its not clear what it is that leads to this inhibition which without objective data to consider that is a problem.

Typically with a mobilization of the proximal and distal tibiofibular joint, you can see an almost immediate return to the strength of the peroneus longus. I have certainly seen that plenty of times clinically and have no doubt about its clinical usefulness. However, I really struggle to come up with a coherent explanation of how the inhibition was  caused and how the mobilization overcomes it. It you have something to contribute, please head over to Podiatry Arena and contribute your ideas in the thread on this topic.

The Supination Resistance Test

In the early days of the Clinical Biomechanics Boot Camps we spent a lot of time on the supination resistance test and the concept of supination resistance, as the concept was so new to so many, but as time went by less time was spent on it as the test has become so widely used and quite pervasive when it comes to prescribing foot orthotics.

The test was first described by Kevin Kirby, DPM and we have done a lot of work on it with a number of studies exploring the concept. Along with that research I used clinically and we did a lot of practical sessions on it in the boot camps – all of this lead to what I think was a good understanding of it and just how useful it was to use clinically when it came to the prescribing of foot orthotics in clinical practice. I think those who did the clinical biomechanics boot camps did get to agree with me just how important that the concept was for the prescribing of foot orthotics and understanding pathology. There are a lot of threads on Podiatry Arena on the topic that get updated regularly.

The supination resistance test is simply a test to estimate just how much force is needed to supinate the foot and then applying that knowledge to how much force is needed to come from the foot orthotic. If the force to supinate the foot is high, then the force needed from a foot orthotic needs to be high. No point using a soft flexible foot orthotic in those with a high supination resistance as the orthotic is probably going to do nothing. If the supination force is low, then a soft flexible foot orthotic is going to be adequate. Using a rigid inverted type of foot orthotic in a foot with low supination resistance is probably going to sprain the ankle.

For our research we used a device that we built to quantify it but that device really has no practical use in clinical practice, so the use of the hands and manually estimating is adequate. There are some devices on the market, such as the Keystone that can be used to put a number on it.

What I used to like saying to people who were unfamiliar with the test is to just do it. Get a feel for it. Find those feet that are high or low and see how that might relate to the pathology that the patient has. Get a feel for how people with different levels of supination resistance respond to different foot orthotic designs. You soon start to see patterns.

Volunteering at the parkrun

I hope no one from parkrun reads this!

The parkrun is a weekly 5k run held in over 2000 locations at 8AM on a Saturday morning all over the world (COVID restrictions permitting). I have run a few and volunteered at a lot. I mostly do the one here at Mullum Mullum in Mitcham. These events do not go ahead without the volunteers

You can read more on the parkrun here and here.

Why do I hope no one from parkrun reads this? I enjoy my Saturday morning interactions with the runners and walkers. I enjoy chatting with them. They have no idea of my interest and expertise in running, running injury and running shoes. I chat to them about what drives their shoe choices, how they managed with their injury, etc. It gives me insight into these issues. I do not generally give my advice. I like it that way. That is why I hope none of my new friends from the Mullum mullum park run see this post!

For those with an interest, please find a parkrun near you and give it a go at running it and helping out as a volunteer.

You may also find this book of interest:

Buy in Australia | UK | USA I Worldwide (free shipping)

Are foot orthotics active or passive physical therapies?

Within physiotherapy there has been a big trend to distinguish between active and passive treatments with the general considerations that active treatments are better and the evidence does generally link better outcomes coming from the active treatments. Passive treatments are generally those that are done to the patient such as manipulations, massage, TENS and dry needling. Active treatments are those that the patients does to themselves such as exercises.

Given this division within physiotherapy, the question comes up as to if foot orthotics come under the active or passive category. I assume the answer to this could be based on someone’s preconceived biases as they want them to be a passive treatments when active treatments are seen as better. I do not think foot orthotics come under either category. Arguments could be made either way. There are other types of treatments that do not fit into one or the other category either, so why would you want to try and put them into one or the other? Is there any point trying? If you need foot orthotics, you need foot orthotics. If you don’t need them, then you do not need them. Does it matter if they are considered active or passive treatments?

I do agree that active interventions are probably preferable for a whole lot of reasons that I will not get into here. That does not mean that there is anything wrong with passive treatments (but there is a lot wrong with some of them and others do not have a lot or any evidence supporting them). For example, what is wrong with self massage for plantar fasciitis with something like a PediRoller? Passive treatments are probably better options during the acute phase of an injury.

Posterior tibial tendon dysfunction or adult acquired flat foot or progressive collapsing foot deformity?

What should it be called? I have long been part of the school that thinks we should be sticking with the posterior tibial tendon dysfunction name as that is the one that has mostly stuck and the problem was considered one of the posterior tibial muscle no longer being able to do its job – it just made sense. Two things are starting to change my mind:

  1. The pathomechanical and other studies have shown there is a lot more to it than just the posterior tibial tendon.
  2. The confusion between posterior tibial tendon dysfunction and posterior tibial tendonitis is too common and leading to wrong treatment choices (especially in runners).

It is the later point that is getting more and more attention. They are not the same thing. Posterior tibial tendonitis is an overuse injury in active healthy people. Posterior tibial tendon dysfunction is a progressive flatfoot deformity in older, often overweight adults. Two totally different sets of symptoms; two totally different populations; two totally different sets of clinical features …. yet some think they are the same thing on a continuum and some mix the two up and use the same treatment interventions. Nope.

I now think we should be calling posterior tibial tendon dysfunction either adult acquired flatfoot or progressive collapsing foot deformity to avoid the confusion and better reflect the underpinning pathological process. This terminology of progressive collapsing foot deformity is the name that seems to be being used more frequently in the most recent literature on this problem.

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