Who is the Boss : the Back or the Foot ?
Retroversion occurs when the angle is decreased below 14 degrees and the angle of the head and neck of the femur is rotated posteriorly with respect to the shaft ( Norkin and Levangie , 1992 ).
To test in supine , rotate the leg outward to the point at which the lateral trochanter falls laterally without falling posteriorly . Other tests include the range of hip rotation , which is excessive in prone and supine with no significant difference between the two ; and Craig ’ s Test in prone , which involves the examiner rotating the hip and determining the most lateral prominence of the greater trochanter , which is the neutral position of the acetabulum ( Magee DJ , 1997 ).
At present time , there are no reliable methods to assess retrotorsion in standing . The relation of tibial torsion , femoral torsion and forefoot abduction remains difficult to assess and is not predictive of turnout in ballet dancers ( Champion and Chatfield , 2008 ). It is recommended that total turnout be differentiated with femoral torsion , tibial torsion measurements on the table and hip range in supine and prone .
In this case study , the patient stands with feet turned out or in the “ Charlie Chaplin ” position and attempts to seat the femoral head in an optimal position in the acetabulum . The retroversion can result in early supination and hitting the lateral side of the foot , followed eventually by excessive and prolonged pronation in stance with medial displacement of the center of gravity .
In this instance , the back is the boss and the foot follows . Treatment consists of accommodating late pronation with a full-contact insert ( see picture , left ). Certain shoes with a straight last control motion allow for some rocking over the toe , maintain hallux range of motion and do not force rotation inward , yet they still stretch the muscles gently into inward rotation . The subject is not allowed to tailor sit .
Coxa Vara
In the frontal plane , the angle of inclination is less than 125 degrees ( Mahers et al , 1996 ). On observation , the lateral trochanter is more visible — the thighs look bigger and the calves smaller . As compensation , the femur is adducted to seat the head of the femur in the acetabular fossa . The contralateral iliac crest is higher during DLS , and the coxa vara creates a leg length discrepancy .
On the pictured subject ( see picture , top right ), the right leg is more affected than the left and the right iliac crest is lower than the left . In this case , there is a limitation of hip abduction or movement of the leg away from the body . The spine suffers from a compensatory side bend to the left and rotation to the right . The iliotibial band on the right side is positioned more forward of the greater trochanter and the right pelvis may rotate forward with tightening of the hip flexors . The result may be painful trochanteric bursitis and hip flexor tendinitis . In order to create a wider base of support , there may be genu valgum or supination of the feet in standing with tibial varum .
Initial treatment of this patient requires addressing the leg length discrepancy associated with the coxa vara . In addition , accommodating and correcting supination using inserts modified with lateral posting and cutouts for first ray as well as shoes designed with neutral cushioning or rocker action over toes can help many patients . Stretching of tight muscles such as the iliotibial band and hip flexors and self-mobilization of the pelvis for anterior rotation of the pelvic bone will help with symptoms . In this case , the back and hip are boss and can cause great pain and suffering to the afflicted individual .
Though there is little research on the effect of hyper mobility on the feet , one study conducted on an athletic population used the Beighton and Horan joint mobility index and revealed that increased medial foot loading existed in female athletes screened for hyper mobility ( Foss et al ., 2009 ). The study also required participants to walk over a walkway with pressure plates and be tested for levels of dynamic peak pressure and maximum force . The study , however , did not take into consideration any of the proximal effects that might accompany joint instability .
Popular research speculates that internal rotation of the lower leg and an upper body forward tilt occurs when there is hyper mobility at the subtalar and midfoot joints ( Pinto et al , 2008 ). Compensations , including a lordosis or a scoliotic curve ( particularly if there is a leg length difference ) are believed to follow . In clinics , a great deal of time and effort is spent trying to correct these issues with orthoses , physical therapy and other stabilizing and strengthening tools .
Ehler Danlos Syndrome
In one case study , a 34-year-old patient with Ehler-Danlos Syndrome sought treatment for stress fractures of the tibia and fifth metatarsal on the right . Although she initially responded favorably to therapy , her poor proprioception and extensive joint instability led to a fall and injury to the left calcaneus . Attempts to stabilize the foot aggressively led to sacroiliac joint pain on the right , and the patient was unable to tolerate an insert with maximum correction . When her right sacroiliac joint became exquisitely painful , she became unable to bend down to tie her shoes and , subsequently ,
16 Pedorthic Footcare Association www . pedorthics . org