Now for this particular person, we aspirated and injected her knees and also injected her pes anserine bursa but still said there were some issues which she should address with a physical therapist.
Our biomechanical findings in this person were much like some of the others that we have seen. Bilateral knee and plantar flexor weakness in this case as well as lack of ankle dorsiflexion. She has bunions as well. She also has more pronounced calcaneal valgus on weight-bearing and does have pronounced pronation. Her body mass index is over 30, which we know puts her well in the range of being obese. What we plan to do is address the foot posture and lack of dorsiflexion that contribute to her knee pain and bunions. She has problems with lower extremity alignment and strength that produces and unstable knee and poor shock absorption, which contributes to joint stress and damage, we speculate. She is sedentary, deconditioned, overweight, possibly depressed judging from her posture and her affect, and at high risk for secondary illnesses related to inactivity.
Our goal is to reduce her knee pain, protect her joints, improve function and get her involved in daily physical activity. We are going to look at customized orthotics for this person rather than just off-the-shelf because of her weight and also because she more pronounced biomechanical problems there, and also try to get her fitted in athletic shoes that have a continuous rocker-type sole, which require less extension at the metatarsal joints and will allow her to move with less pain and less stress on that area. Also shoes that have adequate depth and room for her forefoot so she doesn’t continue to get pressure on her bunions.
Here’s some examples of what we call semi-rigid orthoses and you can see here these all have an example of not only having some kind of control of the rear foot but also to support the medial longitudinal arch. They are worn easily in extra depth shoes. You can see here an example of what happens. What you can see here is the same person with a semi-rigid orthotic that has been customized for them and does support their medial longitudinal arch. So you can look very easily and see what happens when you change and control the foot, what happens at the knee. This is an example of a rigid foot orthoses which is not being used in arthritis as much but we are trying some trials of it at our institution now. It doesn’t give at all. It’s heavy, tough plastic, and what you see in there that people talk about as being the golf balls they have to walk on, are actually inserts that are firm and fit up right under the sustenaculum talus to actually mechanically support that bone so it doesn’t drop during weight-bearing. To wear orthotics like these is quite … people need a lot of support for the break-in period and they certainly need shoes like this to be able to accommodate them. I wanted to show you the shoe on the right, the white one, the Good Guy. That gives you an idea of a rocker-bottom sole that’s available commercially. The heels are often notched and the toes are up a little bit and it makes it easy for the person to progress over their forefoot, so they can be very comfortable and not expensive.
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