Pudendal Neuralgia and Lower Extremity (Feet) Biomechanics - ICS 2011, Glasgow, Scotland

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Pudendal Neuralgia and Lower Extremity (Feet) Biomechanics
ICS (International Continence Society) 2011, Glasgow, Scotland
29th August - 2nd September 2011

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  • Original itention
    It’s really ironic ...
    I think my avoidance stems from that fact that feet mechanics are just really very complex, the feet are riddled with genetic deformities and the load on them is tremendous, in addition to that there isn’t really any agreement on how to treat foot dysfunction or even on the terminology used to describe foot dysfunction.
    So, I had to laugh when I went to leave the clinic one night…
    My first thought was, “I sure hope not!” At any rate, I started taking a closer look at feet and two issues have emerged.
    over 80% if not 90% of our patients with Pudendal nerve issues have this relatively short 1st metatarsal that characterizes the Morton Foot Structure. I’ve since then learned that a Morton foot structure in isolation doesn’t always seem to be problematic, but when it exists with additional abnormal foot mechanics, can become a problem.
    treating the feet seems to correlate with faster healing times.
  • **
  • CAUSES: Pudendal Neuropathy as with many neuropathies, is thought to be a consequence of trauma from compression, traction, or chronic aberrant nerve stimulation as a result of convergence and the associated abnormal reflexes and with surgery related traumas less common. It’s my experience that it’s rare to see a patient in whom just one of these conditions can be implicated as the sole mechanism of PN irritation or injury. More commonly, my evaluation process nearly always confirms events and conditions that fall into two if not three of these categories.
    Also worth noting, is that while impaired biomechanics are often listed as a situation unto itself, a closer look at this reveals impaired biomechanics as an underlying component in many of these mechanisms.
  • On that same note, it’s my experience these patients frequently present with not one, but a remarkable collection of clinically significant and interrelated findings coexisting in multiple layers of the body.
    Very commonly these conditions include, pudendal neuropathy, pelvic floor muscle dysfunction, connective tissue dysfunction, impaired biomechanics, myofascial pain, visceral pain & dysfunction, central sensitization, history of trauma, impaired neurodynamics.
    **What I believe this coexistence of findings implies is simply this ~
  • Impairments and pathological events that are relatively innocuous in isolation, in coexistence, can frequently give rise to complicated and severe chronic pain and dysfunction.
    Biomechanics are just one piece of this puzzle and subject to the same implication.
    For example, it is unlikely that a structural problem in lower extremities, like excessive foot pronation, alone will cause Pudendal Neuralgia. However, when a structural problem, such as excessive foot pronation co-exists with a history of recurrent bladder infections and discomfort induced, reactive pelvic floor muscle guarding, the likelihood of a myofascial problem at the very least may increase. Adding, a fall on the tailbone, a surgery or just emotional stress into this mix (which is a very common scenario in my practice) can quickly escalate the severity of the problem.
  • Compromised neural biomechanics or neurodynamics are usually the primary feature of pudendal neuropathy. Pathodynamics describes combination of pathomechanical and pathophysiological events in take place when there is injury to the nervous system - with pathomechanical referring to an impaired relationship between the musculoskeletal system and the nervous system or the mechanical interface (MI) and pathophysiological referring to the abnormal physiological response of neural tissues.
  • For my purposes here pathomechanics and specifically, the musculoskeletal piece of the MI is the focus. “where the nerves are presented with muscles, joints, fascia and fibro-osseous tunnels, against which the neural structures contact during daily movement and postures.”
  • The MI of the pudendal nerve essentially includes the piriformis muscle, the ligamentous clamp formed by the sacrotuberous and sacrospinous ligaments, Alcock’s canal within the obturator internus muscle and the pelvic floor muscles – all structures that could be referred to as the local mechanical interface of the pudendal nerve and that have been implicated as sources of pudendal and sacral nerve root irritation and entrapment.
  • Beyond the local MI of the pudendal nerve lie the structures that could easily be referred to as the global mechanical interface. And as is the case with most systems, global events affect local events. This global MI of the pudendal nerves essentially includes any structures the lower extremities and their associated movement patterns that influence hip and pelvic function.
  • **The Foot: Osseous Anatomy
    The tarsal bones make up the rear and mid-foot.
    The talus and the calcaneus make up the rear-foot their articulation forms the subtalar joint which is part of the functional unit that allows for pronation and supination of the foot.
    The rest of the tarsal bones make up the mid-foot
    The metatarsal bones, and the phalanges (the toes) make up the forefoot.
    Together the 1st cuneiform and the 1st MT make up the first ray, the functional unit of the forefoot that creates power for pushing off the ground to propel the body forward during gait. – This is also the structure that can become dysfunctionally hypermobile with a Morton type foot structure as well as with other foot pathomechanics.
  • 3 main goals
    adapt to accommodate uneven terrain
    to absorb shock on impact
    form a rigid lever during push-off
    when the foot fails to meet these goals, structures both proximally and distally can be affected
  • The foot’s connection to the pelvis can be understood through its role in walking and the kinetic chain. The detailed mechanics of walking, very far exceed what I will cover here, but none-the-less a little is necessary…the gait cycle of each leg is divided into a STANCE (support) PHASE, (when the foot is in contact with the ground which makes up 60% of the gait cycle and is the phase in which the lower limb is particularly susceptible to injury and the phase that is of concern here) and a SWING (unsupported) PHASE (when the foot is off the ground while the swinging forward).
  • The stance phase is further divided into heel strike, midstance and push-off phases of gait. The rear-foot, mid-foot and forefoot all influence how the foot adapts to and pushes off from the surface it’s walking on.
  • The key to understanding how abnormal foot function relates to hip and pelvic dysfunction is the Subtalar Joint. The motions of this joint alternate between pronation and supination during the stance phase of gait.
  • Pronation unlocks the mid-foot allowing the foot to become a flexible adaptor to uneven terrain, and very importantly also to absorb ground reaction forces.
    Supination transforms the foot from a flexible adaptor into a rigid lever in preparation for push-off.
  • In normal gait, during heel strike the foot immediately begins to pronate, converting the foot into a mobile adaptor in order to accommodate variances in terrain. During this phase the weight is shifting from the lateral foot to the medial foot toward the first ray and great toe. From mid-stance to push off the foot begins to re-supinate, a motion is crucial for the foot to function as a rigid lever in preparation for push off. During the push off phase of gait, the foot continues to supinate, and weight is shifted to the medial side of the foot supported by the strength of the 1st ray and the great toe.
  • **In the lower extremity kinetic chain when the distal segment is fixed, the proximal segments move. In gait, because the STJ and the hip are inextricably linked, movement patterns of the feet and ankle are reflected through the kinetic chain to the pelvis through the hips.
    Specifically, the lower extremity internally rotates with subtalar joint pronation and externally rotates with subtalar joint supination. Furthermore, synchronized activation of the hip adductors as hip internal rotators and the Obturator Internus as a hip external rotator, supports sacral nutation and counternutation, sacroiliac joint compression and decompression, and anterior and posterior pelvic tilt.
  • SKIP: Abnormal biomechanics of the foot can lead to disruption of connective tissue integrity and fascial lines, inefficiency of the pelvic and hip muscles, impaired movement patterns, impaired joint alignment and mobility, dysfunction proximally in the kinetic chain, and impaired ability to attenuate ground reaction forces.
  • The problem of excessive pronation or poorly timed pronation:
    A certain amount of pronation at the correct time during the stance phase of gait is imperative for normal foot, hip and pelvic function and in order to attenuate the forces put on the contractile and non-contractile tissues of hips and sacroiliac joints.
  • What exactly is a Morton Foot Structure?
    A Morton Foot structure is characterized by a short first metatarsal in comparison with the adjacent second metatarsal. It can be problematic because normally, during the stance phase of gait, the pressure on the foot should move toward the first metatarsal so that the very powerful great toe flexors can facilitate push-off and propel the body forward. When the first MT is shorter, the second MT takes on the job, of weight acceptance, for which it is not well-suited and the function of the foot is impaired.
    Due to complex changes in foot function, these abnormal mechanics can lead to abnormal pronation and subsequent hypermobility of the first ray. When this functional unit loses stability, the great toe can deviates away from midline (Hallux Valgus), bunions develop, and the stability needed to “push off” during walking is lost.
    Ensuing weakness develops in the muscles involving the foot, calf, and back leg, including the gluteus medius and maximus, all of which play and important role in the health of the pelvis. In theory then, muscle imbalance within this group of muscles may then also lead to excessive stress and possible instability of the SI joint.
  • There is no agreement in the science about whether or not it should be seen as a problem. Using toe pads under the 1st MT is definitely not the answer for all patients with this foot type, and yet has shown to be extremely effective for some. What I do know, is that the prevalence of Morton toe is high among patients with Pudendal Neuropathy and seems to make matters worse when it coexists with other foot pathologies.
  • Two other foot types that I very commonly see in patients with diagnosed PN are Rear foot and forefoot varus, which are different foot types but they both can result in compensatory and abnormal pronation. With rear foot varus foot the calcaneus is more inverted than normal so that the medial side of the heel is farther from the ground.
    With a forefoot varus has normal rear foot orientation the medial side of the forefoot higher or further from the ground than the lateral side.
    As a result the STJ compensates for the structural impairment of the calcaneus and the forefoot by pronating , in order to assist the medial side of the calcaneus or the forefoot to the ground.
    The result is too much pronation, too soon in the gait cycle.
  • For complicated reasons related to abnormal control of pronation, but as a means of identifying the problem, individuals with a rear foot varus frequently have a Tailor’s bunion (on the 5th MTPJ), hammer toes, a plantar callus under 2nd MTPJ, and a Haglund's deformity or heel bump due to movement of heel against shoe.
    * Symptoms
    o Leg fatigue and nocturnal leg cramp.
    o Low back pain or fatigue.
    o Lateral ankle sprains.
  • Individuals with a forefoot varus foot structure very frequently have hypermobility of the 1st ray evidenced by the laterally deviated great toe (Hallux abducto valgus), may or may not have a bunion of the 1st MTP, hallux limitus/rigidus (a stiff great toe), overlapping toes especially 2nd, a history of heel pain and or Plantar fascia pain
    * Symptoms
    o Hallux bursitis.
    o Generalized forms of metatarsalgia.
    o Chronic low back pain.
    o Inferior calcaneal bursitis or plantar fasciitis.
    o Severe fatigue.
  • The problems associated with Morton’s toe and varus deformities of the rear and forefoot are related to improper timing and excess pronation at the STJ. Due to the foot’s compulsory relationship with the proximal kinetic chain, whenever the STJ pronates the lower leg must internally rotate. Because the knee has very little capacity for rotation, the hip and or sacroiliac joints almost always absorb the extra internal rotation.
    If the femur is internally rotating to accommodate the excessive pronation, while the pelvis is reversing direction to move forward with the swinging leg, the piriformis and the obturator internus muscle due to their bony attachments inside the pelvis and femur, both undergo tremendous strain at both their origin and their insertion.
     
    As a consequence, neuromuscular and myofascial dysfunction and poor functionality can develop in the piriformis, obturator internus as well as the Gluteus maximus and the SS and ST may also be subject to greater strain. A very common set of finding in my practice in patients with these types of structural foot problems and pudendal neuropathy.
  • Additionally, the foot should become stable (an effect of supination) during the mid-stance phase in order to effectively support the full weight of the body and keep the pelvis level. Excessive pronation leaves the foot unstable and therefore compromises the muscles responsible for pelvic stability.
    Consequently, the gluteus medius in particular can become fatigued, weak and develop myofascial trigger points and tender points indicative of neuromuscular dysfunction in hips and SIJ. In their compensatory role in stability, the piriformis, TFL, adductors and psoas undergo even further strain and overtime can become painful and loose functionality.
     
    The impaired muscle function can very likely contribute to impaired dynamic stability and overall impaired functioning in the pelvic-hip complex adding strain to the passive support structures of the pelvis, the ligaments and bony structures
  • UNDERPRONATION – THE SUPINATORY FOOT
    Can lead to:
    Impaired foot, hip and pelvic function
    Decreases foots ability to absorb GRF
    Puts excessive strain on the joints, contractile and especially the non-contractile tissues of the pelvis
    The plantar flexed 1st ray is another problematic structural problem I see in patients with long standing pudendal neuralgia –
  • characterized by a fixed and plantar flexed (closer to the ground) position the first MT relative to the other metatarsals which overtime because of its position closer to the ground inhibits STJ pronation and results in rear foot varus. Except in this condition, the STJ does not pronate to compensate because the great toe is already too close to the ground. This lack of STJ pronation then interferes with the normal internal rotation of the lower leg during the stance phase. Consequently, the entire kinetic chain experiences less hip internal rotation.
  • When the hip doesn’t experience hip internal rotation ROM during gait, severe muscle imbalances can result in the proximal hip muscles, especially, the piriformis, Obturator internus and gluteus maximus muscles.
  • Identifying the supinatory foot
    foot structure characterized by a higher arch
    1st MT lies below the plane of the others
    calluses beneath the head of the first MT and the great toe
    the “peek-a-boo heel sign in which the medial heel fat pad can bee seen from the front
    c/o painful iliotibial bands and hip pain, and posterior leg pain - usually due to myofascial dysfunction in the piriformis and/or obturator internus
  • A greater problem is that an underpronating supinated foot does not allow the subtalar joint to unlock leaving the foot rigid, and unable to absorb ground reaction forces efficiently. which leads to additional effects in the proximal kinetic chain. Ground reaction forces that are normally absorbed in the pronated and unlocked foot are forced proximally and can in combination with weakness of the SIJ stabilizers can contribute to the development of sacroiliac hypermobility.
  • As a sequel to both a plantar flexed 1st ray and the previously described excessively pronating feet is a stiff great toe. In this condition the great toe loses extension ROM needed for normal gait.
    A stiff great toe can result in profound abnormal biomechanical effects of the lower kinetic chain.
  • Pertinent to the situation of pudendal neuralgia
    loss of hip extension and concurrent relaxation of the hamstring muscle and sacrotuberous ligament during midstance
    interferes with proper sacral nutation and the inherent locking mechanism of the sacroiliac joint  SIJD
    puts the sacrotuberous ligament under increased strain and can increase the load on the psoas and piriformis
  • The list of dyfunctions that are related to these basic foot abnormalities is extensive and these are just the very basic foot abnormalities, but they do in some ways represent the ends of a very interesting continuum of human architectural forms.
    In general, however, patterns do exist. The problems associated with varus deformities of the rear and forefoot due to the foot’s obligatory relationship with the proximal kinetic chain, impart impaired biomechanical stresses on the hips and sacroiliac joints and specifically the structures involved in health of the pudendal nerve. More specifically, all of the foot abnormalities here result in excessive and poorly timed rotational stresses on the hip internal and external rotators - piriformis and obturator internus, gluteus medius, maximus - contributing to the formation of neuromuscular dysfunction in the form of myofascial trigger points, pain and weakness, subsequent length tension dysfunction and overall poor functioning of the pelvic-hip complex.
    Weakness of the gluteus and the resulting weakness in piriformis and Obturator internus muscles known to contribute to stability of the sacroiliac joint may be the basis of some cases of sacroiliac instability, leading to subsequent strain and remodeling of the ST and SS ligaments. All of which are conditions which have been implicated in the development of pudendal nerve irritation.
  • an appropriate rehabilitation plan is necessary to address range of motion impairments, and to restore muscular strength, balance and proprioception to the foot/ankle complex
    weight-bearing closed-chain exercises are more suitable as this is the functional realm of the foot
    if necessary, foot orthoses can be prescribed that help to ensure correct foot and therefore, limb and pelvic alignment.
    Recommendations:
    Start looking at the feet of your patients with symptoms of Pudendal neuropathy.
    Look for bunions, deviated toes, abnormal callus patterns, toeing out gait pattern, the peek-a-boo heel sign, claw and hammer toes, etc.
    Ask about history of foot or ankle dysfunction
    Stay tuned, there is still more to learn on this front
    Find and refer to a or Physical Therapist who specializes in foot and ankle rehabilitation and orthotic fabrication
    Refer to podiatry
  • So while the condition of PN is likely a result of coexisting dysfunctions, of which abnormal biomechanics are just one, ignoring faulty biomechanics and their influence on abnormal neurodynamics, myofascial pain and joint function that can result in neural irritation may result in prolonged dysfunction and incomplete resolution of the problem.
    Again, it’s my opinion, based on 1) what I see in practice, and 2) generally accepted ideas about biomechanics and the kinetic chain of the lower extremity, that biomechanics is important. Even in the presence of a discernibly distinct cause of Pudendal Neuropathy, such as a traumatic vaginal delivery, pelvic fracture or surgical trauma, faulty biomechanics should be explored as a reason for the exacerbation or perpetuation of symptoms.

Transcript

  • 1. feet Cristina J. Shupe, MPT • San Francisco, CA, USA
  • 2. Overview • Pudendal neuropathy • Neurodynamics, the local and the global the mechanical interface of the pudendal nerve • The foot, gait and the foot’s relationship to the hip and pelvis • Abnormal foot biomechanics seen in patients with pudendal neuropathy • Recommendations for addressing foot dysfunction
  • 3. OBJECTIVES • Encourage practitioners to consider and look for abnormal biomechanics as a primary cause or perpetuator of impaired neural dynamics in patients with pudendal neuropathy • Encourage the practitioner to improve their very basic understanding of how abnormal foot biomechanics could contribute to the development of pudendal neuropathy
  • 4. Pudendal Neuropathy Symptoms • (aggravated by prolonged sitting) • pain within and around the peripheral nerve field • numbness, hypersensitivity and/or paresthesias within the peripheral nerve field • voiding dysfunction of the bowels and bladder • sexual dysfunction Peripheral Nerve Field of the Pudendal Nerve
  • 5. Pudendal neuropathy Mechanisms of injury Compression Tension or Traction •prolonged sitting •hypertonus PFM: pain, emotional stress, postural muscle imbalance •overdeveloped PFM: gymnastics, ballet, wrestling •fall(s) onto the buttocks •cycling, horseback riding •impaired biomechanics •chronic constipation and straining •extended vaginal delivery •under-active PFM •descending perineum syndrome •squatting with excessive weight •impaired biomechanics Chronic aberrant nerve stimulation (convergence) Surgery related •viscero-somatic reflexes •somato-visceral reflexes •somatic-somatic reflexes •post-hysterectomy •post-radical prostatectomy •bladder suspension surgeries
  • 6. Pudendal Neuropathy Coexistence of clinical findings
  • 7. ~ Impairments and pathological events that are innocuous in isolation, in coexistence can frequently give rise to complicated and severe chronic pain and dysfunction ~
  • 8. Pudendal Neuropathy  Compromised neural biomechanics or neurodynamics pathomechanical pathomechanical impaired relationship between the impaired relationship between the musculoskeletal system and the musculoskeletal system and the nervous system (mechanical nervous system (mechanical interface) interface) patho(neuro)dynamic patho(neuro)dynamic s s pathophysiological pathophysiological abnormal physiological response abnormal physiological response of neural tissues of neural tissues
  • 9. Mechanical Interface (MI) • Compromised neural biomechanics or neurodynamics (neuro)pathomechanical impaired relationship between impaired relationship between the musculoskeletal system and the musculoskeletal system and the nervous system the nervous system (mechanical interface) (mechanical interface) “where the nerves are presented with muscles, joints, fascia and fibro-osseous tunnels, against which the neural structures contact during daily movement and postures.” Michael Shacklock, 1995
  • 10. The LOCAL Mechanical Interface of the Pudendal Nerve Sites of PN Irritation  Entrapment
  • 11. The GLOBAL Mechanical Interface of the Pudendal Nerve GLOBAL MECHANICAL INTERFACE Distally: Lower extremity structures that influence hip and pelvic function: THE FOOT and ANKLE LOCAL MECHANICAL INTERFACE PIRIFORMIS ALCOCK’S CANAL LIGAMENTOUS CLAMP
  • 12. The foot, gait and its relationship to the pelvis The foot bone is connected to the pelvic bone:
  • 13. The Foot: Osseous Anatomy rear Subtalar foot Joint (STJ) mid foot fore foot 1st Ray First cuneiform First metatarsal Talus Calcaneus First Ray
  • 14. The Foot: Function: • 3 main goals – adapt to accommodate uneven terrain – to absorb shock on impact – form a rigid lever during push-off
  • 15. The Gait Cycle • STANCE PHASE (support) – when the foot is in contact with the ground – 60% of the gait cycle – the phase in which the lower limb is particularly susceptible to injury • SWING PHASE (unsupported) – when the foot is off the ground while swinging forward
  • 16. Stance Phase HEEL STRIKE •Gluteus Maximus •Hamstrings •Quadriceps femoris •Anterior crural muscle MID STANCE •Gluteus medius & minimus •Quadriceps femoris •Gastrocnemius; soleus •Tibialis anterior •Tibialis posterior TOE OFF •Gastrocnemius; soleus •Fibularis longus •Fibularis brevis
  • 17. The Subtalar Joint (STJ) • The key to understanding how abnormal foot function relates to hip and pelvic dysfunction is the Subtalar Joint. tibia fibula subtalar joint talus calcaneous
  • 18. Normal movements of the STJ Pronation lateral Supination medial
  • 19. The Stance Phase of Gait Rearfoot orientation during stance phase of gait pronating supinating Path of weight acceptance during stance phase
  • 20. Pelvic Tilt Anterior External Hip Rotation Internal External Knee Rotation Internal External Tibial Rotation Internal Supination Subtalar Joint Motion Pronation The Kinetic Chain Posterior
  • 21. Abnormal Foot Biomechanics commonly seen in patients with pudendal neuralgia
  • 22. Abnormal foot and ankle biomechanics • Can lead to: – Disruption of connective tissue integrity and fascial lines – Inefficiency of the pelvic and hip muscles – Impaired movement patterns – Impaired joint alignment and mobility – Dysfunction proximally or distally in the kinetic chain – Impaired ability to attenuate ground reaction forces
  • 23. EXCESSIVE PRONATION (or abnormal control of pronation) • Can lead to: – Impaired foot, hip and pelvic function – Inefficient attenuation of GRF on the contractile and non-contractile tissues of hips and pelvis • Morton’s Toe • Rear foot varus • Forefoot varus
  • 24. MORTON’S TOE • What is a Morton Foot Structure? – characterized by a short 1st MT relative to the 2nd MT. • Why it is potentially a problem? – when the first MT is short, the second MT takes on the job of weight acceptance and the function of the foot is impaired – can lead to abnormal pronation
  • 25. Morton’s Foot Structure
  • 26. VARUS DEFORMITIES REARFOOT VARUS Uncompensated FOREFOOT VARUS Uncompensated Compensated Compensated Posterior View (left foot) STJ pronation STJ pronation • Rear foot inverted • medial side of the HEEL elevated • rear foot normal • medial side of FOREFOOT elevated • compensatory STJ pronation, excessive and happening at the wrong time • leaves the foot in an unstable position propulsive phase of gait
  • 27. Identifying RF Varus • medial bunion (1st MTPJ) • Tailor’s Bunion (on the 5th MTPJ) • hammer toes • callus under 2nd MTPJ, • Haglund's deformity (heel bump due to movement of heel against shoe)
  • 28. Identifying Forefoot varus • Hallux abducto valgus – abducted great toe • bunion medial side 1st MTPJ • hallux limitus/rigidus • overlapping toes especially 2nd • A history of heel pain and or Plantar fascia pain.
  • 29. Global mechanical interface affects the local mechanical interface • Consequences of abnormal pronation due to Morton’s Toe, Rear/Forefoot Varus – – – – The problem: improper timing and excess pronation at the STJ STJ pronation = the lower leg internal rotation the hip and or sacroiliac joints absorb the extra internal rotation piriformis and the obturator internus muscles undergo tremendous strain at both origin and insertion • neuromuscular and myofascial dysfunction develops in in the piriformis and obturator internus muscles
  • 30. Global mechanical interface affects the local mechanical interface • Consequences of abnormal pronation due to Morton’s Toe, Rear/Forefoot Varus – foot should be supinating during the mid-stance to support weight of the body and keep pelvis level – Excessive pronation leaves the foot unstable which compromises the muscles responsible for pelvic stability • Muscle dysfunction can occur in gluteus medius, piriformis, TFL, adductors and psoas – impaired dynamic stability and impaired functioning in the pelvic-hip complex – Strains passive support structures of the pelvis – ligaments and bony structures
  • 31. 46 y.o. – PNE, post-op bilateral PN decompression AND bilateral PN decompression revision with tendon reconstruction - multiple TPI for recurring, piriformis, obturator internus, ongoing complaints of anal pain Morton’s Toes Moderate Rear foot an Mild Forefoot Varus Subtalar Joint Pronation Pump bump
  • 32. UNDERPRONATION (The Supinatory Foot) • Can lead to: – Impaired foot, hip and pelvic function – Decreases ability of foot to absorb GRF – Puts excessive strain on contractile and noncontractile tissues of the hips and pelvis • The PLANTAR FLEXED 1ST RAY with REARFOOT VARUS
  • 33. THE PLANTAR FLEXED 1ST RAY • • • Less common but still prevalent in patients with long standing pudendal neuralgia – characterized by a fixed and plantar flexed (closer to the ground – dropped) overtime because of its position closer to the ground normal STJ pronation is inhibited and causes rear foot varus Compensated STJ supination Dropped 1st MT Posterior View (left foot)
  • 34. Underpronation – The supinatory foot pattern • • • the STJ does not pronate to compensate because the great toe is already too close to the ground No STJ pronation =  LE Internal rotation Consequently, entire kinetic chain experiences less hip internal rotation ROM 52 y.o. patient with >30 yrs. Left sided symptoms related to PN – limited left hip IR, ongoing piriformis and O.I dysfunction, fall on tailbone was initial injury. High arch
  • 35. Identifying the supinatory foot • • • • foot structure characterized by a higher arch 1st MT lies below the plane of the others calluses beneath the head of the first MT and the great toe the “peek-a-boo heel sign in which the medial heel fat pad can bee seen from the front • c/o painful iliotibial bands and hip pain, and posterior leg pain - usually due to myofascial dysfunction in the piriformis and/or obturator internus
  • 36. The supinatory foot The plantar flexed 1st ray • A greater problem … – an underpronating supinated foot does not allow the subtalar joint to unlock – foot stays rigid and unable to absorb GRF – effects in the proximal kinetic chain – increase load on proximal ligaments - sacroiliac joint hypermobility and dysfunction
  • 37. Supinatory Foot – Plantar flexed 1st Ray • > 3 years of bilateral pudendal neuralgia and dysfunction • - 2/5 gluteus medius MMT Peek-a-boo heel sign High arches Rear foot varus
  • 38. The plantar flexed 1st ray and dysfunctional Hallux Limitus And another problem … • Hallux Limitus – When the great toe looses extension ROM necessary for normal gait – A stiff great toe can result in profound abnormal biomechanics in the lower kinetic chain. Hallux Limitus
  • 39. Hallux Limitus • Pertinent to the situation of pudendal neuropathy – loss of hip extension and concurrent relaxation of the hamstring muscle and sacrotuberous ligament during midstance – interferes with proper sacral nutation and the inherent locking mechanism of the SIJ – puts the sacrotuberous ligament under increased strain and structural changes and can increase the load on the piriformis and psoas – May lead to SIDJ/hypermobility
  • 40. SUMMARY • • • Abnormal pronation Abnormal supination Abnormal mobility of the 1st ray & great toe Adversely affect contractile & non-contractile structures of the hips and SIJ that are associated with pudendal neuropathy
  • 41. TREATMENT • • • • address range of motion impairments, restore muscular strength, balance and proprioception to the foot/ankle complex weight-bearing closed-chain exercises are more suitable as this is the functional realm of the foot if necessary, foot orthoses can be prescribed that help to ensure correct foot and therefore, limb and pelvic alignment. Recommendations: – Start looking at the feet of your patients with symptoms of Pudendal neuropathy. – Look for bunions, deviated toes, abnormal callus patterns, toeing out gait pattern, the peek-a-boo heel sign, claw and hammer toes, etc. – Ask about history of foot or ankle dysfunction – Stay tuned, there is still more to learn on this front – Find and refer to a or Physical Therapist who specializes in foot and ankle rehabilitation and orthotic fabrication – Refer to podiatry
  • 42. • So while the condition of PN is likely a result of coexisting dysfunctions, of which abnormal biomechanics are just one, ignoring faulty biomechanics and their influence on abnormal neurodynamics, myofascial pain and joint function that can result in neural irritation may result in prolonged dysfunction and incomplete resolution of the problem.
  • 43. Thank You The central nervous system, presumably, has an overriding biological mandate that locomotive efficiency dominates over anatomical integrity. Erl Pettman, MCSP, MCPA, FCAMT