Last week I posted on Instagram about an interesting patient that I had in the clinic with a rare condition and a unique solution that I found that seems to be working well for her. The post got quite a bit of views, so I thought it would be good to share more details and write in depth about the patient and the technique that I used.
The patient is an 18 year old young woman who just graduated high school. At age 9, she was diagnosed with a rare peripheral vein disorder that affected her left foot and caused her to accumulate fluid in her mid foot and arch. Basically, her heart does a great job of pumping blood to that area, but her veins disrupt the blood flow back to the rest of the body, causing it to accumulate in the tissue on the bottom of her foot. This fluid has caused her a lot of pain and irritation for many years.
She has traveled the country, seeing physicians and specialists, to find a solution to her condition and no one has been able to give her any good options. She has considered a surgical intervention, but no one can guarantee it will be successful, so at her young age, she has decided against it.
I am certainly no expert in the field of peripheral vascular disorders, so I can’t help her much there, but the reason she came to me for a consult is because she has developed left hip pain, low back pain and now shoulder issues. So, I have been tasked with trying to improve her overall function. Due to the complexities of her condition, this will prove to be a difficult task.
As I performed her SFMA, nothing out of the ordinary jumped out. She has multiple areas of dysfunction and for someone with poor foot mechanics on one leg, she has a very normal dysfunctional pattern. Her issues carry up 1 leg until it hits the trunk and then the dysfunction travels through the Thoracolumbar Fascia to the opposite shoulder. Nothing new here that I haven’t see 100 times before.
What makes this situation so challenging goes back to the foot. She is a moderate pronator on her left foot (much more than her right) which initiates her dysfunctional patterns up the chain. I believe that her over pronation on the foot with the vein disorder is caused by the increased fluid in the mid foot. Over time, the consistent fluid left in the foot will cause irritation and poor neurological control over an area of the body that strives to be stable. The brain will be threatened by that area of the body and the brain has essentially shut it down and sent a pain signal out to make sure the body understands that this isn’t right.
The challenge is that I don’t see a great solution for all of her dysfunction that does involve solving her foot issue. With that asymmetry and poor postural position, it is going to make it very difficult to solve her problems long term.
I would like to solve this issue with foot postural exercises and retraining. But, with the constant fluid, I am skeptical that this will happen quickly, if at all.
The next solution that comes to mind for her is an orthotic. While orthotics aren’t my favorite intervention, they are good for people who aren’t overly athletic, have low global tone, and/or poor motor learning. She fits into this category, except for the sensitivity on the bottom of her foot. She has had multiple sets of orthotics in the past and the only ones that she can tolerate are so soft that they don’t help her mechanics at all.
As I completed her evaluation, I concluded that the ultimate goal for her is to improve global stability (proximally first) and then layer some strength on top of that foundation. This should keep her pain free and functioning well throughout the chain. If her foot mechanics improve, my experience tells me that this can all be accomplished over time and she won’t have a need for a long term maintenance program. But, if we can’t improve her foot mechanics, she is always going to have to do some sort of maintenance work to keep the system in tune. That’s not my first option for an 18 year old for a lot of reasons.
Her foot can be likened to a tire on a car with a slow leak. You either fix the leak, or you have to put air in it every day or two in order to keep the care running.
To go after the foot dysfunction, I used a tab arch taping technique. This is a technique that we don’t teach much as part of the standard Rocktape FMT courses, but I am becoming more and more of a fan of it all of the time. The technique follows a similar vector as the lower extremity helical taping but uses a lot of stretch on one section of the tape and a tab to be protect the skin from blistering. Check out this video of the technique to learn more:
There are several reasons this technique works so well:
- With the tape on the skin and applied in subtalar neutral, you are stimulating the brain to support the foot neurologically and improve stability.
- The tab allows you to use stretch without the fear of blistering the skin.
- Using maximum stretch on the tape mechanically supports the foot because the tape won’t be able to stretch further with weight bearing. When on, it feels like an orthotic is in the shoe without the pressure and bulk of the orthotic.
- When we use this technique over a joint that is “opening” excessively (as she pronates in this case), we can use this technique to pull the skin together over that area of the body and send a signal to the brain that the joint is “closed”, and ultimately in a better position. This perceived closing of the joint will decrease the threat to the brain and ultimately lead to less pain in the area with tape on. This theoretical construct relies on Hilton’s Law as an way to understand how stimulating the skin can affect the nerves within the joint and muscles.
For this patient, her improvement was immediate and she stated that she felt more stable, stronger and had less pain. She was very excited! I don’t want to get ahead of ourselves and try to claim that this is the cure all and solution for all of her problems. But, it does provide her with an immediate, comfortable foundation to work off of, so now we can get to work on everything else.