Ever wondered how those seemingly insignificant lateral compartments of your leg and foot function as crucial stabilizers for your ankle joint? We're about to unravel the intricacies of lateral compartment pain, its unique diagnoses, and presentations. Our mission is to make you see that the key to the right diagnosis often lies in truly hearing what the patient has to say. This podcast is our way of sharing precious knowledge, aiming to contribute to the greater professional community.
Join us as we welcome the expert insights of our esteemed guest, Sophie Fitt from Fitzroy Podiatry. Sophie brings her extensive experience to our discussion, and together we delve into the realm of peroneal pain treatment and management. We unravel techniques ranging from taping, massage, dry needling, to wedges, and even modifications to activity and training for managing proximal compartment issues on the lateral aspect. Sophie enlightens us on when to consider an ultrasound referral and the magic of dry needling in releasing a tight band of skeletal muscle. Whether you're in the profession or are someone trying to understand these maladies better, this episode is sure to be an eye-opener.
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Ever wondered how those seemingly insignificant lateral compartments of your leg and foot function as crucial stabilizers for your ankle joint? We're about to unravel the intricacies of lateral compartment pain, its unique diagnoses, and presentations. Our mission is to make you see that the key to the right diagnosis often lies in truly hearing what the patient has to say. This podcast is our way of sharing precious knowledge, aiming to contribute to the greater professional community.
Join us as we welcome the expert insights of our esteemed guest, Sophie Fitt from Fitzroy Podiatry. Sophie brings her extensive experience to our discussion, and together we delve into the realm of peroneal pain treatment and management. We unravel techniques ranging from taping, massage, dry needling, to wedges, and even modifications to activity and training for managing proximal compartment issues on the lateral aspect. Sophie enlightens us on when to consider an ultrasound referral and the magic of dry needling in releasing a tight band of skeletal muscle. Whether you're in the profession or are someone trying to understand these maladies better, this episode is sure to be an eye-opener.
This podcast is recorded and produced on Naarm and Bunurong the traditional lands of the Kulin Nation. We pay our respects to the elders, past present and emerging and the land, seas and skies for which we all live.
Speaker 1:
Hey there, welcome back to Simply the Best Pediatry. I'm Jason Agosta and we are up to the Michael Jordan episode being number 23. Never thought we'd get there, but here we go. I should also say to begin with to you Pediatrists, I've had a few people ask me recently about why am I doing this show, which is a good question.
Speaker 1:
I'm family friends, pediatrists, and I thought about this, and particularly after the last episode with Matt Dillnott, and I have to say that it's a really good time for me and I'm sure others the same vintage, in that after 35 years of practice, it just feels so right to pass on as much as possible and hopefully it's all worthy and informative. But it feels like a time of service and give back and being as supportive as much as possible, and that's whether through the show or mentoring or just passing on tips and ideals to people who you come across or through your days or conversations on the phone or whatever. But it feels right to be of service and that's where this show has stemmed from and continues from. Anyway, I hope simply the best Pediatra has been interesting and maybe even a little bit helpful. And talking about helpful, we have Motorheads number one fan back, sophie Fit from Fitzroy Pediatra. Hey, so thanks for joining me.
Speaker 2:
Thank you, Jason. Bit of pressure putting me in the Michael Jordan episode.
Speaker 1:
Yep, you number 23. It's been a snake.
Speaker 2:
Jane Warren, another one.
Speaker 1:
There's been a lot of Buddy Franklin, number 23. There you go. Dermot Broden maybe, yeah, maybe I'm not sure, don't know. I'm quite pleased with the footy stuff.
Speaker 2:
I'm so not into footy.
Speaker 2:
No, that was a nice intro to touch on why you're doing this and you really do have so much to give back and you've always given back to our profession. Yeah, so that was a yeah. I really enjoyed hearing you say that. And, yeah, I can absolutely say you've always had your door wide open to students and graduates and junior pediatrists and I've been certainly benefited from your support over the years. You're only ever a phone call away and it's I know how many people would be getting a lot out of you just sharing your pearls. So thanks.
Speaker 1:
Yeah, well, I don't know. It's just a fun thing to do though, too, and when you pass on things, you also there's something. You always forget that when you pass on tips or you talk about things, you actually learn twice. Of course you do by going over things. So, yeah, so hopefully we can get sort of achieve that through this show and helping people out.
Speaker 2:
I'm loving your episodes, everything you're putting out. The episode with Matt last week was just terrific, absolutely sensational, and yeah, I've really enjoyed all of your episodes. As I've said to you, fiona Allen is a really good mate of mine and I loved her discussion around private practice and, yeah, actually everything you've put out has been really helpful to me, and I know I would not be the only person in that position.
Speaker 1:
Thank you. So I mean, hopefully it's diverse like that, because with Fiona we were talking about practitioner management, so it's a classic for all the younger people and all the employers. And then last week, matt do not dive into the depths of strengthening and just blew me away. And if anyone hasn't heard that episode, you need to go back and do number 22 before this one, the legendary episode of number 23. No pressure, si.
Speaker 2:
No pressure.
Speaker 1:
I should also say that every time I say simply the best podiatry, I think, oh my God, just cringe. A bit and it sort of came up as a bit of a joke the name of the show and most people wouldn't know. But I think I just finished the presentation and someone said, oh, that was simply the best. And I thought because I'd already planned that I was going to start the show, and I thought, oh, that's the name of the show Just off the cuff and it's stuck and anyway, that is what it is.
Speaker 2:
I think it's a neat name, it's awful, it's a bit of a joke. No, it's just awkward that it was. I think he launched the podcast the week, Tina.
Speaker 1:
Turner died. Tina Turner died exactly.
Speaker 2:
Your timing was awkward, but that's okay.
Speaker 1:
This show is dedicated to her. Yes, and my head All right, so well. We're going to follow on from Matt Dillnott's amazing presentation last week of Lower Limb Strengthening, and we are going to discuss more of the Lower Limb being lateral compartment pain through the perineals, and I know that when lateral compartment problems and lateral foot problems walk in the door, it's like, oh, here we go, we better think about what we're doing, but there are some really good, easy tips to pass on. So, and we should also start with different presentations and different diagnoses that you've got to be aware of.
Speaker 2:
Yeah, for sure I really love this presentation.
Speaker 2:
You know, sometimes you get that patient in front of you and just as you start to work through the initial stages, you think, oh good, I like this one. I don't know if you do that, but I definitely have those moments with certain things. And then there are the other things that I'm like, oh no, not this. However, lateral, let's sort of start with the patient walking in and pointing more directly at their foot, but very much hovering on the outside of the foot, often distilled to the lateral malleolus, and it is very obviously outside of the foot pain and that, as you've sort of touched on so much throughout other or previous episodes of the podcast.
Speaker 2:
Start with your really detailed history taking when you're listening, and I think a good place to explore this presentation would be to look at the role of the lateral compartment of the leg and the lateral foot and really focus on the role of stabilizing the ankle joint and foot.
Speaker 2:
And so it's really in that history taking when you start to learn more about the patient.
Speaker 2:
It's even before a biomechanical assessment that you are hearing about activities that have probably caused the foot to be in that position of you know, lateral ankle instability and then that's tying in nicely with what you're seeing clinically in terms of lateral foot pain.
Speaker 2:
So if we start with the history taking and get an idea of the activities that they've been doing I'm often seeing it in a trail runner, for example, so you know, rolling over tree roots and all sorts of things that are causing that instability and the firing of the lateral compartment Then often it's just that that whole complex has become, that has been overworked, basically, and is very, very tight. So once the history has been taken, we've got a clear understanding of the activities the person's been doing, starting to paint a bit of a picture, I will, in my physical assessment, will often be able to trace that lateral foot pain back to the compartment in the leg, and that's why I think in our discussion tonight it might be good to really focus more on the muscles in the lateral compartment of the leg and understand the role they're playing in causing that foot pain.
Speaker 1:
Sure.
Speaker 2:
Am I sort of on track, or am I yes, so we're also talking about multi-directional sports as well, aren't we you?
Speaker 1:
mentioned the trail running and shifting in position, but you're like the antennas basketball netball, for instance.
Speaker 2:
Absolutely, yeah, so, oh yeah, and I completely agree with that, with what you're just saying, then. So let's make it clear that tonight we're really gonna focus on it sort of the soft tissue, muscular component of this, probably less so on lateral ankle joint ligaments, and even not really diving into the lateral or the lateral aspect of the mid-tarsal joint region as well.
Speaker 1:
So I think A few boy problems.
Speaker 2:
Yeah, they're probably, and that's probably another whole episode in itself in the uniform, cuboid and all that sort of thing. What we're really talking about, just to make it really clear in the listener's mind, is the muscle is comprising that make up the lateral compartment of the leg. So once I've done that history taking, I've got a bit of an idea. Obviously we'll always carry out a biomechanical assessment, but I will start with my pelper tree stuff and it's almost always right at that perineus brevis attachment. So as perineus brevis travels, literally passes posteriorly to the lateral malleolus and then comes in at the base of the fifth, almost even just some resisted eversion of the foot, you can see that tendon attachment and that is almost always.
Speaker 2:
I mean, I don't wanna make massive generalizations here, but that is where the person is often presenting with pain.
Speaker 2:
We know we can trace perineus long as down through the planar aspect of the foot and that's helpful too. But let's just keep it simple and focus on that perineus brevis attachment, because I find that's where the pain is often. However, I don't focus very much on treating that area because, as I've said previously, I'll be going straight approximately right up to the head of the fibula and that's where I focus my treatment. So I will be palpating through the perineals and I find these are really easy structures to get my fingers into and it can be my thumbs or my fingers, and it might be on resisted eversion, but it often doesn't need to be, because the band of muscle can be so taut that it's very, very easy to just roll over these really tight spots. That are very uncomfortable in patient and often comparing to the other side or the other leg sorry, the other leg if only one leg is presenting a sore, it can just be so much softer and nicer on the other side.
Speaker 2:
Very easy to compare.
Speaker 1:
So it doesn't have that real ropey hard view Ropey ropey absolutely.
Speaker 2:
So once I have a clear understanding or in my mind, I'm really focusing on the muscles in the leg.
Speaker 2:
I don't do much with the foot because I find that tendon attachment you just aggravate it if you gnaw away on it too much. So I'm sort of hands off in terms of the foot and I'm focusing my soft tissue treatment on the leg and that's with often some dry needling, if the patient can tolerate it and if they wanna give it a go. It's not a particularly nice muscle to dry needle because of the perineal nerve and you can actually sometimes just get up close to that nerve sheath, sorry, and it is a little uncomfortable. So it's sort of with education to the patient that if they feel any kind of pins and needles or anything, to let me know straight away and obviously advising them on what that sensation is, and it's being near the nerve sheath. But it can also be very easy to avoid that. So if the patient is comfortable with some needling, I find the perineal compartment responds really nicely to some dry needling, but needling doesn't necessarily need to be part of it, just some soft tissue treatment through there, remembering posterior and anterior compartments as well.
Speaker 1:
And not down in the tennis. So you're not massaging down distally near the latrine maleolus. It's all proximal, yep, all proximal.
Speaker 2:
Yeah, all outside of the foot. And this is where I get the patient back seated with knees bent, feet flat on the bed and show them how they can do two to five minutes once or twice a day of this lateral compartment massage, because I find this is a compartment and I say the same about the anterior compartment of the leg that responds beautifully to I wouldn't say gentle massage, but nothing too aggressive, just some long, slow movement through those muscles into the tendon, but staying in the leg and they've felt it and seeing what I've done, and then I'm just educating them on how they can do it at home for themselves. So that's sort of a little bit of acute relief. I feel that can be achieved quite easily. And then it's sort of more about setting the foot up for the next week or two, and I proceed with almost always a lateral wedge to promote a version in the shoe, under the insole, and this is going to be really untechnical, but it's those light blue ones, the light blue, and then the EVA wedges.
Speaker 2:
And they are almost nothing's happening. And the patient's like is she for real? Like she's literally given me a toothpick, Like this is nothing and it's like nothing and I think they are terrific.
Speaker 2:
I pop them under an insole. I use a Jason and Gosta tip of only rip off half the backing paper because they're very easy to pull off when you need to. And this patient may already have a heel, if that doesn't bother me, the wedge goes in as well. And then I'm doing some eversion taping where I'm starting dorsally, pretty much in the middle of the foot, I'm coming under the word crossing the navicular, coming under and cranking up into eversion and educating the patient on how to do that taping technique themselves. Another Jason and Gosta special three strips of tape. You do it to promote supernation, but I'm doing it literally in the opposite direction. It's the way, yeah, opposite way. And you know when they stand up and they sort of look at you like, well, this feels very weird that you've hit the nail on the head, because it does feel very unusual. And so once I've educated them on self massage, I've taped the foot, I've put the wedge in.
Speaker 2:
I do talk about and you know, I guess the jury is a little bit out on the ice first heat kind of thing. But I really do think that 10 minutes of ice application just for some local inflammation. I think it's worthwhile doing and I support patients who are happy to do that If you understand their lifestyle and you tell them the little windows throughout their day where they can put some ice on the area, just because it's often a little bit acutely inflamed and then it's, you know. I mean you take into consideration the footwear, especially the footwear that they're wearing for activity. I'll be looking at wear patterns on the shoes and often this will lead to probably some advice on some new footwear. Not necessarily to um, it might just be getting into a neutral foot, a neutral shoe, like I'm not trying to change the direction. What I'm trying to say here. I'm not trying to stop the foot from doing what it's been doing. That caused this, yeah, yeah, it's often just there's some real instability in that aspect of the shoe.
Speaker 1:
So You're not trying to change alignment, really at all.
Speaker 2:
No, I think that's not because it's often not necessary. It's often not necessary, it's often activity related, and I find just a few simple things to tweak because we don't want the foot going too much into a version on a long term basis if it's not needed.
Speaker 1:
Well, I was just thinking that, because if we push laterally too hard and you push across the centerline of the foot immediately, does that mean the perinals have to work harder. You're sort of offloading to one degree, but then do we have to work harder in knowing that the perinals are massively powerful in stabilizing your forefoot? So there has to be a fine line there.
Speaker 2:
Has to be yeah.
Speaker 1:
So are you using orthoses as well, then, with applying the lateral wedge to them, or just the lateral wedge on a time.
Speaker 2:
In most cases just the lateral wedge. Very much case by case With everything I'm saying here. I'm talking about your more general yeah, sure. No red flags in terms of lateral ankle joint instability that's causing some serious motion, causing the perineals to overwork. I'm more talking about eight out of 10 presentations that have flared up because of something, a very easy causal factor.
Speaker 1:
So this is where we will do another episode on the more distal perineal cuboid problems, because this does lead into it. But, what about stretching? Because stretching is good for those well, some of those lateral foot problems, in trying to stretch out the perineal tendons and massage approximately. But when we talk about this issue of more the proximal compartment problems laterally, are you stretching at all distally or leaving that alone as well?
Speaker 2:
I don't give any stretches for this presentation. So once they've walked out with their self massage advice, their ice regime, the tape on their foot, the wedge in their shoe and some modifications to their training or activity, I'll see them probably 10 days to two weeks later and then I'll implement some strengthening, not stretching, and the strengthening would involve theraband work and that resisted eversion to allow some strength back into the perineal compartment. And I find after that the patient is almost back to normal, no pain.
Speaker 1:
Sure.
Speaker 2:
And that is the kind of full circle presentation where you seldom see them for that problem ever again.
Speaker 1:
So what you say? Quite a quick response.
Speaker 2:
Really quick response, and it's the same with tiband, I find. As soon as you just get some regular routine soft tissue therapy through the compartment, it just responds really nicely and often you don't need to change anything or turn anything on its head from a long term management point of view to achieve a really good outcome with this simple little regime.
Speaker 1:
Sure. So what if we have someone who doesn't respond that well and we start looking at the differential diagnosis?
Speaker 2:
Yeah, good question. So I would. I'd probably pull them back from activity for a little bit longer and keep up some of these more simple techniques or management strategies just for a little bit longer, maybe a week or two longer, get them off the foot a little bit more. If they've responded to the tape technique, I'd keep taping them in that position, but I wouldn't give it much longer than another week or so before I referred for an ultrasound through the lateral aspect of the foot to get a better understanding or idea. Because in that what I spoke about previously was when I relate the presentation back to the lateral muscle compartment if the foot is still vocal and localised, there's still that vocal, localised pain I would definitely be referring for an ultrasound at that point.
Speaker 1:
So we're talking, taping, massage, dry needling, wedges, footwear, decreasing activity if needed. If it doesn't respond that well, can you give me a very quick rundown of what the needling does?
Speaker 2:
Yeah, so dry needling or trigger point therapy is where a small dry needle same kind of needle is used in acupuncture is once palpation has been done and essentially the trigger point, which is a very taut band of skeletal muscle, is identified. As the needle goes into that taut band of skeletal muscle, there is a very quick or immediate vascular response and that allows so it's a myofascial response at the site of the skeletal muscle and that allows the myofascia to release somewhat and a vascular response or a rush of sort of healthy, oxygenated blood to the area to release that tight, taut band of skeletal muscle.
Speaker 1:
Okay. So it's got to be quite focal. It's not just like oh, the whole muscle is really tight, you've got to actually get to find that focal point, find those trigger points.
Speaker 2:
But what we do when you do dry needling, course, is we find what I think they really just referred to them as textbook trigger points and we understand that in each muscle and each muscle group there are these very, very common areas, or very, I guess, commonly seen locations, where those trigger points arise. So you can bet your bottom dollar if you help that area you'll find that trigger point. And the more pelopetry stuff you do repeatedly, day in and day out, you find these trigger points. Now of course you've got to still hover around and see what else you can find.
Speaker 2:
But once you know that feeling of a trigger point, it's when that rope here, you rock over it, you literally and you say to the patient this is the point, feel as I roll over the top of it and I go, oh yeah, that hurts and it can give off some local referred pain and also some more distilled referred pain. So you might be pelpating up near the fibula head and they can feel it almost down to the lateral malleolus. So you've pelpate your trigger points and then you dry needle them. I have a technique of I don't pepper it too much, peppering's the in and out. I only do a little bit of that and I leave the needle in situ for just a couple of minutes and I'll just and I step away and just allow the needle and then I'll pull it out and always finish off with some soft tissue massage after the needling.
Speaker 1:
So the point of that the massage of the needling is to reduce the tension on the distilled tendon region, isn't it? Because earlier you were talking about a pain around the perineal tendons looping around the lateral malleolus. But that's what we're trying to do is reduce the tension in that compartment approximately.
Speaker 2:
Absolutely so. Myofascial release approximately to alleviate distal sensation and pain.
Speaker 1:
Perfect. So thank you so much. This discussion being so concise is wonderful, but this is going to lead into the lateral foot problems. We see, which I think for most people, when the lateral foot pain comes in, it's a bit vague around that mid-tarsal sort of cuboid area. It is sometimes one of those ones where what am I gonna do? Yeah?
Speaker 2:
I know I might really enjoy those ones that much.
Speaker 1:
So this, your discussion or your presentation here, is huge in proceeding into that which we will do in the next couple of weeks. We're gonna go into the lateral foot problems after this episode in a couple of weeks time, so stay tuned because this is almost the precursor to the lateral foot pain episode. Yeah, that'll be good. Thanks for joining me again. You've, I think, the third time you've come on. It's great.
Speaker 2:
Yeah, and I'm really enjoying it, thank you. Thanks for having me.
Speaker 1:
Yeah, that's wonderful to see you again and I hope you're well and I really appreciate your contribution.
Speaker 2:
I appreciate coming on. Thank you very much.
Speaker 1:
Thank you, speak soon.
Speaker 2:
Bye.
Speaker 1:
Bye. Thanks for listening. This is simply the best paddartree. You can check out more details in the show notes, where you can follow and support the show. You can also follow the show on Instagram at simply the best paddartree. Thanks for listening once again and we'll be back with you soon, thank you.
