Sever's Disease is a traction apophysitis of calcaneal tuberosity. In the specific apophysitis is a painful irritation and inflammation of the apophysis (the growth plate). The growth plate is made up of cartilage, which is softer and more vulnerable to injury than mature bone. The growth plate usually fuses by age 15-16. Sever's Disease is the most common cause of heel pain in physically active children, and it is usually seen in soccer, basketball and gymnastics.

Causes

Tightness of the Achilles Tendon or calf muscles, leading to increased pressure on the growth plate.

High impact activities.

Poor fitting shoes

Growth spurt

Diagnosis

Sever’s disease is more common in boys. They tend to have later growth spurts and typically get the condition between the ages of 10 and 15. In girls, it usually happens between 8 and 13

The most obvious sign of Sever's disease is pain or tenderness in one or both heels, usually at the back. The pain also might extend to the sides and bottom of the heel, ending near the arch of the foot. 

The main diagnostic tool is pain on medial-lateral compression of the calcaneus in the area of the growth plate (figure below).

X-Ray is indicate with acute traumatic injury/onset.

Treatment

Rest (1-2 weeks  usually sufficient).

Proper fitting shoes.

Heel pad or orthotic heel support (should be wear bilaterally, to avoid causing leg lenght asymmetry).

Gently stretch plantar fascia and calf muscles.

Massage calf muscles. 

Consider deep water exercises in difficult cases.

References

Scharfbillig, Rolf & Jones, Sara & Scutter, Sheila. (2008). Sever’s Disease: What Does the Literature Really Tell Us?. Journal of the American Podiatric Medical Association. 98. 212-23. 10.7547/0980212. 

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Meralgia paresthetica (Meros= thigh, Algos = pain) is a sensory mononeuropathy. This condition is characterized by pain, paresthesia, or sensory impairment along the distribuition of the lateral femoral cutaneous nerve. 

Meralgia paresthetica is caused by compression or entrapment of the nerve as it crosses the anterior superior iliac spine and runs beneath the inguinal ligament to enter the thigh.

Causes

The most common cause of damage to the lateral cutaneous nerve is entrapment at the level of the inguinal ligament, often seen in association with obesity or pregnancy, in which the nerve may be compressed by the bulging abdomen.

However  wearing tight trousers (such as jeans), tight belt, trauma to the groin area where the nerve passes posterior to the inguinal ligament, avulsion of ASIS,  surgical operations, pelvic mass or neuropathies (such as diabetis) also could cause this condition.

Diagnosis

The patient complains of sensory disturbance over the anterolateral aspect of the thigh (anesthesia, pain or hyperesthesia of anterior thigh). Palpation of the nerve near the ASIS may increase pain or paresthesia. Light touch may be decreased on the lateral thigh and pinprick response may be increased.

There is no motor loss (positive in L2-L3 radiculopathy).

Nerve conduction velocity studies are rarely needed and may help to exclude L2-L3 radiculopathy, femoral neuropathy, etc.

When a structural lesion is suspected a X-Ray, MRI, pelvic ultrasound or CT scanning may be needed.

Treatment 

Most patients with meralgia paresthetica achieve satisfactory pain relief from conservative treatment by correcting the causes listed above, such as weight loss, correcting posture, avoiding external compressive and traumatic factors etc.

Physiotherapists/osteopaths/chiropractors may perform:

• pelvic, low back and hips manipulations or mobilization. 
• massage therapy, myofascial release
• acupuncture
• taping

Administration of analgesic and anti-inflammatory drugs may help.

Pulsed radiofrequency has shown some success if conservative treatment fails.

Surgical decompression  or transection of the nerve as a last resort.

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Morton's neuroma is an entrapment neuropathy of an interdigital nerve resulting in the formation of a fusiform swelling called a neuroma between contiguous distal metatarsals. The most common area affected is between the 3rd and 4th toe, followed by the 2nd and 3rd. Middle-aged women are more affected than men.

Causes

The exact causes is still a point of contention. However current theories postulate that Morton's neuroma is a consequence of the combination of repetitive mechanical and ischemic trauma, entrapment and tethering caused by:

1) pressure against the deep trasverse metatarsal ligament by:

• Tight toe box (ex. rock climber)
• Hyperextension of the toes (ex. high heels)

2) hard surfaces or high-impact activities (ex. dancers, runners).

3) metatarsal mobility (ex.4th relatively mobile, 3rd relatively immobile, 2nd least mobile).

4) high arches or flatfeet (ex. lax trasverse metatarsal ligaments allow spreading of the toes which further pulls the ligament down causing compression of the nerve.

Diagnosis
Forefoot pain is the most common complain, patients may also complains of a burning, sharp pain or paresthesia, llocated in between the 3rd and 4th toe. The pain is exacerbated with wearing tight or constricted shoes, toe extension or walking on the toes and relieved with non-weight bearing postures or walking barefoot.
No history of trauma should be reported by the patient (otherwise stress fracture may also be considered in the differential diagnosis), sensation of a stone or pebble under the toe or forefoot when walking can also be mentioned by the patient.
Useful test for Morton's neuroma is the squeeze test or the digital nerve stretch test.
Imaging may be necessary to rule out serious condition (infection, tumors) or less serious (stress fracture, metatarsalgia, peripheral neuropathy, tarsal tunnel sydrome, etc.).
MRI and ultrasonography are helpful to confirm the diagnosis, inflammation will be shown in the former and non compressible hypoechoic interdigital mass in the latter.

Treatment

Researches suggested that conservative treatment should be tried from 3 months to 1 year (1-2).

Conservative treatment

Patient should avoid wearing high heel shoes or with a narrow toe box, instead should wear wide, low-heeled and confortable shoes with a large toes box. Pad under the metatarsal should be used to cushion (do not position pad to increase pressure on neuroma).

Manipulation of the ankle, back, knee,foot may be performed by an osteopath, chiropractor or physiotherapist. Ultrasound and electrical stimulation may help.

GP may prescribe anti-inflammatory medications

Operative treatment

Many surgical methods have been used:

• Interdigital nerve excision with intermetatarsal ligament division, with or without submuscular transposition.
• Isolated intermetatarsal ligament division.
• Isolated interdigital nerve excision.

References.

1. Singh A IJ, Chiodo C. The surgical treatment of Morton's neuroma. Current Orthopaedics 2005;19:379-84.

2. Wu KK. Morton's interdigital neuroma: a clinical review of its etiology, treatment, and results. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 1996;35:112-9; discussion 87-8.

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Shin splints (or tibial periostitis or medial tibial stress syndrome) is a common injury that affects athletes who engage sports with repetitive impact or overuse the muscles of the leg (runners, dancers, basket and football players, etc), This condition is characterized by pain (usually sharp) in the lower part of the leg between the knee and the ankle. Shin splints injuries are caused by repeated trauma to the connective muscle tissue surrounding the tibia.
The 2 most common causes of shin splints are:

• The Tibialis Anterior Strain (Anterior Shin Splints) is defined as a muscle strain, tendinopathy and/or periostitis involving tibialis anterior and other anterior muscles. Patient complains of pain along anterolateral aspect of leg.
• The Posterior Shin Splints (or Medial Tibial Stress Syndrome) is defined as a muscle strain, tendinopathy and/or periostitis involving tibialis posterior or flexor digitorum longus and/or soleus. Patient presents with pain along posteromedial aspect of middle 1/3 of tibia.

However a thorough exam by a practitioner should be conducted to exclude: stress fracture, compartment syndrome, intermittent claudication.

Causes
The most common cause of shin splints is overdoing activities that constantly pound on the legs and feet. This may include sports with many stops and starts, running down hills and/or uneven surfaces, repetitive impacts. Simply training too long or too hard, especially without proper stretching, warm-up and poor shoes can cause shin splint. People with flat feet, high arches, externally rotated hip (feet that turn outward) and leg length discrepancy may be more prone to shin splints.
Muscle imbalance, including weak core muscles, can cause lower-extremity injuries, and inflexibility and tightness of the soleus, gastrocnemius and plantat muscles (such as the flexor digitorum longus) may contribute as well.

Diagnosis
A typical clinical presentation of this condition involves pain, palpable tenderness, and possibly swelling. The pain is anterolateral or posteromedial, increase during activity and initially is relieved with rest. In early diagnosis, individuals may experience pain at the beginning of a workout, which may go away by continued activity and then occur again at the end of the activity.
X-ray may be needed if patient complains of constant or night pain.

Treatment
Usually a period of 2-4 weeks rest is recommended to let the area heal, though the time varies depending on the patient and injury severity.

Acute phase
Initially should be treated with rest, ice, NSAIDs (such as Ibuprofen), ultrasound, soft tissue (unless is an acute traumatic strain) and manipulation of the joints in dysfunction. Patients should gently stretch the tight muscles and avoid high impact/distance, hills. Taping could help taking some pressure off the muscles.
Shoes should be changed and orthotics should be considered.
To maintain fitness patient can jog in shallow end of pool, swimming or cycling.

Post acute phase
Gradually resume hills, jumping, sprinting, longer distance, etc.
Deep tissue massage can be done and further stretching.
Strength (isometric and then isotonic) soleu/gastrocnemius, tibialis anterior and posterior, quadriceps, hip flexors/extensor/abductors, hamstings.
Vitamin C, E, aminoacidis could speed up the healing process.
6 weeks of treatment may be needed to reduce scarring/adhesions.
If the shin splints does not respond to conservative care, lifestyle changes may be needed or gait analysis performed.

Prevention

• Warming up and stretching calf muscles before running or jogging
• Wearing quality shoes with arch supports. Runners should purchase new shoes about every 400 miles
• Runs should be started at a slow pace and gradually increased
• Avoid/limit hard surfaces, hills, uneven surfaces
• Build up distance carefully, avoiding over-training. As a matter of fact increasing activity, intensity, and duration too quickly leads to shin splints because the tendons and muscles are unable to absorb the impact of the shock force as they become fatigued.

Hints
You can strength the muscles in the front lower leg (anterior tibialis) with resistance exercises or by walking on the heels three times daily for about 30 yards.
Neoprene shin splint support may provide firm, comfortable compression to help relieve pain and discomfort associated with shin splints.
Suspect stress fracture with constant or night pain.
Evaluate feet, leg length, shoe wear, gait pattern, dysfunction SIJ, scoliosi,knees,hips.
Check for normal pulses & changes in the skin (suspect vascular problems).
***Refer if acute compartment syndrome, DVT, intermittent claudication or tibial stress fracture.***
See your physiotherapist, chiropractor or osteopath for further information.

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Leg length discrepancy is a condition where the length of one leg is different than the other (shorter or longer) because of either or both a functional (muscle/posture) or structural (bone/cartilage) abnormality. In the specific a functional leg length occurs when your legs are the same, but another condition such as pelvic tilt or piriformis shortening creates the appearance of one leg being longer or shorter than the other. A structural leg length inequality it means that there is a true difference. Osteopaths, chiropractors and physiotherapist should be able to determine the degree of leg length inequality using visual inspection and manual tests.
Causes

1.Neuromuscular

• Muscle imbalance causing different pull on pelvis (anterior superior Ilium or posterior inferior ilium).
• Muscle tightness/shortness especially piriformis (which lead to an external rotation of the femur thus shortening of the leg) and QL (raising ipsilateral iliac crest).
• Genu recurvatum, valgus, varus
• Asymmetrical fallen arches or over pronation
• Polio, Cerebral palsy.

2. Trauma

• Fracture
• Injury epiphyseal plate
• Iatrogenic (such as hip or knee surgery)
• Idiopathic
• Hip disorder (such Legg-Perthes-Calve’ or Slipped capital femoral epiphysis).
• Advanced degenerative changes

Signs & Symptoms
The patient/athlete may present with an altered gait (such as limping) and/or scoliosis and/or low back pain.
Lower extremity disorders are possibly associated with LLD, some of these are:

• Increased hip pain and degeneration (especially involving the long leg)
• Increased risk of: knee injury, ITB syndrome, pronation and plantar fascitis, asymmetrical strength in lower extremity.
• increased disc or vertebral degeneration.
• symptoms vary between patients, some patients may complain of just headaches!!!!!

Diagnosis
On standing examination one iliac crest may be higher/lower than the other. However a physiotherapist, osteopath or chiropractor will examine the LLD in prone or supine position and measure it, confirming the diagnosis of structural (or functional) LLD.
–LLD in supine position–

The LLD should be measured using bony fixed points 
1. ASIS to medial malleoli
2. ASIS to knee joint line

X-Ray should be taken in a standing position. A full three exposure to a full spine film (divided in 3 sections). The osteopath, physiotherapist or chiropractor will look at:

• Femoral head & acetabulum
•  Knee joints
• Ankle joints.

Treatment/Management
Treatment of leg length inequality involves many different approaches, which vary among osteopaths, physiotherapist and chiropractor and whether the LLD is functional or structural. Thus is a combination of:

• Myofascial release (massage) & stretching of shortened muscles.
• Manipulation or mobilization of the spine, sacro-iliac joint (SIJ), hip, knee, foot,
• Orthotics – shoe lift can be used to treat discrepancies from two to six cm (usually up to 1 cm can be inserted in the shoe. For larger leg length inequalities, the shoe must be built up. This needs to be done for every shoe worn, thus limiting the type of shoe that the patient can wear).
• Surgery (epiphysiodesis, epiphyseal stapling,bone resection).

Hints.
Lift height should be built up gradually to allow body time to adapt to changes. Heel lift may reduce low back pain, scoliosis, improve weight distribution.
Athletes require a more precise and dynamic lift.
Orthotics, why do supinated or pronated foot influence leg length? (look at the figure below).

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome