1.feetCristina 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 foots 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 dysfunctionPeripheral Nerve Field of the Pudendal Nerve 5. Pudendal neuropathy Mechanisms of injury CompressionTension or Tractionprolonged sitting hypertonus PFM: pain, emotional stress, postural muscle imbalance overdeveloped PFM: gymnastics, ballet, wrestling fall(s) onto the buttocks cycling, horseback riding impaired biomechanicschronic constipation and straining extended vaginal delivery under-active PFM descending perineum syndrome squatting with excessive weight impaired biomechanicsChronic aberrant nerve stimulation (convergence)Surgery relatedviscero-somatic reflexes somato-visceral reflexes somatic-somatic reflexespost-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 pathomechanicalimpaired 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 spathophysiological pathophysiologicalabnormal 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 NerveSites of PN Irritation Entrapment 11. The GLOBAL Mechanical Interface of the Pudendal NerveGLOBAL MECHANICAL INTERFACE Distally: Lower extremity structures that influence hip and pelvic function: THE FOOT and ANKLELOCAL MECHANICAL INTERFACE PIRIFORMIS ALCOCKS CANAL LIGAMENTOUS CLAMP 12. The foot, gait and its relationship to the pelvisThe foot bone is connected to the pelvic bone: 13. The Foot: Osseous Anatomy rear Subtalar footJoint (STJ)mid footfore foot 1st RayFirst cuneiform First metatarsalTalus CalcaneusFirst 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 PhaseHEEL STRIKEGluteus Maximus Hamstrings Quadriceps femoris Anterior crural muscleMID STANCEGluteus medius & minimus Quadriceps femoris Gastrocnemius; soleus Tibialis anterior Tibialis posteriorTOE OFFGastrocnemius; 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.tibiafibulasubtalar joint taluscalcaneous 18. Normal movements of the STJ PronationlateralSupinationmedial 19. The Stance Phase of Gait Rearfoot orientation during stance phase of gaitpronatingsupinatingPath of weight acceptance during stance phase 20. Pelvic TiltAnteriorExternalHip RotationInternalExternalKnee RotationInternalExternalTibial RotationInternalSupinationSubtalar Joint MotionPronationThe Kinetic ChainPosterior 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 Mortons Toe Rear foot varus Forefoot varus 24. MORTONS 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. Mortons Foot Structure 26. VARUS DEFORMITIES REARFOOT VARUS UncompensatedFOREFOOT VARUS UncompensatedCompensatedCompensatedPosterior View (left foot)STJ pronationSTJ 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) Tailors 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 Mortons 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 Mortons 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 painMortons Toes Moderate Rear foot an Mild Forefoot VarusSubtalar Joint PronationPump 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 varusCompensated STJ supination Dropped 1st MTPosterior 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 ROM52 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 MMTPeek-a-boo heel signHigh archesRear 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 toeAdversely 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 YouThe central nervous system, presumably, has an overriding biological mandate that locomotive efficiency dominates over anatomical integrity. Erl Pettman, MCSP, MCPA, FCAMT