Rigid supinator treatment

[Dugal]

Hi all,

I'm keen to hear you advice on treating this case:

S/E
24 yo male; triathlete doing 12 hours a week training
-mod pain posterior to L med malleolus: is sore/tiff in morning and after prolonged immobility that warms up with exercise (seems to be early L tib post tendinopathy)
-after races also experiences mild pain at head L 1st and 4th MTs, L post-medial knee pain, L back pain, L ant hip pain
-history or L inversion sprains (several Grade I)
-history of bilateral patellar tendinopathy (former basketballer)
P/E
-rigid supinator bilaterally (L worse than right); plantarflexed 1st rays
-L dorsiflexion range is 3cm knee to wall test; R is 7cm - both seem to be capsular; not muscular restriction and has a springy end-feel
-L control/stability of hip, knee and ankle are all poor; R is much better
-R external rotators of hip, L & R quad's, and L hip flexors are all tight
-marked L glut weakness and decreased muscle bulk
-Lx stiff throughout but non-provocative; hinges off T12-L1

Rx to date:
-local pain relief
-eccentric tib post exercises - almost pain free now
-TC MWM for dorsiflexion range - only 1cm improvement bilaterally after 3 sessions
-TA, glut med, VMO, glut max work
-lengthening all short muscles
-changed shoes to cushioned neutrals and trialled 3/4 orthotics with FF valgus lift

The patient is going to be increasing their training volume over the next year and I am somewhat worried that their lack of shock absorption will lead to stress # (1st & 4th MT head pain).

A question: have you had success with mobilising such feet (ie plantar flexed 1st rays)? If so please give detail.

All other comments welcome