Orthosis assistance please

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Hi all

I have a 50 something female suffering with blistering and heavy callusing over the medial aspect of her 1st MPJ LF. In gait she is pronated (L>>R) and apropulsive with associated abd twist and medial roll off. This essentially increases the pressure over the 1st MPJ and plays a substantial role in callusing and blistering of the area.

O/E it was noted that the client had had surgery on her LF. ROM of STJ was normal with ratio of inv:ev 2:1. Of interest though was the lack of movement through her MTJ. Muscle lengths and ROM of other joints were well within normal limits and the STJ seemed medially placed. J/Test proved v.difficult. Essentially in stance with her STJ "in neutral" her forefoot is in a varus position and is fixed (cannot reach the ground). I provided her with a 3 deg inverted device with a small 2mm skive to assist with resupination (SRT - hard). Perhaps stupidly I left the forefoot alone.

At review she is complaining of MLA and plantar foot discomfort and it is evident to me that in an effort to allow the forefoot to rest on the supporting surface she is pronating heavily on the device.

I have followed many discussions on this forum with regard to FF posting and the lack of need for them. Is there another way I can assist this lady. If I shouldn't use a FF post to aid her 1st met to contact the ground what do I do?

 

Andrea

Unless you know what type of surgery (particularly osseous) this lady has had, it is difficult to make a suggestion.

A few simple questions about the nature of the surgery, and a plain WB x-ray should reveal all, and go a long way to providing some answers to your question.

LL

 

Hi Andrea,

As was eluded to in another thread we should be getting away from looking at the foot in neutral position. This not the position of the foot when the pathology occurs. John Weed used to teach about trying to place his fingers under the foot with the patient standing relaxed. The question for this patient is how much force is there on the 1st metatarsal head when they are standing relaxed. In some feet, there is quite a bit of force and under the lateral forefoot there is very little force. In other feet you will see the opposite. In feet with high force under the medial forefoot I would recommend a valgus forefoot wedge or a reverse Morton's extension to decrease force on the first metatarsal and increase the force on the lateral metatarsals. If the foot is standing relaxed and there is little force on the first and high force on the lateral forefoot, I would add a varus forefoot wedge. In this foot type the patient will often walk with the foot abducted and end up rolling over the forefoot from lateral to medial and this is how they could get a blister sub 1.

I hope this helps,

Eric

 

If she has a fixed ff Varus why not use FF varus wedging? it should reduce her medial toeoff/blistering. The windlass effect is too focused on these days. Get the GRF up to the 1st Met and Hallux, by adding a Mortons wedge which accomodated the Hallux. the 1mpj will still dorsiflex.

 

Here, here. Rather, the windlass effect at the 1st MTPJ is too focused on these days. With the windlass effect at the lesser digits completely ignored.

 

good point

 

From the exam described, you don't know if you need a forefoot varus wedge or not. Measurements taken witht he foot in neutral position only have relavence with reality if the patient actually stands in neutral position. Very very rarely will your othotic put the patient in neutral position. So, you need to bring the ground up to the foot only when there is little pressure under the first met head when the patient is in relaxed stance. Even then, this still may not address the chief complaint of blisters on the hallux.

If the patient has high loads under the 1st met in static stance, a forefoot varus wedge would be unlikely to help the blister. A lot depends on rang of motion of the 1st mpj, which was also not mentioned in the exam. (j/test?)

Eric

 

Jtest 'Jacks test, 1st mpj dorsi-flex. But doesnt it make sense to reduce Medial / varus rollin at toe off , to bring the ground up to it before it has to come down to the ground?

 

It does, if that is what you have. However, it may just be a functional hallux limitus with a normal load, or even high load, on the medial forefoot in static stance. There is not enough information in that presentation for me to add a forefoot varus wedge. Increased load on the 1st met might make the problem worse. You can't tell from the information given. There may even be a hallux rigidus wich would explain the difficult Jack's test. We don't even know what the surgey was. MPJ fusion? That could cause hallus blistering too.

Eric