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Toe extensors tendinopathy. What to do?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podB, Jan 29, 2020.

  1. podB

    podB Welcome New Poster


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    A 34 y/o white female stay-at-home mom with a dorsal pain on left foot for more than 18 months.
    Past medical history is unremarkable. Patient is overweight.
    Gradual onset started with beginning of running on a treadmill. Has done 2 sets of physiotherapy with manual therapy, ultrasounds, strengthening in dorsiflexion and inversion without much improvement. Has less pain in high heels. Known for an accessory navicular in both feet.
    Neurological: WNL
    Dermatological:WNL
    Vascular: PT and DP 2/4 BL.
    Patient has low arch in decubitus. 5 degrees in ankle joint dorsiflexion knee extended going in abduction to get more dorsiflexion. STJ axis is medially deviated bilaterally in relaxed bipedal stance with mid-tarsal break in abduction. Forefoot varus less than 5 degrees bilaterally. Too many toes sign. No palpable edema. Maximum tenderness is following course of extensor tendon of 3nd and 4rd toes over the metatarsal base and proximal stopping and the ankle joint on the left foot. No pain in resisted toes dorsiflexion. Pain in passive inversion with plantarflexion.Also pain palpable around the navicular BL. Pain in bipodal
    Slight pronation in contact phase, then midstance pronation, a moderately early heel off with and abductory twist. Angle gait is in abduction.
    Pes plano-valgus caused by accessory navicular bone.
    Toe extensors tendinopathy left foot
    Did orthotics with neutral casting in neutral posting forefoot with medial heel skive and a retrocapital pad. Also, recommended three times a day gastrocnemius stretching exercises.
    The patient does not tolerate orthotics. It causes pain around the navicular and pain in the arches in the end of the day. Also begin to feel pain posterior heel. Patient feels better when adding heel lift 4mm and adding heel wedge in varus.
    My question is how can I do better, the patient still has her initial pain but also has now new pain. What am I missing?
     
  2. scotfoot

    scotfoot Well-Known Member

    Hi Pod B .
    I am not KK or SS or even a pod , but have you ever heard of the initial windlass phase of gait ? It involves the dorsiflexion of the toes prior to foot strike and helps , in my opinion , with the rate at which tissues load during weight acceptance . If you make it hard for toe extensors to function during gait , with certain types of footwear ,then problems might arise with these muscles . Note that I am not offering advice for a specific case , but just introducing a general idea .

    Cheers
    Gerry
     
  3. podB

    podB Welcome New Poster

    Thanks for your answer. I have been aware of the DMICS, but not the name though. Was nice to refresh my memory by reading the thread. I have not been able to recreate pain when I did plantarflexion of the forefoot on the rearfoot, nor when I did dorsiflexion of the forefoot on the rearfoot. This is why I did not consider to treat this.
     
  4. efuller

    efuller MVP

    Is there a lot of extensor activity in gait? Anecdotally, I've seen people with midfoot break that use their extensors a lot in the stance phase of gait. If that is the case an orthotic can be helpful. If she is not tolerating the orthotic the arch of the orthotic may be too high. One way that orthotics cause supination is by making the patient use their posterior tibial muscle more. (this can hurt at the posterior tibial attachment site.) If the arch of the orthotic is uncomfortable, they can try and lift their foot off with the extensors. One of the measures I do when making orthotics is measure the standing medial arch height with a little bit finger pressure. It's not very accurate, but I got a lot less arch irritation when I started doing it. You want some arch pressure in the arch, but there can be too much.

    If your first orthotic had minimal fill and the arch of the orthotic is much higher than the standing height of the orthotic, you could make her another one and take the cost from your continuing education funds. ;)
     
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