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Can a plantarflexed 5th be misdiagnosed as a forefoot varus?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by R Buni, Mar 29, 2012.

  1. R Buni

    R Buni Member

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    I'm a podiatry student and have been told that a plantarflexed 5th can sometimes be misdiagnosed as a forefoot varus, is this true?
  2. Bill Bird

    Bill Bird Active Member

    I personally have this condition in my 4th and 5th ray so I have a particular interest in it.
    It could be misdiagnosed but only if the difference between the two conditions is not understood. The plantarflexion comes from a downward bend in the shape of the 4th and or 5th metatarsal shaft. The relationship between the base of the metatarsal and the cuboid is normal. If I stand with my foot on a book so that the 4th and 5th metatarsal heads hang over the edge, the foot returns to normal. A forefoot varus is where the whole forefoot is rotated in the frontal plane with respect to the rearfoot so that the medial side is higher. Both conditions can be complicated by a Windlass Effect which can be made worse by raising the 1st mpj.
    I treat my condition by having the 4th and 5th metatarsal heads lying about 8mm lower that the rest of the foot. I was first diagnosed in 1979 and have symptom free feet.
  3. R Buni

    R Buni Member

    Thank you for you reply Bill Bird
    Can you tell before you were diagnosed with the condition did you suffer from callus on your 5th MTPJ and your 1st MTPJ/1st IPJ? I am currently doing a case study about a man who has a plantarflexed 5th ray, he has callus on his 5th MTPJ (due to being plantarflexed) and on his 1st MTPJ/1st IPJ due to his foot slapping to the ground during gait. My initial plan was to provide an orthotic with a wing to the 5th MTPJ but due you think a 5th ray cut out would be better?

    R Buni
  4. RobinP

    RobinP Well-Known Member

    R Buni,

    Forefoot varus is not a diagnosis. In fairness, a plantarflexed 5th met/ray is not a diagnosis either.

    In your case, the chap upon whom you are doing has callus on his 5th MPJ. Is it painful? If not, is there any reason to actively treat it biomechanically?
    are you wure that the 1st MPJ is callused because the foot is "slapping the ground"?

    I'm not saying it is or it isn't or that you are right or wrong(other than ff varus and plantarflexed 5th rays being a diagnosis), it is just that if you are doing a case study, these are probably quite pertinent questions to ask

    Just one other thing - the 5th ray is supposed to plantarflex. Perhaps think about dorsiflexion stiffness/copmliance of the 5th ray - it might lead you down a completely different road for your case study

    Good luck
  5. Bill Bird

    Bill Bird Active Member

    Yes I agree with R Buni that the 5th ray is supposed to plantarflex and the problem occurs because it reaches the maximum dorsiflexion before the other metatarsal heads reach the ground.

    What happened in my case was that the whole ray then rotated laterally producing what could have turned into a tailor's bunion. Even the widest shoes were agony until I stretched them through wear until I was overhanging the lateral edge of the shoe and wearing out the upper on the ground. I would get through two pairs a year that way from the age of about 18. I don't remember calluses on the 5th because it rotated instead but the callus on the 1 ipj was there until I learned how to control the windlass effect.

    From the age of about 14, I was plantarflexing my hallux in order to create two points of support on the forefoot, thereby developing a hugely strong and shortened plantar facia which prevented dorsiflexion due the the windlass effect. I have gradually stretched the plantar facia but still have a bit of osteo arthritis leading to Hallux limitus as a result of the early non treatment of the condition.

    The condition was described to me by Ray Anthony in one of the early London Post Graduate Study Groups in 1979, where he used me as a demo of the condition. He offered to open up my foot, saw through the bone, break it and reset it straight... I declined and opted for the orthotic, bespoke footwear option!

    Interestingly, I had a 31 year old woman come to see me today in London, with a 5th ray that is doing just the same thing amongst other problems she has.

    I'm glad I did. When people ask me how I got into orthopaedic shoemaking, I tell them I had a foot deformity and wanted to solve it. It gives me a feeling of rapor with my patients!
  6. Bill Bird

    Bill Bird Active Member

    Correction to the above, I meant to say I agree with RobinP about the restricted dorsiflexion. Robin I appreciate your distinction between the use of the word diagnosis which is about determining the nature of a disease or the art of distinguishing one disease from another, and a set of clinical observations about a range of motion or analysis of shape or relationship of one part to another. The more we are accurate with language the better.
  7. R Buni

    R Buni Member

    Bill Bird and RobinP,

    Thank you for your help and I will use the information you have provided to help me produce my case study.

    R Buni
  8. drsha

    drsha Banned

    From a foot typing perspective, 5th met callus (the characteristic of a plantarflexed 5th ray) is 90 % seen in the rigid forefoot types and the flat forefoot types.

    In the rigid forefoot types, the 1st ray is "platarflexed" as well and there is a 1st ray callus. This foot type couldn't possibly be mistaken for a forefoot varus.

    In the flat forefoot types, there is never a 1st ray callus and in fact, although this is a rare functional foot type there is a forefoot varus in Rootian terminology due to the met primus elevatus.

    Foot Typing will give you the differential ...

    My advice is....using any evaluation system, to follow the callus.

  9. blinda

    blinda MVP

    Yep, agree with that. Callus pattern learns (I would say `teaches` but that`s the youf of today...) us a lot. Talking of dermy stuff... how`s about a crystal clear answer to my request for a definition for `pathologic keratinization` and `hyperkeratinisation`? ;)

    The Pathogenesis of Nail Unit Dystrophy - Here it is Dennis


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