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Help and advice needed for patient with forefoot pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sspod2001, Jul 14, 2009.

  1. sspod2001

    sspod2001 Active Member

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    Hi guys I have a pt that is proving difficult to fix and I would love to hear any ideas as to how to help this guy, unfortunately the detail is long so bare with me.

    CC: 45y/o male nurse c/o a 'ball' type sensation in his right forefoot along with pain on the dorsum of R/1 MPJ.

    HPI: pain was made worse after 15 mins of 'fast active walking' to the point pt needs to stop or slow down. Footwear have no bearing on the pt's pain as he has recently bought new asics runners yet the problem still persists, pt's GP prescribed NSAID's to little effect.

    PME: No medical Hx of note.


    Musculoskeletal: Bilateral AJ equinus of 12 degrees knees extended, reducing to 6 degrees knees flexed, bilateral rearfoot varus of 4 degrees, STJ axis in sag plane is HIGH/rom wnl, STJ axis in transverse plane is medially deviated in RCSP. Bilateral forefoot valgus of 3 degrees. Bilateral 1st ray hypermobile. Bilateral forefoot plantarflexed, prominent extensor tendons due to retracted digits. Palpation of Extensor Hallucis tendon dorsal to R/1 MPJ caused tenderness, pain was also felt on palpation of R/1/2 intermetatarsal space.

    Gait exam: A ‘bouncy’ gait pattern with hyperextended digits on contact phase, mild pronation during midstance, and very early heel lift. Bilateral forefoot splaying is noted.

    1. R/1 extensor tendonitis,
    2. R/1/2 nerve irritation/neuroma

    Treatment plan short term:

    1. R/1 tendonitis – NSAID’s, ice therapy,
    2. R/1/2 neuroma – SCF met pad to see if anyimprovement.

    Treatment plan long term:

    After improvement from short term treatment Casted prescribed with R/forefoot met button increasing R/1/2 intermetatarsal space.

    Stick with me almost done! Pt reported complete recovery from original symptoms at 1st review after 6 weeks however he reported an annoying altered sensation in R/3-5 toes after 15 mins of ‘active walking’. Not enough to stop walking though.

    I therefore increased the size of the met button which then produced altered sensation in R/4-5. progress. a further increase then was applied but this caused tingling in R/4-5. I have tried altering this met button location, size, height, material and the best result I can get is just a mild annoyance of altered sensation after 15 mins of ‘active walking’.

    After observing his gait during this active walking I notice that heel lift happens more rapidly and was thinking that due to the plantarflexed forefoot he is driving his forefoot into the met button causing this problem, but removal would put him back to square 1.

    Thank you in advance for taking the time to read I look forward to any advice.
    Now go get a beer you deserve it! :)
    Regards Steve
  2. Re: help and advice needed

    Hi Steve

    I would look at the shoes he is wearing. As you said the forefoot splays and as you increase the size of the met button there is less room in the shoe and therefore more compression on the foot. This could be causing some nerve compréssion and the symptoms.

    So reduce the met button to orginial levels and get the patient into wider, softer upper shoes and see if the symptoms reduce.

    Michael Weber
  3. sspod2001

    sspod2001 Active Member

    Re: help and advice needed

    Hi Michael,

    Thank you for your reply. He currently wears a new pair of asics running shoes to walk in, but I shall check the toe box width to make sure he has enough room.


  4. Johnpod

    Johnpod Active Member

    Re: help and advice needed

    Hi Steve,

    I just want to highlight the obvious 'wears...running shoes to walk in'. Is this a good idea? Surely running shoes are designed for running, walking shoes for ...... you get the idea.

    I find that many forefoot problems are caused by footwear that is too flexible. I would give consideration to footwear that has a stiffer sole and limits foot flexibilty in the manner of a splint.

    Commercially produced footwear is always made with the 'hinge' (point of maximal flexure) dividing the shoe 70/30. Not all feet conform to these proportions. Hence the hinge of the shoe does not always work happily with the MPJs of the foot, leading to shearing forces across the met pad area. A displaced vamp crease often puts pressure on the dorsal surfaces of foot and/or toes and can be the source of considerable discomfort.

    Shoes also need room across the throat, not just a cavernous toe-box.

    Just thoughts......
  5. Re: help and advice needed

    People were walking in running shoes with absolutely no problem even before "walking shoes" were invented by the running shoe industry. There is little to no problem with patients walking in running shoes. In fact, running shoes are actually better shoes for walking, in many cases, than are "walking shoes".
  6. Sammo

    Sammo Active Member

    Re: help and advice needed

    My ha'pennies worth..

    the pain over the right 2nd may have settled/healed enough for you to remove the met dome. If he stays in his runners and orthoses most of the time, you may have altered the kinematics of the foot sufficiently to reduce the force to this area of the foot to within non pathological limits, meaning the pain may not return if you do remove it..
  7. hi steve, a couple of heel lifts might do the trick-regards pmc
  8. Peter1234

    Peter1234 Active Member

    hi Pmc,

    I think you will find that heel lifts will shift the pressure toward the forefoot, thereby increasing pressure at the forefoot,

  9. Sammo

    Sammo Active Member

    Not neccessraily true. If you have a patient with forefoot pain due to an ankle equinus where the heel doesn't load for long enough (i.e. early heel lift) and this causes strain on the forefoot due to excessive loading, a pair of heel lifts can (in the right patient) allow the heel to load for longer and reduce the stress in the forefoot.

    I have no evidence for this, and am not sure if there is any, but I have seen it clinically quite alot.

    Of course, if it is a soft tissue equinus, heel lifts in the long term may cause more harm than good, so I usually use them to help control symptoms initially and add a stretching programme, and often use a variation on the fibular mobilisation (as seen on TV ;-) ).


  10. Peter1234

    Peter1234 Active Member

    hi Sam,

    yes good point, makes a lot of sense, thanks

  11. Sammo

    Sammo Active Member

    You are most welcome. :drinks
  12. podhugh

    podhugh Member


    I think I have a case like this at the moment? He is a footballer with forefoot pain presenting 60 minutes into the game which is so painful he can't continue playing. He also runs but does not get the pain when running or at any other time.

    He has a pes cavus foot type, fairly rigid but with no lesions. His heel lift is premature and he has v.tight gastroc & soleus calf muscles. He wears gel insoles in his football boots to help shock absorption at the moment, but he says they are inadequate. There's no evidence of overpronation. Have I asked all the right questions? Can anyone help me to keep him playing?:wacko:

    Appreciate any practical help

  13. ladyfaye

    ladyfaye Active Member

    Methinks part of the solution would be to get him to stretch those tight calf muscles-its not unheard of for pts with tight gastrocs/soleus to c/o metatrsalgia.

    Also most soccer boots dont have enough space for an orthotic-also players want to "feel" their boots and not have anything bulky in their shoes;so an orthotic consideration will have to be carefully considered. A heel raise taken doen over time as the tight musculature statrts stretching out?

    a thought...if he mostly gets the pain during the game and not whilst doing other running-could the boots be exaccerbating the problem? Also I would imagine that the mechanics associated with running would be slightly different than running on a tredamill or flat surface.

    good luck.I look forward to hear if you achieve success with this pt
  14. I treat soccer injuries such as this, and quite successfully, with a shank-independent custom foot orthoses made of plastazote #3 (dense polyethylene foam), made with the anterior edges thicker than normal (about 3-5 mm thick), with the orthosis made longer distally by 2-3 mm, with a neoprene topcover and ground to fit the contours of the soccer boot. This orthosis is lightweight, can be ground very easily to fit the athlete's boot and can be customized to either add or subtract from the orthosis plate with minimal work.

    This athlete's pain is most likely caused by excessive ground reaction force and pressure (high force/small surface area) in his forefoot due to his tight gastrocnemius-soleus complex and cavus foot structure. You shouldn't expect a foot like this to be pronated. Cavus feet tend to resist pronation forces well, due to their high medial forefoot dorsiflexion stiffness, but they don't resist supination forces as well. These feet also tend to be more likely to develop peroneal tendinopathy and/or suffer from chronic inversion ankle sprains as a result of their high medial forefoot dorsiflexion stiffness.

    Cavus feet have a very small surface area of plantar contact with the ground compared to a normal arched or planus type foot so the goal of orthosis therapy in an athlete with a foot and symptoms such as this is to decrease the load on the plantar forefoot by redistributing the load to the plantar aspect of his longitudinal arch and plantar metatarsal neck region of his forefoot. Take all the other insoles out of his shoe and make an orthosis using the design concepts as described above and likely his pain will be significantly reduced or cured.

    Also, just as important as the orthosis is to start the patient on 3-4 times a day gastrocnemius and soleus stretching exercises, especially before his workouts or competitions in order to decrease the resistance to ankle/forefoot dorsiflexion from his gastrocnemius, soleus and Achilles tendon, other posterior ankle joint structures and plantar fascia. He likely won't ever achieve normal ankle joint dorsiflexion measurements, but you are not looking necessarily for normal motion, but rather trying to create a reduction in plantar forefoot pressure during his activities. Stretching will help achieve the goal of plantar forefoot load reduction, if done routinely and frequently.

    Hope this helps and please keep us informed of his progress.
  15. Sorry, on my last posting it should read "shank-dependent" not "shank-independent".:morning:
  16. podhugh

    podhugh Member

    This is great - thank you, but the vagaries of American / English vocabulary and, no doubt, my inexperience as a practitioner force me to ask a question: what does shank dependant mean??? Do you mean weight bearing?? :)

    The stretching exercises have been advised.

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