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Orthotic needed for pain in right second MPJ area

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podtiger, Jul 10, 2011.

  1. podtiger

    podtiger Active Member


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    Hi all.

    I have a 35 year old patient who has recently returned to playing cricket.
    He is getting pain in the plantar surface of the right second MPJ area. It occurs on walking and running.

    Pain is illicited on palpation and extension of the the second toe.

    On gait analysis I have noted that he has an apropulsive gait style. Quite flatfooted with pronation extending beyong the midstance phase of gait.

    The patient could not afford custom made orthoses which did compromise treatment a bit.

    I prescribed custom foot adjusted orthoses form my local lab(these are polyprop arch supports which support the foot to about 4 degrees inversion). Initially I decided not to have any forefoot adjustments/modifications.
    I also suggested more supportive footwear. Laceup sturdy shoes to work. Brooks beast runners for training/cricket.

    These measures have helped to some extent but he is still getting some pain.

    My next plan is to add some padding/rubber modification to the front of the device.
    Should this be a pmp with u for 2nd MPJ or should I make an extension so as to prevent the 2nd toe from extending too much?

    Sorry to ramble on what is essentially a simple case.


    Thanks
     
  2. CFC

    CFC Member

    Sounds like he might have 2nd MTPJ instability with synovitis or les likely, a plantar plate tear. I would be taping the 2nd and 3rd digit to limit movement and trying a met dome in combination with the orthotic. Resolution can be slow and frustrating, even with complete complience unfortunately.

    Hope that helps.
     
  3. Diagnosis 1st treatment after.

    As CFC said it does sound like a plantar plate tear - here is some reading for you.

    as I said diagnosis then treatment Plantar plate tear thread
     
  4. Griff

    Griff Moderator

    Give this thread a read too - http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=65459
     
  5. RobinP

    RobinP Well-Known Member

    Like Mike said, diagnose it, then treat it.

    Probably a bit late as you have already used a prefab but these are new (not sure if you are in the Uk or whether these are actually available elsewhere). Moderate anti pronation control, postings supplied that can be added to your spec and hexagonal plugs for localised relief

    TRIO PR

    Bizzarely, Talar Made do not have them on their website as far as I could see?! I haven't used them but for £25 approx(?), a fairly comprehensive prefab. Questionable thing is how long the padded forefoot extension lasts before the other hexagons start falling out.

    Whether its lifespan is long enough is dependant on your diagnosis, which you haven't made as yet. How you manage 2nd met pain is entirely dependant on your diagnosis.

    Best of luck
     
  6. Innes

    Innes Active Member

    Im confused as to why your being advised to 'diagnose it before you treat it'. The patient has come to you because he has foot pain - initiate management of the pain by offloading the area (i.e start treatment immediately). Simple patient management skills like this will help install confidence and you'll find far better compliance once you have a diagnosis. Your entry level treatment should be at least a simple insole with Ud plantar PMP to the 2nd made from medium density EVA. Better than this would be a prefab device to reduce pronation and enhance forefoot loading with a met dome and the same forefoot Ud modification. Your best option is a prescription functional foot orthotic with appropriate rearfoot angles and increased transverse arch contour and 4mm PE140 Ud plantar cover. No matter what the diagnosis the patient will require a foot orthtoic of some description whether it be temporary or permanent until further intervention. Its usually easy to get pain reduction in cases like this so achieve this first and go from there. Easy peezy my good man.
     
  7. So in this foot, with a possible plantar plate tear, you suggest that we should give an insole which may well plantarflex the second met, and by inference, may well dorsiflex the toe. The toe which causes pain on dorsiflexion.

    THAT is why you need to diagnose before treatment. :drinks

    Good old appropriate rearfoot angles. Someone come in with a hurty 2nd met? Lets get that pronation stopped right away!

    Why are we so hot to "treat" pronation before we even know what the problem is? Why why why. Is pronation the cause of all 2nd met pathology :hammer:

    As Robin said,

    I think rather not.
     
  8. RobinP

    RobinP Well-Known Member

    Podpod

    You are talking about managing a 2nd MPJ pathology without having a diagnosis and your treatment may well be contraindicated. So in diving right in you may well increase the patient's problems.

    And the less said about the transverse arch the better.

    I've just written a massive post on another thread so can someone else do this properly please

    Robin

    EDIT: Sorry Robert, cross post.
     
    Last edited: Jul 11, 2011
  9. Admin2

    Admin2 Administrator Staff Member

  10. I think cross is a bit strong. Mildly ill tempered at most.
     
  11. RobinP

    RobinP Well-Known Member

    Well, you did say that I smelled of damp rabbits!
     
  12. A bit ;)
     
  13. Ryan McCallum

    Ryan McCallum Active Member

    Hi all,
    I am sure what I am writing here has been covered in numerous other posts and probably more succintly but thought I'd stick my thoughts in anyway.

    I definately wouldn't say easy peezy! I personally find persistent 2nd MTPJ pain cases can be some of the more difficult cases I have to manage, especially where deformity is a confounding factor.

    I certainly think that arriving at a diagnosis is essential on order to provide the most appropriate treatment. As mentioned above in the other posts, treatment options will vary depending on diagnosis.

    When it comes to assessing forefoot discomfort I always remember in my training being told to go through the 'surgical seive' (this has always stuck with me) and consider the possible structures that may well be inflammed/damaged or in some way pathological.
    Personally, the three most common causes I see for discomfort within the region of the 2nd MTPJ are 2nd MTPJ synovitis, plantar plate attenuation or tear, 2-3 IM space neuroma and 2nd MTPJ OA (in that order). Other less frequent cases I have come across recently include flexor tendon tenosynovitis, occulsion cyst and unfortunately a synovial sarcoma.

    For the majority of these cases, I will in the 1st instance insist that the pataient addresses their choice of footwear as invariably they are wearing shoes with a particularly flexible sole and in my experience, very little else works (in the long term) unless this is changed.

    As for orthoses, I am certainly not the most appropriate member here to be giving recommendations and as the nature of my work dictates, I refer on for this. I would however say that I do not seem to have managed 2nd MTPJ OA or neuromas well in the past with orthoses (maybe a reflection on how I went about it?).

    I also frequently administer intra articular steroid injections, recommend ice 20mins twice daily and discourage barefoot walking where i have determined the joint to be the problem

    Diagnostically, few of these cases require imaging modalities to provide the diagnosis but I will often x-ray these patients to look for underlying causitive factors and to look for subtle changes to joint congruency if i suspect early plantar plate pathology.

    Hope this maybe provides something useful,

    Ryan
     
  14. blinda

    blinda MVP

    `Surgical seive`, like it :drinks. I`ll steal that phrase before Isaacs does.

    Cheers,
    Bel
     
  15. efuller

    efuller MVP

    Good post.

    The case can be made that offloading the 2nd met can help the vast majority of those anatomical structures. In terms of the offloading causing the met to plantar flex and the toe to dorsiflex, we need to look at kinetics and not kinematics. If a plantar plate tear is caused by tension in the fascia, off loading the met will reduce tension in the fascia. There are other better examples of getting the diagnosis before initiating treatment where the treatment could be harmful, but I don't think that this is one.

    Of course, treating a synovial sarcoma with offloading would probably be malpractice if you and the patient were that unlucky.

    Eric
     
  16. podtiger

    podtiger Active Member

    Hi all.
    Thanks for all the replies. Apologies for not attempting to explain possible diagnosis.
    Thanks especially to Mike Weber who has replied to a few of my posts now and has been quite helpful. i don't know you Mike but you seem like a great bloke. Cheers.
    I am seeing this patient again on Frday and have added anextension to help prevent toe dorsiflexion. Will endeavour to diagnose future cases more comprehensively and state them a little more clearly to patient and pod arena. Thanks
     
  17. gaittec

    gaittec Active Member

    From a pain management perspective, considering the pronation, I would look for a hyper mobile
    first ray. If so, you might add a Morton's extension under the first met and halux in addition to the met pad/dome and U relief. Some cases require a relief channel to extend from under the met head to the end of the orthotic reducing hyper extension of the toe.

    To calm down inflamed cases, where hyper extension of the MPJ and pain at push-off are high, I have had great results from heating a thin rigid graphite plate and shaping it to the mid-sole of the patient's shoe to lay under the orthotic. This prevents the extension off the toe by transferring push off forces to the tip of the shoe. Rocker sole walking shoes work best for this.
    After the area calms, the plate can be removed.

    As a C.Ped, I don't diagnose, so the amelioration tips I have will only be of benefit if they are consistent with your diagnosis.
     
  18. Ninjasox

    Ninjasox Active Member

    at the risk of being incinerated, I noticed no one has asked whether the 2nd met is longer than the 1st met. I thought this would be a pretty important consideration in the scheme of things?
     
  19. efuller

    efuller MVP

    Actually a good question. However, we already know it hurts and offloading it is part of the plan whether or not it is long.

    Eric
     
  20. Ninjasox

    Ninjasox Active Member

    Just interested in why no one has asked the questions of why the injury happened in the first place. Was there pain prior to resumption of cricket? Cricket is a pretty sedentary game on the whole, with the only the bowler and batsman involved in any significant amounts of running.

    Has anyone checked that the footwear is suitable? If the patient is short on cash, then would be good to find out what the actual cause is first, before prescribing orthoses. I've had plenty of 'pes planus' patients that were pain free prior to activity modification. Always thought orthoses were the last resort, instead of the first. Just my 2 cents
     
  21. If custom foot orthoses have the best chance, of any other therapy, of relieving the patient's pain, then why should they then be considered as a last resort?
     
  22. Ninjasox

    Ninjasox Active Member

    My understanding is that the patient doesn't have the funds for custom orthoses, so try everything else first. If that fails then custom orthoses would be the next step. Usually find that pain levels have an inverse relationship to the patients willingness to part with their cold hard cash. Majority of the patients I see would rather take a 'pill' before considering an orthoses, even if it has the best outcome.
     
  23. There is a big difference between what the clinician's first choice for therapy is for the patient and what the patient's first choice is. The clinician should always let the patient know, up front, what the best treatment is for their condition and then what the alternative treatments are, regardless of their cost. Then, if the patient decides they don't want the best treatment and doesn't get better, the patient should then intrinsically understand that it was their own decision to have the less effective treatment that prevented them from having a better treatment result.

    This is one of the keys to a successful podiatric practice: if the patient wants to choose their own treatment, then they should know, before they begin, what the consequences will possibly be in them choosing the cheapest or easiest treatment instead of the most effective treatment for their pathology. In my very busy practice, most of my patients want the best treatment with the fewest side effects and fewest potential harmful sequellae, rather than the cheapest treatment.
     
  24. Ninjasox

    Ninjasox Active Member

    Indeed, cultural differences I guess. Here in singapore, patients always want the cheapest option, and often come in with various tcm medicaments already applied, which are often rather pungent to say the least. Also very hard to insert an orthoses into a flip flop :D You do tell the patient the best option, but..............
     
  25. Ryan McCallum

    Ryan McCallum Active Member

    I agree with Eric in that as far as conservative treatment is concerned, it matters little what length the 2nd metatarsal is; treatment options will revolve around offloading. Having said that, I also agree that consideration of the metatarsal parabola is important. I almost always x-ray patients who complain of 2nd MTPJ pain and evaluating the met parabola will certainly play a part in surgical planning if ncessary.

    What is last resort and first option should have nothing to do with financial restraint. Unfortunately, we all know that in private practice, and in some cases, public health care systems, what we want and what we get is not always the same thing. I think for the sake of discussion on this common problem, we could maybe avoid the financial side of things?

    I'm not entirely sure where the idea of foot orthoses as a last resort came from. Personally speaking, I consider surgical intervention in the majority of pathologies to be the last resort.
    Getting good results from foot orthoses doesn't necessarily rely on the provision of the most hi-tec computer generated device (the most expensive option).
    I feel our role should be less of 'playing God' and telling what should be done but rather providing the options and hoping the patient takes the advice onboard allowing for a rational and informed decision on how to proceed with the treatment programme.

    I find this topic particularly interesting because I actually find it quite difficult to treat. From a surgical perspective, I am not overly convinced that persistent lesser MTPJ pain is managed particularly well with predictable outcomes and I reluctantly list patients for surgery unless I am happy that they have exhausted conservative care.
    I have enjoyed this thread so thanks to those who have contributed.

    Ryan
     
  26. timharmey

    timharmey Active Member

    If the chap is a bowler , cricket , with the front foot rule is nearly designed, to give foot problems , a tall guy runs in , full speed and slams his foot on a line , follows thru on the other foot and repeats . Maybe he should become an umpire ?
     
  27. podtiger

    podtiger Active Member

    Hi all.
    Thanks for continuing discussion of this case. It's probably given me the impetus to present a more detailed case presentation in future. I apologise as it has left more questions than answers.
    This patients abnormally pronated gait style definiely needed addressing so I had no misgivings in providing at least some form of orthoses control to stabilise his gait as I could see this problem as being a large part of this patients' problem.
    My mistake was not to add some forefoot modification at the initial stage. This would have saved the patient some time.
    The patient now wears much more appropriate stiff soled lace up shoes to work which has helped. His running shoe choice is now more appropriate(Brooks Beast). It is cricket off season so he is in a non training period at moment.
    I agree with some posters who like an exact diagnosis from the outset. Unfortunately it can be difficult to get that exact diagnosis straight away. I agree it is the optimum in patient care to strive for this. By our own assessment skills we can eliminate certain pathology to be able to proceed in some way so as to help the patient right away. I believe I was able to do this to some extent.
    The conclusion to this is that the patients pain has almost completely resolved through forefoot modification incorporated onto the original prefab.
    The patient is clear that it would be very much in his interests to have prescribed a custom made orthoses which would further address his lower limb postural problems.

    Thanks again,
    Podtiger
     
  28. Innes

    Innes Active Member

    Some good discussion here chaps. Wouldn’t be the same without some over analytical comments from BertyIssacs and RobynP. I felt the need to chip in a little more and remind these boys that my original post was a basic summary of what I feel works well for the original complaint. A diagnosis is needed but I believe you can initiate pain relief (and patient management) without it until which times you have confirmation. RobinP, to suggest this proposal would be contraindicated or make the problem worse shows your inexperience in managing such a problem – show me one paper that indicates or even suggests a contraindication for such intervention. Important to note at this stage you recommend Talormade devices and other foot orthotics that you stick things on that may fall off . . . enough said. My reference to “an increased transverse arch contour” was terminology for completing a prescription form for the manufacturing of an orthotic, NOT as you suggested in relation to an anatomical structure in the foot – again clearly showing an inexperience in appropriate orthotic prescription. As for your ‘massive thread on this topic’ . . . as a riveting read Im sure it is, I do have other more important things to be attending to, but thanks all the same. In our busy private practices I see 2nd MPJ pain multiple times a week and to be honest I have never, ever found that any intervention we have put in place has made even a single patient with this pain worse (hence I felt that my input here was worthwhile). I only recall one recent case where we were unable to offer the patient a satisfactory outcome – surgery was ultimately completed by a foot and ankle orthopaedic specialist colleague. Im sure PodTiger that you find all the information that everyone has given you useful and form your own opinion on what is appropriate in the treatment of this patient. (just looking at your last post - well done).
     
  29. podtiger

    podtiger Active Member

    Thanks Podpod.
    Pretty much agree with you there. Well said. It just goes to show that good patient results can be arrived at from different angles. Some pods may see things as being black and white, however.
    I think the writing styles of some pods can make them come across as being terse and preacher like. Let's hope they have a better bedside manner in person.
    In saying that I appreciate this site warts and all.
     
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