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Unilateral MTPjt pain - Rx / Orthotic challenges

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Joanne Moore, Oct 20, 2016.

  1. Joanne Moore

    Joanne Moore Member


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    I wonder if anyone out there could suggest anything which I might have overlooked for a patient who is suffering terrible pain from her left 1st MTPjt, and seriously considering surgery.

    CC:
    A 32 y/o white female with a 6/12 history of aching pain over dorsolateral aspeht of the L/1st MTPjt. Its onset was gradual. It is now causing great concern re future ability to become personal trainer.

    HPI: pain is made worse by walking activities, and particularly doing tip-toe squats, and made better with rest . Shoes with higher heels exacerbate symptoms, and pt has avoided them since onset, but wore in work previously. No previous Rx undertaken. GP diagnosed (by visual assessment) OA of joint and "fallen arches".

    PMH: Good general health. Pt looking to become personal trainer, and studying at present.


    Musculoskeletal: No erythema/ swelling/ dorsal exostosis noted over L/1st MTPjt. Generalised pedal hypermobility noted bilaterally. Bilateral mild HAV; with R/1st MTPjt noted to have greater RoM than L/1st. Pain when L/1st IPJ is maximally dorsiflexed.


    Gait examination: No overpronation in stance or gait noted. Gait antalgic when assessed due to discomfort so little to be drawn from assessment.

    Neurological: No abnormality noted.
    Dermatological: No abnormality noted.
    Vascular: No abnormality noted.

    Diagnosis:

    1. Left 1st metatarsophalangeal joint inflammation ? OA

    Treatment Plan:
    1. x-ray requested and pending
    2. Kinesiology taping planarly to reduce end range of motion dorsiflexion of the left 1st MTPjt for weight bearing activities? Mortons / reverse mortons addition to orthotic would I think not be possible due to the degree of dorsiflexion needed for tip-toe squats etc (which pt is determined to continue)
    3. Avoid high heels; EVA dome to be trialed under 1st met head to reduce dorsiflexion in trainers (for gym and walking).
    4. Ask experts on Podiatry Arena!!

    Any suggestions?
     
  2. efuller

    efuller MVP


    That is a textboot history for hallux rigidus or hallux limitus with a large component of functional limitus. There are plenty of threads here on the arena that could give you a lot more information.

    In short to treat hallux rigidus/ limitus (you still have to make that diagnosis): the windlass mechanism causes increased compression forces in the mpj so to treat first MPJ pain related to the windlass, you need to decrease load on the windlass. Supinate the STJ and decrease load under the first met head. An orthotic can do those things.
    It hurts to bend the toe so protect it when it tries to bend. Rigid rocker tip shoes. Or flexible rocker tip shoes like running shoes.

    Eric
     
  3. Not much more to add than what Eric said, but X-rays will be key to knowing where to start

    And then you will need to think short term - Long term

    I for 1 would not use Kinesilogy tape though too flexible, good old fashion sports tape will be much more effective
     
  4. Dieter Fellner

    Dieter Fellner Well-Known Member

    1. Carefully evaluate XR for evidence of talo-tarsal subluxation - medial column elongation from the talar subluxation can wreak havoc with 1st MTPJ function; there is a work in progress for publication. Get the XR, chart the angles and post back. Ideally get XR in neutral and relaxed CSP. (I would speculate she already has increased IMA / HAA / TSP problems)
    2. Evaluate patient for Functional Hallux Limitus (trial out device(s) to facilitate 1st met PF)
    3. Consider injection therapy (cortisone, hyaluronic acid)
    4. Consider manipulation therapy
     
  5. Joanne Moore

    Joanne Moore Member

    "...you need to decrease load on the windlass. Supinate the STJ and decrease load under the first met head. "

    Eric[/QUOTE]

    Eric, thanks a million for that.

    With regard to supinating the STJ, that's fairly straight forward (medial Kirby Skive / varus heel), I'd be fairly confident with that. But with regard to decreasing the load under the first met head would that be achieved by raising the lesser mets with a reverse Mortons extension, or blocking it with a Mortons extension shifting the momentum laterally?
     
  6. efuller

    efuller MVP

    Eric, thanks a million for that.

    With regard to supinating the STJ, that's fairly straight forward (medial Kirby Skive / varus heel), I'd be fairly confident with that. But with regard to decreasing the load under the first met head would that be achieved by raising the lesser mets with a reverse Mortons extension, or blocking it with a Mortons extension shifting the momentum laterally?[/QUOTE]

    Use a reverse Morton's extension. I don't believe that a Morton's extension shifts the momentum. You may see a lateral shift in the center of pressure with a Morton's extension, but my belief is that the Morton's extension will increase load in the windlass causing pain and the posterior tibial muscle will start working harder to decrease that pain. That is why you would see a lateral shift in the center of pressure.

    Eric
     
  7. Use a reverse Morton's extension. I don't believe that a Morton's extension shifts the momentum. You may see a lateral shift in the center of pressure with a Morton's extension, but my belief is that the Morton's extension will increase load in the windlass causing pain and the posterior tibial muscle will start working harder to decrease that pain. That is why you would see a lateral shift in the center of pressure.

    Eric[/QUOTE]

    Joanne:

    First of all, an x-ray is in order to assess the structure and cartilaginous thickness of the joint. Secondly, if there is pain at the end of dorsiflexion range of motion, which appears to be the case, I would use a Morton's extension (not a reverse Morton's extension) with a foot orthosis in order to prevent the pain that occurs at the end of dorsiflexion range of motion during walking. Sometimes I will actually try both types of extensions in the office to see which one (reverse or normal Morton's extension) works the best at relieving pain.


    Finally, you should have her try the Hoka One One running shoes which have a very thick forefoot with relatively stiff rocker-bottom sole which can take a patient from pain with every step to virtually no pain with walking. I have had very good success with Hoka shoes for these patients.

    However, with all that being said, a 32 years old with such pain, barring a negative x-ray, will likely need a surgery in order to more permanently produce good reduction of symptoms during her activities. These surgeries, in my hands, are very successful and I would suspect that if you can find a good foot surgeon in your area, then she may benefit from consult to discuss possibly surgery.
     
  8. efuller

    efuller MVP

    It is important to think about how a Morton's extension will limit dorsiflexion of the MPJ. The Morton's extension will dorsiflex the first ray, increasing tension in the fascia and this will increase compression forces at the MPJ. Certainly, it is valid to prevent dorsiflexion of the hallux if the MPJ hurts at max dorsiflexion. A Morton's extension could provide temporary relief, but I would not use it for long term relief. I too like the Hoka's for hallux limitus/rigidus.

    Eric
     
  9. Joanne Moore

    Joanne Moore Member

    Thank you both very much. I'm wide-eyed that people as knowledgeable and busy as you both could, and indeed do find the time to answer queries that must be very basic to you. I really am in awe.

    Can I ask about the idea that if the easiest route for body weight and momentum to travel is impinged (in this case due to functional hallux limitus care of tight p.fascia etc), the forces in question then travel to the next available avenue to allow the momentum through the lesser metatarsals and low gear propulsion. I thought that that was how the Mortons extension worked, but I wonder now is that just, as you say Eric, a short term fix, and long term being footwear and reverse Mortons?

    I hope I'm not confusing theories and terms here, but I look forward to your reply to put me straight!
     
  10. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin,

    Surgery to the 1st MTPJ was on my mind also. However ... we all know this often can/may/will create a degree of iatrogenic joint stiffness. Problem here is ... the patient has an expectation of full and unimpeded restoration of function and range of motion.

    I appreciate this is not yet a part of mainstream thinking but controlling the STJ position, aka Hyprocure , really can reduce 1st mtpj impaction and free up movement (depending of course on the condition of the joint and grade of HR). All the same, this should be evaluated and considered and the option put to the patient.
     
  11. efuller

    efuller MVP

    It is important here to understand what momentum is. Newton's first law is that things will stay at rest or continue moving in straight line unless acted upon by an external force. Momentum is mass x velocity. Since velocity has a direction, momentum will have a direction (vectors) In gait, the momentum of the body will push the body up over the leading leg, that then becomes the stance leg. The body will slow (lose momentum) as it climbs up over the stance leg, and then the body will accelerate as it falls forward (gaining momentum) after it passes the stance leg. (it might be better to think here in terms of kinetic and potential energy, but we were discussing momentum)

    One way to think about this as the body is vaulting over the stance foot and the foot can be thought of as a peg. There can be differently shaped pegs. What you are describing is not really momentum, but internal forces that are occurring within the foot. The body can pivot over the ankle joint, the metatasrsal head, or the tip of the toe, or the rocker of the shoe under the foot. There will be different internal forces within the foot depending on where the pivot point is. Different muscular activation can alter where the pivot point. Increased ankle platnar flexion moment from tension in the Achilles with prevent pivoting at the ankle joint. Increased activity of the posterior tibial muscle will decrease resistance to dorsiflexion of the hallux and shift weight laterally so that you would see "low gear" push off.

    If you had a rigid 1st MPJ (structurally or functionally) there would tend to be a pivot over the tip of the first toe. Now to your question "if the easiest route for body weight and momentum to travel is impinged ... travel to the next available avenue to allow the momentum through the lesser metatarsals and low gear propulsion. " Would increased force on the tip of the hallux cause a "tip" into low gear push off? It depends on the location of the STJ axis. If the axis went above or medial to the tip of the toe, then force on the tip of the toe would not cause a supination moment. So, with the axis in this location you would not get supination of the the STJ and movement toward a low gear axis, unless there was supination moment from some other source. With high force on the tip of the hallux you would tend to see hyperextension of the IPJ. So, if you see supination of the STJ in the presence of a medially deviated axis and hallux limitus, it is probably from some other source like the posterior tibial muscle and not because of redirection of momentum.

    Eric
     
  12. Dieter:

    I have yet to see one of my shortening osteotomies of the first metatarsal along with a dorsal bunionectomy (i.e. cheilectomy) cause a decrease in hallux dorsiflexion post-surgically. These procedures always increase range of hallux dorsiflexion. In addition, if after the dorsal bunionectomy (and before the first metatarsal osteotomy is performed) I still see a decrease in hallux dorsiflexion, I will use a McGlamry elevator to loosen up the plantar soft tissue structures that may be restricting hallux dorsiflexion (nearly always from trauma or another 1st MPJ surgery). I just did exactly this procedure one week ago in a patient that had a previous bunionectomy and resultant joint stiffness and her hallux dorsiflexion went from only 10 degrees pre-operatively to 60 degrees dorsiflexion post-operatively. Very dramatic and the patient was super excited to see the post-operative result yesterday.

    As far as subtalar joint arthroereisis procedures are concerned, only one podiatrist (out of about 75 surgical podiatrists) in the Sacramento metropolitan area is doing these procedures on adults (and she uses the Hyprocure implant). I get to see her failures including chronic sinus tarsi pain, chronic lateral column pain (i.e. iatrogenic lateral dorsal midfoot interosseous compression syndrome) and lack of adequate correction on a routine basis in my practice. I would be very careful using these implants in adults since their success rate is probably much better in younger individuals or children rather than adults.
     
  13. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin.

    I congratulate your personal surgical success but would instill a word of caution nonetheless. It is not the experience of many others, not in the long term. Sure, on the table the outcome looks great. The simple cheilectomy regularly under performs and rarely stands the test of time.

    Kevin, I am working in a Manhattan office that specializes in Hyprocure with Master Surgeons. Of course a sub-optimal outcome is possible, as with any other procedure, technique is key. If your local Hyprocure surgeon regularly has poor outcomes this is likely a technical issue, or poor patient selection. So while I endorse the procedure it is predicated on the implicit understanding the surgeon is competent and well trained.
     
  14. What is a "Master Surgeon"?
     
  15. Dieter Fellner

    Dieter Fellner Well-Known Member

    The designation of the Master Surgeon is an accreditation provided by Atlas. Underpinning this is additional training, which includes a test that requires a 100% pass mark, in addition to a minimum requirement of logged cases.

    With experience of many cases it is apparent there are pearls that can be acquired to know which patients benefit the most. And how to manage some of the post-operative events you describe, or others that might be seen. Clearly not all patients are Hyprocure candidates but the literature exists to show the Hyprocure removal rate is the lowest among all arthroereisis options.

    The sinus tarsi is God's gift to Podiatrists, according to Dr. Harold Schoenhaus. Many others are inclined to agree with him.
     
  16. What is "Atlas"? I have been doing surgery for 31 years, maybe I can also become a "Master Surgeon"....not that I would ever want to be known by such a pretentious name...
     
  17. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin:

    Some Americans, so it seems, appear to like such distinctions, along with pompous uniforms (from doormen upwards) with shiny badges - don't shoot the messenger.

    But I wouldn't dwell on it too deeply - this is simply a mark of experience and, with it, some distinction of quality assurance.

    What's wrong with that?

    How about "Master Techniques in Podiatric Surgery" T J Chang. Too pompous? I don't find this at all offensive or pompous - but that's just me. Perhaps I'm now Americanized ....

    If you are interested you can contact Dr. Michael Graham, at GraMedica - ask about the Atlas Foot Alignment Institute.

    While his approach may appear pompous, to some, Dr. Graham is making a sincere effort to ensure this technology is correctly applied and by well trained surgeons.
     
  18. Dieter,

    I did not use the word pompous, I used the word "pretentious".

    pretentious
    1. self-consciously trying to present an appearance of grandeur or importance.

    When you say that a podiatric surgeon is a "Master Surgeon" what does that mean to me, someone who has been practicing with orthopedic surgeons and doing surgery with many other types of surgeons (plastic surgeons, hand surgeons, oral surgeons, general surgeons, gynelocologic surgeons, eye surgeons, etc) in the same hospital/surgery center for over three decades? To me it means absolutely nothing since I know these surgeons well and none of them would call themselves a "Master Surgeon". They would be be embarrassed to do so and would probably fall down laughing if a podiatrist were to be so pretentious to call themselves a "Master Surgeon".

    Surgeons are all specialized in what they do and even though they may be very good at performing some surgical procedures, there is no one surgeon that is good at performing all surgical techniques. Using the term "Master Surgeon", at least in my eyes, is pretentious since it is being used for the sole purpose to attempt to make the public believe that these podiatrists are actually podiatric surgeons that are "Masters" in all podiatric surgery and not just being experienced in the use of a Hyprocure implant and passing a test by a trademarked company which promotes the use of only one subtalar arthroereisis implant.

    http://www.atlasfai.com/

    Tom Chang is a good friend of mine and I'm sure that when he titled his book "Master Techniques in Podiatry Surgery" that he didn't expect any of the surgeon-authors in that book to start calling themselves "Master Surgeons" just because they wrote a chapter in his book on a certain surgical procedure. In fact, my bet is that Dr. Chang would be embarrassed if someone he respected enough to write one of his book chapters was so pretentious to use the title of "Master Surgeon" for themselves.

    I suggest that you should ask the question more widely to other US podiatric surgeons on PM News. I would suggest that you ask what they think of the term "Master Surgeon", a title that some podiatrists are being anointed with because they have done a bunch of Hyprocure procedures and passed a test. If you don't want to ask the question, I would be happy to submit it to Barry Block for discussion.

     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin,

    Thanks but I'll pass on the suggestion. It's not my choice of designation, this belongs to the orgnanization. If you don't like it, please take it up with Hyprocure.

    I am far more interested in the application of the technology. Obsessive quibbling over titles is futile and misses the point.

    Peace out
     
  20. Dieter Fellner

    Dieter Fellner Well-Known Member

  21. Dieter:

    Maybe it's different here in California than in New York, but I do think the term "Master Surgeon" is pretentious and is a title I think most podiatric surgeons I respect would avoid publicizing or even using. I'll go ahead and post it up to Barry Block and PM News to see what others think. Should be interesting.

    I do agree that the technology is interesting. The last time I spoke with Jeff Christensen, DPM, one of my classmates from CCPM, he was doing some research on a new STJ arthroereisis implant design that was trying to minimize the relatively high implant-bone interface pressures seen with the metallic threaded STJ implants like the Hyprocure. The problem I see with these metallic-threaded STJ screw-in implants is that none of them contour the surfaces of the sinus tarsi and tarsal canal well, so that high contact pressures on the bone can occur. This would be worsened with individuals who are heavy, have more medially deviated STJ axes, or who have equinus deformity. Jeff is a very smart guy and I think a more anatomic design of such implants would help reduce the sinus tarsi pain seen in many of these individuals post STJ arthroereisis.

    Amol Saxena, DPM, and coworkers just found a 22% removal rate of STJ arthroereisis implants in a recently published study. STJ arthroereisis is definitely not a cure-all, but seems to be a worthwhile procedure when done appropriately on properly-selected patients...like most all other surgical procedures of the foot. http://www.jfas.org/article/S1067-2516(15)00577-3/abstract
     
  22. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin:

    I will argue the designation can be meaningful to a patient. This can provide a measure of confidence in the surgeon's level of competence and experience. Irrespective of the surgeon's pedigree, if a surgeon has never used the Hyprocure he/she will be a novice surgeon, in the use and delivery of this technology. That's a fair assessment. When a surgeon has completed the required training and cases, the surgeon will likely become more competent with a greater probability of a successful outcome.

    Kevin, I watch TV commercials regularly. Prestigious hospitals advertise their services to the audience. The narrative contained in such a commercial is aimed at the layperson. Compared, side-to-side, the pretentious designation (as you put it) of Master Surgeon, pales into insignificance. However, the solution to the problem is simple: when you qualify for the designation simply ask Hyprocure to remove it.

    As for the implant:bone interface. The threaded portion does not provide the working component of the implant, which is in fact smooth. In addition, Hyprocure is now on version two of implant design, which is even smoother.

    Saxena's article: there was not a single Hyprocure implant removed.
     
  23. Dieter Fellner

    Dieter Fellner Well-Known Member

    Addendum:

    Also from the Saxena article:

    In our study of 104 procedures, we did not find any significant differences between patient age and the removal rate. Thus, patient age should not be considered a surgical contraindication for STA.

    This very useful article goes on to identify possible reasons, together with their remedy, to understand better why those other implants might require removal. The great majority of factors identified appear to point towards patient selection, co-morbidity and improper technique or implant selection. Which dovetails, quite nicely, with the desired requirement of a surgeon to have experience and technical competence to optimize on the potential for a good outcome. In other words, the 'Master Surgeon' (or if you prefer, the experienced surgeon) will likely succeed, where the less experienced surgeon might fail more often.
     
  24. Dieter:

    I have no problem with arthroereisis implants. In fact, I have written an article on them and lecture on them.

    http://www.podiatrytoday.com/understanding-biomechanics-subtalar-joint-arthroereisis

    The problem I have is with the title "Master Surgeon" being used to describe a podiatrist who has shown proficiency in only one surgical procedure out of the many surgical procedures that podiatrists do perform. To me, the term "Master Surgeon" implies proficiency in the wide variety of surgical procedures that podiatrists perform, not just in one surgical procedure. This is especially the case when that title is being bestowed upon a podiatrist by some surgical implant company that only is interested in their wallets.

    If the title "Master Surgeon" was to be given to any podiatrist, I believe it should be given to exemplary podiatric surgeons who are "masters" of a very wide range of surgical procedures which are voted upon by a nation-wide group of other podiatrists who have an interest in protecting the public and promoting the profession of podiatry, and not just on how much money that podiatric surgeon makes for one surgical implant company.
     
  25. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin:

    I believe we both have made a case. I will now rest the case - except to say, Hyprocure has indeed applied the designation to imply Master Surgeon capability (along with other distinctions based on experience) and ONLY within the context of this one procedure. There is no pretense to suggest otherwise. If a doctor abuses this designation to suggest otherwise, this doctor will be misleading the public.

    Your criticism, that Hyprocure is interested only in their wallet, is a harsh one. The capacity for abuse exists anytime. My interaction with GraMedica is comparable with many other companies who promote equipment and implants. It is a capitalist market, and an element of product marketing will always play a part. Take a look at the TV infomercials marketing anti-diabetic medication, anti-rheumatic medication and Viagra, to name a few. With ambulance chasing lawyers in hot pursuit offering their services to sue for damages. Perhaps the west coast has a different experience. On the east coast this is simply a daily reality.

    The company that is 'only' interested in money requires the co-operation of a complicit end-user. In other words, the doctor. In the end you, the doctor, will maintain a grip on that final decision and control, to know if your patient can benefit, or not.
     
  26. Dieter:

    OK, I agree that I was a harsh saying that a surgical implant company is only interested in their wallet by bestowing the title of "Master Surgeon" to those podiatrists who have passed a test and used x number of their implants. I apologize.

    I also see surgery equipment reps in my office every week and, in general, I believe these companies do have their financial interest in mind, but also have the well-being of the patients in mind. I suppose my main complaint is with the title "Master Surgeon", not with the companies, since these companies are a necessary part of what we do as podiatric surgeons and do help us all perform more advanced surgical procedures on our patients for the benefit of their health and comfort.

    Even though I do I love the surgical technology, I still worry that these surgical companies may have too much influence over what we do and what we teach to our residents and podiatrists. But that is another subject......

    http://www.podiatrytoday.com/podiatry-seminar-content-science-or-infomercials

    http://www.podiatrytoday.com/should-you-become-skeptical-podiatrist
     
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