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1st Met-cuneifrom arthritis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by drsarbes, Feb 11, 2009.

  1. drsarbes

    drsarbes Well-Known Member


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    I have a 50 Y/O F patient with pain in the 1st met-cuneiform joint, medially and plantarly, with any weight bearing, worse at push off. Duration 6 months at it's present intensity.

    I have not had much luck with orthotics for these in the past, but prior to suggesting an arthrodesis, I'd like to try again.

    Any advice per orthotic type would be appreciated. Aside from her aforementioned pain, her foot is asymptomatic, as is the contralateral foot. She has a mild forefoot valgus with no other obvious pathomechanics.

    Thanks

    Steve
     
  2. Asher

    Asher Well-Known Member

    Hi Steve,

    The things I’d be thinking of are:

    Assuming the windlass mechanism is not working well (high force and/or delayed), I’d look to use a 2-5 forefoot valgus extension (increasing lateral forefoot dorsiflexion moments and thereby reducing 1st MPJ dorsiflexion moments) and maybe preload the hallux with a cluffy wedge or similar.

    Assuming there’s too much arch flattening (high 1st ray dorsiflexion moments), I’d use a minimum arch fill and a first ray wipe on the positive cast (MLA of orthotic is higher proximally and lower distally meaning reduced dorsiflexion moment from the orthotic under the first ray). I’d probably use some degree of medial heel skive depending of what I thought of the STJ pronation moments.

    And if there was high ankle-foot dorsiflexion stiffness (limited AJ dorsiflexion) as measured by the lunge and modified lunge tests, I would give gastrocnemius and/or soleus stretching (if I thought tight), mobilise the lower tibiofibular joint (if I found stiff) and use a heel raise and / or give advice about wearing shoes with some degree of heel height differential (particularly if there’s an anterior cavus or the other two things don’t improve the lunge / modified lunge measurements).

    Having said that, I notice that patients mostly complain of dorsal and medial pain, not so much plantarly. I have made a lot of assumptions with my advice above as the information you provided was a bit light-on. But these are the things I think of in regard to the first metatarsocuneiform joint.

    Rebecca
     
    Last edited: Feb 12, 2009
  3. Peter

    Peter Well-Known Member

    Dr Sarbes,

    Aside from orthoses, I consistently find ( albeit anecdotally) that periosteal pecking with an acupuncture needle gives effective pain relief, and sometimes used in conjunction with a sock with a gel lining on the dorsal aspect of the foot.
    That is my first cat skinning technique with this condition.
     
  4. Phil Wells

    Phil Wells Active Member

    Steve

    Have you thought about using a Rocker sole modification?
    If the CoP or CoM is 'stopping' at the 1st met cuneiform joint, then a rocker sole can get things moving and allow more progressive loading at propulsion.

    Phil
     
  5. Steve:

    Rebecca has given some excellent recommendations for foot orthoses for this patient.

    Pain at the medial-plantar aspect of the first metatarsal-cuneiform joint (MCJ) is not generally a case of osteoarthritis, but is probably rather a case of inflammation due to excessive tensile loading forces within the insertion of the anterior tibial tendon or plantar 1st MCJ ligament. Osteoarthritis in this area of the foot would nearly always present more as dorsal joint pain, rather than plantar pain.

    For conservative treatment of these conditions, using the tissue stress approach for mechanical foot therapy, the foot orthosis must reduce the tensile loading forces within the plantar ligament-tendon complex of the 1st MCJ. In order to do so, the orthosis must be designed to increase the subtalar joint (STJ) supination moments (e.g. medial heel skive, firm and well-contoured medial arch) and decrease the first ray dorsiflexion moments (e.g. firm and well-contoured medial arch, reverse Morton's forefoot extension). I have found that 90% of patients with similar symptoms become asymptomatic with properly constructed foot orthoses such as above. In addition, having the patient avoiding flat heeled shoes (i.e. low heel height differential) with the orthoses will help also.

    One clinical test that I use for patients such as this is what I have described previously called the Barefoot Standing Orthosis Test (Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002, pp. 163-164). This is where I stand the patient, while barefoot on top of the orthosis to assess the conformity of the orthosis to the plantar foot to see how the orthosis is working to support the area of interest (i.e. 1st MCJ in this case).

    In addition, if you now have the patient "walk" over the orthosis, by stepping forward with the contralateral foot with the affected foot on top of the orthosis, this what I have described as the Orthosis Deformation Test (Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002, pp. 157-158) which allows the clinician to assess how much the orthosis deforms in response to the increased flattening of the medial arch/lateral arch as simulated late midstance phase occurs on top of the orthosis. Both of these tests will give you a much better idea of how your foot orthosis is responding to the loading forces acting upon it from the patient's foot and how you might better design the orthosis to reduce the excessive tensile forces on either the plantar 1st MCJ ligaments or anterior tibial tendon insertion that is most likely causing your patient's pain.

    Hope this helps.
     
  6. drsarbes

    drsarbes Well-Known Member

    Thank you for all the suggestions.

    Kevin: Just one follow up note re: dorsal vs medial and / or medial plantar pain at the first metcun joint.

    I have found that the dorsal pain in these are normally from dorsal exostosis or "bossing" but the plantar and / or medial plantar pain is arthritic when crepitus is present. I should have mentioned in my original post that this particular patient has clinical signs of DJD (as well as radiographic DJD.)

    These are the patients that I have not had much luck with when treating with orthotics and I usually end up arthrodesing.

    I will get this patient into an orthotic as you have all suggested and see what happens.

    Thanks again

    Steve
     
  7. drsha

    drsha Banned

    In Neoteric language. This patient most likely has a rigid rearfoot, flexible forefoot foot type.
    The elavation of the medial forefoot upon weightbearing during midstance and beyond is causing major stress into the 1st Met/Cun.
    I would cast this patient prone starting in "Root Neutral" semi weightbearing (not suspension) and then using rearfoot varus correction technique, I would reduce the need for some of the rearfoot varus usually posted into orthotics. I would use forefoot vault correction techniques to lower the medial forefoot and create more vault into the shell. I would use hammertoe correction technique to reduce the doming effect of the toes from translating into the Centring.
    I would post the rearfoot in 0 -2 degrees varus depending on the exact rearfoot type. I would add a 3-4 degree forefoot varus post with an aggressive first ray cutout. I would add a small amount of heel lift, B/J (1/8") to offset the equinus influence that exists in the rigid rearfoot type and I would advise the patient to wear shoes with a positive heel whenever possible.
    This Foot Centring will fit in many shoe styles that a reverse mortons and other bulky corrections wouldn't tolerate and if you wish, you could continue to work with upgrading the shells with test pads down the road as you add physical therapy to stregthen p. tibial p.longus and a.tibia (which would prove very successful if done in closed chain with Centrings in place.
    Dennis
     
  8. Funkster

    Funkster Member

    Before embarking on a treatment plan it would be helpful to have some more data on the clinical reasoning on the diagnsosis, any investigations, extent of oa and causes.

    Howver, at this point I think to be the most helpful I need to assume it is purely oa on the basis of the title of the thread!

    Given this; it is the degree of biomechanical dysfunction and degeneration within the joint that would be the most likley factors that would affect the tx plan in my experience.

    If there was gross joint destruction there would be little point in trying to create "normal" movement and function as this could make them worse. I would adopt an approach of reduce movement in the joint using a rocker and/or orthoses. If that failed surgery would be the next stage.

    If there was minimal degenerative change but poor biomechanics I would go the FFO route to improve first ray function and movmener; then a steroid injection if it improved significantly but didn't settle completely.

    Simon
     
    Last edited: Feb 22, 2009
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