Hi.
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I see a number of ulcerations to the 1st MPJ in (some) pes cavus feet.
My working theory is;
- significantly laterally deviated STJ requiring high activity of peroneus longus which consequently plantarflexes 1st ray due to insertion on med cuneiform and 1st met.
- plantarflexed first ray coupled with calcaneal inversion makes for maximally engages windlass mechanism due to elevation of medial column.
- little saggital plane motion left available at 1st MPJ due to maximal windlas engagement and position of 1st met predisposes to large amount of sheer as external leg rotation drives transverse plain motion at propulsion.
I have had some (anecdotally) good results with heel raises and lateral posting to encourage pronation to relax the windlass prior to propulsion & reduce peroneus longus workload in the hope it relaxes pull on the 1st met.
I faced some push back as appeared counter intuitive to attempt to load the medial column with a 1st met head ulceration. Despite this, it does appear to work well in those I have trialled it with, whether it is because of my rationale or something entirely different.
So, my questions are; do you believe the rationale is reasonable. Would you post lateral on the rearfoot even though this is medial to STJ (thinking K.Kirby SALRE) or would a valgus forefoot post be more appropriate.
My goal is to improve outcomes for these difficult to treat patients so all ideas welcome and any recommendations for further reading would be gratefully received.
Lastly, is there a risk of throwing out knee kinematics by attempting to collapse (partially) the medial arch in this patient group.
Many Thanks, Dan
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Stiffness of the Lower Leg Muscles in Patients with Medial Tibial Stress Syndrome
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