Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

5th MTPJ Overloading

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Dieter Fellner, Dec 3, 2006.

  1. Dieter Fellner

    Dieter Fellner Well-Known Member

    Members do not see these Ads. Sign Up.

    A patient with multiple trauma also had a triple rearfoot arthrodesis (post near fatal RTA - 1998) (patients own account; clinical findings: Left AJ/STJ fusion - awaiting sight of XRF) .

    A second calcaneal osteotomy (opening wedge) several years later helped improve the rearfoot / forefoot alignment but there is still now residual forefoot varus. Now left with fused plantar flexed AJ, inverted rear foot and the forefoot follows this alignment, with overloading of the 5th MTP joint. This patient pivots on the 5th MTPJt to get the forefoot to the ground, which is achieved, in a manner of speaking.

    The result is painful button callus sub 5th in spite of regular podiatry (and this is the most painful problem for this patient), inferior heel pain, achilles tendon pain (a percutaneous tenotomy was also performed) and a world of misery. The orthopaedic surgeon and a Podiatrist could obtain no further improvement.

    The Podiatrist has tried out various simple insoles (silicone based / sorbothane) / sneakers / ?simple deflective type insole - either no help or uncomfortable. Unfortunately non of the many devices are now available for inspection.

    Patient had heard about and was interested in silicone soft tissue augmentation injections. I doubt this is the way forward but also I am reluctant to consider further surgery. Can a well designed orthosis help ?!

    I am considering this formula:

    Accommodative insole design incorporating

    1. heel raise - partial correction. ? add shoe build up as necessary
    2. tarsal cradle to help off load the forefoot and direct pressure away from 5th MH
    3. extend (2) to include a forefoot plantar cover with cut out to 5th MTPJt.
    4. ?incorporate medial forefoot wedge depending on subjective outcome at
    review. (I suspect intrinsic soft tissue stress is causing plantar fasciitis)

    I had also speculated that a full contact orthosis might work.

    I am interested to hear from anyone with experience of this kind of patient.

  2. Admin2

    Admin2 Administrator Staff Member

  3. David Smith

    David Smith Well-Known Member


    I assume from your info that the foot is fixed in plantarflexion and inversion. What compensation does he make for the functionally long leg? Does he abduct and circumduct or have exaggerated knee flexion? I presume he has a toe strike. Is the knee extended by GRF at foot strike?
    I would think a full length full contact eva orthosis with heel lift and a rocker shoe would do the trick. Plus some raise on the contralateral shoe to facillitate swing thru of affected foot/leg. Pretty much what you intend by the sound of it.

    All the best Dave Smith
  4. Deflective

    How about a full contact EVA or 10mm lunarsoft FFO with an implant of somthing like maxacaine or poron 94 under the lesion?. I've had some good results using casts with cavities for pressure delection in trickier cases. I've found poron 94 to be much better than standard poron for small areas and maxacaine is supurb for torsional trauma. Depends if the patient is just pivoting on the joint or if there is an abductory flick going on as well.

    Could be combined with the heel raise and rocker suggested by Dave.

    Kind regards

    Robert Isaacs
  5. Dieter Fellner

    Dieter Fellner Well-Known Member


    Thanks for your replies. This is a lady patient who, now with a fused cervical spine and fused ankle and the after effects of multiple organ / emotional trauma is desparately clinging on to some form of (footwear) normality. I hear what you are saying about rocker soles etc but ..... it is of course possible expectations are set too high but I am resolved to see what could be done. I have made a start to gently eased the way towards an 'easy' fitting shoe.

    There is indeed currently an asymmetry with a pronating right foot producing related symptoms, which I plan to address with a FFO so that should move asymmetry in the right direction.

    lunaform/maxacaine ? never heard of this .... (?)
  6. Lunarsoft


    Lunarsoft is A heat mouldable casting material which is somewhat more elastic / softer than EVA but primarily plastic. I use it mainly in 10mm thickness in shank dependant devices particularly if i need some thickness in the device (for example if i am implanting a softer elastic material for heel cushions, mid tarsal pressure lesions etc.)
    Maxacaine is a silicon gel stabilised between an impermiable but flexible base and a fabric cover so that it can be glued and incorperated into custom devices. Comes in varying thickness and was (i beleive) originally meant to be a covering material. Very good for spin callus and friction trauma, pretty fair for bog standard cushioning over large areas but bottoms out rather fast if you use it on its own.

    Jamie are you lurking? Any more scientific descriptions available?


  7. efuller

    efuller MVP

    I had a very similar patient who had been in a motorcycle accident fused STJ and MTJ in varus with pain sub cuboid. He did very well with an accomodative device with a full length varus wedge. His foot and the device barely fit in the shoe, but he was so happy with the pain relief that he did not care.

    In your case where shoes are a concearn I would try some felt forefoot varus wedging to give her an idea of what might work. It may take a lot. (In stance can you run your fingers under the medial column?) Then the two of you will have to figure out how to get the wedge into an acceptable looking shoe. You could have a shoe cut and a varus wedge added and then resoled. You can find an extra depth shoe for comfort occaisions and then another shoe with a wedge for dressy occaisions.

    The medial column symptoms are usually the result of medial roll off with an abducted gait. This occurs with the classic lateral column overload with an uncompensated or partly compensated varus. The treatment is quite simple bring the ground up to the foot.

    This patient exposes one of the problems of the Root paradigm. How does an orthosis that ends proximal to the metatarsal heads support an uncompensated varus when the heel begins to lift in gait. You have to bring the ground up to the metatarsal heads and not just the arch.

    In school the surgeons used to teach "Thou shall not varus" when performing tripple arthordesis. The above is the reason behind that. I've seen going to far into valgus, it wasn't pretty either. The medial column/ forefoot is much more able to adapt to the fused rearfoot position than the lateral. The ideal fusion is where the distribution of forces is even across the met heads.

    Good luck with her.

  8. Dieter Fellner

    Dieter Fellner Well-Known Member

    Eric - thanks for your input. I expect there is a need to experiment commencing along those very lines and to coax patient co-operation with a view to softening her shoe fixation, if an improvement in pain can be demonstrated. I am reviewing this Friday and will feed back my findings.

    Robert - who is your supplier for Lunarsoft / Maxacaine?

  9. Materials


    Algeo's in liverpool. If you are considering trying some new materials i would warmly recommend poron 94 Lambda to have a play with as well. It's nowhere near as hard wearing as standard poron but i have had some very, very happy patients back with it after i had despaired of them. If you are anywhere near kent and wanted to pop over i would be happy to show you some of the weirder materials and how they can be used. Alternativly i'm sure algeos would send a rep out to you with samples if you asked them nicely.


    Robert Isaacs
  10. Dieter Fellner

    Dieter Fellner Well-Known Member


    Robert - do you think maybe Algeo's will send the samples and forget about the rep? :rolleyes:
  11. David Smith

    David Smith Well-Known Member

    I agree with Eric and this is where the Amfit system really works well. The scan is taken semi w/b and the gaps are automatically filled to the precise depth require. Just Scan and mill and you have a full length accomodative insole with no excessive thickness anywhere. The insole can be made in a variety of densities although it still may not fit in the shoe. Personally I have given up trying to do favours. If the patient can't compromise and use something like the correct shoe I don't try and fit a compromised orthosis. Almost without exception (barr Erics example ) they will continually return with complaints about comfort, toes cramped, shoe rubbing etc or the compromised orthosis does not quite do the job and they will never be completely satisfied.

    Perhaps you know of an clinic near you with an Amfit system? Or while your in Kent UK you could visit me also (all the best people live here you know ;) )

    All the best Dave

    {A good deed never goes unpunished}
  12. Dieter Fellner

    Dieter Fellner Well-Known Member



    Do please let me know if there are any openings for Pod Surgeons in Kent - it is clear that I need to relocate.

    Sadly I do not know of any Amfit-ted clinic nearby - I do have a trick (or two) up my sleeve - I have a hunch this can be done without a scanner with the same effect. I will report back once I have tested this out. It will be either smug satisfaction or humble pie for me.

    Normally I agree, patients need to be realistic .. am working on it. This is a 'special' patient though. ;)


  13. Amfit


    Oooo, where in kent do you have an amfit system? I'm still slogging away in an NHS lab in Maidstone. It is state of the art. The art, in this case, being pottery. You may also be interested in an exciting new technique we have here called "trepanning" to release the evil humours. However i maintain that i can match any CAD CAM device, and produce things the system cannot. It might take me six or seven times as long but i can do it!


    Tell you what, cos it's you i'll snail mail you a few samples if you give me an address. Spare you the rep. :eek:

    And i would'nt know about surgery vacancies, i'm just a humble SRCH, (tugs forelock deferently, shine your shoes for a bob etc etc.) ;)

    Kind regards

    "theres no business like toe business"
  14. David Smith

    David Smith Well-Known Member


    There are always limitations to any technology and the Amfit system has many and so many times I still use PoP casting and a lab. The lab I use (Talar Made) have CAD CAM technology for Scanning and direct milling of the cast. I have found this lab and direct mill method superior to any other.
    When running a commercial practice fast turnover is preferred and the Amfit system is the fastest. 1 hour assessment, half hour design and if you have the mill one hour to mill, finish fit and cover. Otherwise email digitised design to mill, get orthoses back next day.

    I have never made an orthoses from a cast so I don't know the limitations well but--
    Robert, What kind of thing can you make? an ashtray or vase for your aunty mabel in York ;) You had better start on it now it's nearly christmas. :D LOL.

    All the very best Dave Smith

    Oh! Folkestone by the way, Have I seen you at branch meetings at Maidstone Hospital?


    True story! I made a very decent snowman yesterday lunchtime out of some plaster i had left over. :D

    Although the idea of an ash tray is a nice one (thanks for the idea) i was thinking more of Hybrid devices using combinations of materials heat mouldable and otherwise, implants, cavities (no wait thats dentists! ;) ) and other such things.

    I'm surprised it takes as long as an hour to direct mill an orthotic! I had visions of a machine spitting out a pair every 5 minutes! I could probably do a pair in that sort of time or less so long as there was a week in between filling the cast and producing the device to let it dry nicly. Switched for wet plaster washing to finish my casts to dry finishing last year and haven't looked back!

    And i doubt you would have seen me at the branch meetings. Wednesdays always clashed with another commitment so i am one of those despicable swine who let the other members down by not participating! :( Sorry.

    Kind regards

  16. David Smith

    David Smith Well-Known Member


    They only take about 5mins to mill (if I had a mill @ £20,000 each) but then you must grind off the excess, fit to the shoe and patient, cut to required length, ie behind mets, sulcus or full length, add any soft additions that may be required, eg put poron in a cavity that was milled in, then cover with leather. Finally assess the patient with the new orthoses. That all takes about 1 hour ish. Brighton and Bolton Pod dept each have this system and it works well for them. Really cuts back on the waiting list.

    I have a standard charge and allow 3 hrs for time, inc 2 month review.

    Maybe I could visit and you could show me some of the things you do there!

    Cheers Dave
  17. amfit


    Firstly please don't call me Roberts. It freaks me out. The meds are working so theres only one of me now. ;) And anyway you're just jealous the voices don't talk to you!

    I'd be very happy to show you how we've got our lab set up and the kind of things we do. I'll show you my toys if you show me yours. Always a worthwhile exercise. I spent a day with Ottobock (an orthotics manufacturing company) once and i learnt vast amounts from how they do things. I would love to see how amfit works. I'll bounce you my email address and we'll talk.

    Kind regards

    Robert (s)

Share This Page