How to off-load base of 5th

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Recently I have seen a number of patients who have presented with pain at the base of the 5th metatarsal. In all cases the base styloid process has been enlarged and sitting more plantarly then would be expected. Gait analysis reveals excess pressure going thru the base of the 5th met base, hence the enlargement and pain. I have had some difficulty in manufacturing devices to off load this area. Does anyone have some ideas or suggestions on what works for them? Do you use formthotics, or custom, what modifications do you do, what do you order from the lab etc. Any suggestions would be greatly appreciated!

 

One of the simplest ways to deal with this is not with an orthosis but with a 1/4" (6 mm) heel lift that ends just proximal to the styloid process. Heel lifts often work wonders for plantar styloid process pain and even lateral plantar fasciitis. If it is peroneus brevis tendinitis, however, valgus wedged orthoses are in order.

 

Are you sure it is simply plantar pressure that's the problem?...

 

You can put a piece of moleskin or felt in the patient's shoe ending just proximal to the affected area.

 

Low dye taping with an emphasis on plantar-flexing the lateral ray(s) may work in the short-term by increasing the height of the lateral arch and increasing load on the head, whilst reducing load at the base. Other options include a half-donut starting under the cuboid and finishing at the 5th shaft. Other options might include a cam walker.

I am guessing, but as for orthotic therapy, a cuboid lift/dome/pad might be considered +/- a 5th ray cut out.


(I had one of these present recently. Ambulating with mild symptoms and dysfunction. "Unloading" the 5th base helped but not sufficiently enough. A subsequent xray highlighted a fracture)

 

In my opinion, the best way to manage this is with a stylod accommodation in an orthosis. We have an option for a styloid process accommodation on our Root Lab Rx form. You can download a copy of it a www.root-lab.com.
Ideally, you should mark the area you want to accommodate on the foot and have it transfer to your positive cast of the foot. Remark it in the positive cast so your lab can readily see it. Styloid process accommodations can be plantar or plantar, lateral depending on the foot type and typically range from 2 to 4 millimeters in depth. Be sure the accommodation is abrupt and creates a pocket for the styloid process to sit into in order to reduce orthotic pressure on the styloid process.

Respectfully,
Jeff Root

Root Laboratory, Inc.
16739 Placer Hills Rd.
Meadow Vista, CA 95722

(877) rootlab
www.root-lab.com

 

I have had some success offloading the styloid by using custom orthoses with a 'sweet spot' similar to a navicular sweet spot. I use a polypropylene shell with sufficient rigidity for the patient's bodyweight and create an expansion on the positive model at the styloid process and then fill with poron. Sometimes even just doing the expansion on the shell without a fill works fine. I then use a poron fill under the shell to prevent lateral column collapse during midstance, and where warranted, valgus posting to have the positive models sit vertical to the supporting surface. I also use extrinsic rearfoot posts as well to ensure lateral column support and have found that a cushion topcover (poron, ppt, neoprene, multiform) can help as well.

Hope this is of some help.