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Advice for orthotic modifications

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sezza, Feb 27, 2012.

  1. sezza

    sezza Member

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    I am just seeking everyone's wisdom and advice regarding one of my patients.

    Clinically, she has pain on palpation in the 3/4 webspace, with direct force on 2 & 3 plantar plates, as well as pain in the lateral aspect of the 5th MPJ with compressive force.

    She is also complaining of numbness on the medial hallux & the dorsum of the foot.

    In weight bearing - she experiences diffuse pain on the plantar forefoot region - no one area is localised as being more painful.
    If she 'takes her weight off the outside of her foot' (everts), she experiences less pain.
    If I invert her foot, she experiences pain along the lateral aspect of her foot.

    In a relaxed stance position, her heel bisection is approx 6 degrees everted.
    She has a high arched foot in non-weight bearing, but displays excessive midfoot and rearfoot pronation during gait.
    Her forefoot is inverted relative to the rearfoot.

    According to the ultrasound, she has:
    - plantar plate tears in the 2nd & 3rd plantar plates
    - 3/4 Morton's neuroma/bursa complex
    - adventitial fat pad changes

    I am just looking for suggestions regarding her orthotic prescription. Obviously I am needing to address all the different pains she is experiencing! I am confused as to how I should use met domes and/or u-padding in order to offload the lesions without increasing pressures on adjacent lesions!

    A met dome in the 3/4 space has only increased her pain. She finds high heels to be more comfortable than flats (in the forefoot) - she finds that sneakers make the pain worse. Any shoes that allows her foot to 'splay' makes it worse, while narrow shoes make it better (?!).
    She wears high (5-8cm) heels every day. She is very resistant to wearing more appropriate footwear.
    The only thing she has found to be helpful so far has been low-dye strapping - but she is very sensitive to anything applied to her skin for more than a couple of hours.

    Any advice anyone can provide would be great.
    Thanks in advice,

  2. Craig Payne

    Craig Payne Moderator

    rheumatoid arthritis?

    what is her age?
    morning stiffness?
    afternoon fatigue?
    any other joints elsewhere affected?
  3. sezza

    sezza Member

    She is 54, nil previous medical history, nil other joints affected except her knee is getting painful from her altering her gait pattern. She is not overweight and has always kept reasonably fit & active with walking & jogging. All her muscle ROM's are 'within normal range' (gastroc, soleus, hamstrings).

    No morning stiffness or afternoon fatigue - no real pattern to pain except when related to footwear or activity. Can't tolerate barefeet or any bumps on pavement; as mentioned before narrow, high heels seem to be most comfortable!
  4. kemplr

    kemplr Member

    Hi Sarah,

    If she has plantar plate tears, it sounds like she needs to be in a CAM-Walker or post-op shoe first and to get out of the high heels ASAP. High Heels are going to be continually aggravating the plantar plates and they will not heal. Taping the affected toes may help. If not it can progress and worsen and she may need surgical intervention.

    Personally I would address this first before considering custom orthotics.

    Cheers, Lauren
  5. I would suggest that there is other alternatives than a surgical boot for the get go

    we discuss tx re plantar plate tears and the anatomy involved here for anyone who is interested - Plantar Plate Anatomy re Plantar plate tear
  6. sezza

    sezza Member

    I agree Mike, I've usually had good success in the past with conservative treatment of plantar plate tears, without needing to use a boot. Thanks for the link, I have read that thread many times, and again today!

    The main aim of my post was to get others opinions regarding orthotic prescription. I am concerned about things such as use of a metatarsal dome for the neuroma being detrimental to the adjacent plantar plate tears etc.. or where I should place met domes & u-pads to specifically offload the damaged areas ... I was just wondering what others thought.

    Thankyou for your post Lauren. Her mechanics are such that she will need orthotics regardless of whether she went into a boot first. Taping has been beneficial but she is unable to tolerate tape on her skin for more than a few hours. Her main pain with palpation is the neuroma (3/4); however with weight bearing it is a diffuse pain in the plantar submet 2,3,4 region.
    I am trying to get her out of the high heels asap, but it is difficult when these are the most comfortable shoes for her, and flats or low heels make things worse!
  7. Lorcan

    Lorcan Active Member

    Personally I would give her a 4 or 5 degree rearfoot varus post,intrinsic forefoot valgus post of approx 4-6mm, kinetic wedge, temporary 2mm heel lift and autonomic inhibition calf strethces. Maybe add a met dome if this didn't give me results.
  8. efuller

    efuller MVP

    It's really hard to give orthotic advice when you can't figure out what is wrong. Ideally you design an orthotic to reduce stress on the pathological structure. If you can't figure out what it is, or in this case, a treatment that has worked in the past for a problem that you do know that she has does not work, then it is really hard to design an orthotic specifically for her problem.

    When I was first reading your initial post, I was sure that her shoes were too tight until I got to the last paragraph. An orthotic would make tight shoes tighter. So, just making an ortohtic and hoping for the best might make things worse.

    It's annoying when your patients don't tell really consistent stories.

  9. Griff

    Griff Moderator

    I doubt I'd even be worrying about what orthosis variables to deliver if this were my patient - I don't think I could confidently say that I could manufacture devices that would (i) fit her shoes, (ii) accommodate her foot as well, and (iii) alleviate her symptoms in the process.

    Before I recommend devices I often want to know what is wrong (as Eric says), what it is that I'm trying to achieve, and that the footwear in situ will be conducive to this.
  10. PodAus

    PodAus Active Member

    Have you considered a course of injection Tx (Prolotherapy), assessing nutritional state (bloods), and even a rocker soled shoe, in conjuction with ortho-mechanical offloading?

    What is it that causes these MSU demonstrable tissue pathologies, and over what time period? Is the patient able to repair / rejuvinate soft tissue, or is there some form of metabolic dysfunction?

    Reverse engineer the process and construct a list of these possible factors, and by a process of elimination, cross them off as you implement appropriate management strategies.

    Yes, a firm Dx is a short term goal, and the detective work to determine the causative/contributing factors has begun.

    Trial and error can provide valuable clues. Particularly with orthotic design features whilst the investigation is continuing...
  11. podcare

    podcare Active Member

    There's been no mention of the size of the 3/4 neuroma/bursa. In my experience, I've found that neuromas greater than 10mm in diameter rarely respond to non-invasive management. I routinely request an estimate of the size of the neroma when the patient undergoes the diagnostic ultrasound scan. If the ultrasound scan shows a diameter of 10mm or greater, I frequently advise a course of injections and/or a surgical opinion re: excision.

    I still discuss the options of wider footwear, orthotics, etc, but when the neuroma is very large, surgery may be the best option.
  12. RobinP

    RobinP Well-Known Member

    I am with Ian on this one. Need to establish, through trial padding etc what is causing the problem

    Pain 3/4 is the biggest problem at present. There is a neuroma on US but all the usual things that would increase pain with a neuroma are negative(if anything, the opposite is true. Is it perhaps sub clinical?

    Inject some LA into the 3/4 IM space and if the pain doesn't go, then the chances are it is sub clinical and you can start thinking mechanical.

    Also, I would probably still think about other neurology. SLR and slump tests would be worth doing to rule out neural tension(probabaly not relating to the 3/4 IM space but the other symptoms)

    Just a quick question, how is the foot taped when she gets pain relief?

  13. pied-a-terre

    pied-a-terre Welcome New Poster

    I am new to the Podiatry Arena, and my experience with the type of problem identified is limited, so I hope my comments are not too off-the-wall. :wacko:

    In reading the initial post and responses, I saw no mention of the patient's health in terms of being tested for diabetes or previous (possibly years earlier) injury to her foot. Is it possible that either of these factors are at play? We know how a sports injury, for example, can impact a person many years later. Could this be the case?

    Would it not be possible to have her fitted for the type of tri-layered, three-densitiy orthotics used for patients who have diabetes or Charcot foot? The cushoning that it provides would conform to the shape of her foot. Doing so might require extra-depth shoes, but the resulting situation would offer more comfort and slow the progression of her problems. I believe she can find feminine shoes to accomodate the orthotics while still providing a foot position she is looking to maintain. And the orthotics can be made to load more weight towards the forefoot and to conform to any plantar irregularities. She would still be positioned towards the forefoot, but with appropriate cushioning to relieve pressure on the neuroma. You might need to show her a catalog of shoes, and maybe find someone who wears them.

    I agree with the need to find the source of the problem, and the necessity to resolve the issues, but there is no reason not to try to make her more comfortable while that is going on. Remaining with her current shoes and lack of suitable orthotics is definitely not improving her situation or making her life any easier. She might also be more complient towards finding the source of her problems and pursuing any therapies if she was more comfortable. Any attempt on your part at treatment that alleviates pain and discomfort could demonstrate to her that a resolution is possible.
    Last edited: Mar 2, 2012
  14. sezza

    sezza Member

    Thanks for everyone's advice so far. I have dispensed some devices with no forefoot padding/offloading at this stage - I will start to add this at my first review appointment with her. She has agreed to wear devices and more appropriate footwear and see how it goes.
    Immediate feedback during the dispense was of some symptom relief.
    Thanks again for your feedback, I will keep you updated if anything interesting pops up.

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