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Idiopathic 1st MPJ Joint Dislocation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by stacer, Jan 13, 2011.

  1. stacer

    stacer Member


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    A 19 year old female patient presented at my clinic recently complaining of frequent episodes of 'dislocation' of the 1st MPJ which were painful and accompanied by bruising around the joint and across the dorsum of the foot. Although she was able to manipulate the joint back into position it would soon dislocate again and this would continue for several days until the episode would spontaneously resolve before recurring some weeks or months later.

    On examination, the joint was considerably enlarged typical in appearance of the arthritic joint in an older patient. The joint appeared correctly aligned but with minimal movement available in the saggital plane. The foot had been subject to a crush injury some 15 months ago and it might seem reasonable to assume that the problem resulted from this. However, the patient describes a history of hypermobility which had required Z Plasty surgery to correct frequent dislocation of the knee joint some years previously. There was nothing remarkable in the degree of motion in any of her lower limb joints and as I have said, the joint in question has only limited motion available. Weight bearing, both forefoot and rearfoot of the affected foot are in a varus position which I assume is a pain avoidance strategy.

    The patient is not keen on pursuing the surgical route so I am interested in any suggestions for an orthotic solution which might help to stabilise the 1st MPJ. At this stage I have provided a temporary orthotic with lateral R/F posting to bring the medial aspect of the foot into ground contact. Any suggestions would be very much appreciated.

    The patient
     
  2. RobinP

    RobinP Well-Known Member

    Re: Ideopathic Joint Dislocation

    If the foot is in varus, as a pain avoidance stategy, why are you trying to increase contact on the medial aspect of the foot - will this not increase the pain?

    It might be an idea to look at this thread on presenting patients for advice as it gives you a better chance of good responses when we are in possession of as much information as is available
    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144

    On the information given, sounds like you need to offload the 1st metatarsal head as much as possible - ie increase the surface area of contact everywhere but the 1st MPJ.

    Look forward to hearing back from you

    Robin
     
  3. efuller

    efuller MVP

    Re: Ideopathic Joint Dislocation

    In which direction does it dislocate? What causes it to dislocate? More info
     
  4. stacer

    stacer Member

    Hi Robin,
    Many thanks for you reply. At the time of my examination the patient was painfree, I suspect that the adoption of a varus attitude had become habitual following previous painful episodes. She was able to cope with the lateral posting on the insole and did not experience any discomfort. My objective at this early stage was to restore the foot to a more stable configuration. I take your point about offloading the 1st MPJ and will incorporate this at her next visit.

    Regards

    Richard
     
  5. stacer

    stacer Member

    For efuller,

    Many thanks for your interest - at the time of my examination the joint was in a normal position but the patient stated that it always dislocates in a lateral direction. She was unable to associate any particular activity etc with the episodes of dislocation.

    Regards

    Richard
     
  6. RobinP

    RobinP Well-Known Member

    Ah OK i get the picture a little more now. When the 1st MPJ"subluxes", it is painful but in times where there has been no acute episodes, the patient is pain free?

    I would be careful about determining what the stable configuration is (assuming that such a position exists - which it probably doesn't) if you do not know what the foot position was pre "episodes of subluxation".

    Is the sub talar joint axis laterally deviated - that should give you an idea of whether the varus position is pre existing

    My guess would be that you are going to have to try and accommodate a (presumably) plantarflexed 1st ray alignment and limit the 1st met head loading then base your success on whether ir not the frequency of the episodes decreases. Possibly don't worry about reducing the supinated foot alignment as it might be erroneous. That is assuming that the subluxation is more likely to happen in a weight bearing environment....which it might not be at all.

    So to conclude.....it depends.

    I'll be interested to know what you find when you see the patient again
     
  7. efuller

    efuller MVP

    Toe goes lateral or metatarsal goes lateral?
     
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