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Help for patient with base 1st met/cuneiform pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markjohconley, Feb 17, 2006.

  1. markjohconley

    markjohconley Well-Known Member


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    73 female, intermittent stabbing pain r/med/s med cun/1stmet base, 3/12 hx, trauma 10y/a > no tx, x-ray only comment ***1st mpj o/a, with tib post active > elicit pain on palp m/s med cun/nav,..... on active+passive ankle dorsi/eversion elicits stabbing pain m/s med cun/1st met base, no heat no hx of heat, no erythema no hx of, however slight swelling same region...any help appreciated, mark c
     
  2. markjohconley

    markjohconley Well-Known Member

    additional.......no obvious assymmetry (re. abducted forefoot) pain is m/s midfoot not med malleoli
     
  3. markjohconley

    markjohconley Well-Known Member

    additional to the additional...............pt on nsaid's
     
  4. Atlas

    Atlas Well-Known Member

    Have you tried low-dye taping and assessed its plantar-flexory effect on the 1st met?
     
  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Take a good look at the weight-bearing lateral of the foot. This is where you will find your answer, more often than not.

    The predominant cause of 1st MT-cun pain is degenerative joint disease related to chronic medial column instability, and this is particularly the case if there has been a history of Lisfranc joint trauma. A couple of things to look for;

    1. Is there a 'sag' in the medial column? If so, where is this occuring - commonly either at TN, NC or 1st MT-cuneiform. In you patient is it occuring at the latter?

    2. Is there 'gapping' at the 1st MT-cun? By this I mean, is there narrowing of the joint space dorsally with concurrent widening of the joint space plantarly?

    If there is no definitive sign of OA in the joint, she may just have chronic chondromalacia/synovitis from any mechanical instability of the joint, particularly from late midstance to toe-off.

    Trial some taping, if this works she needs to try an orthotic. If this fails, consider a Lapidus fusion.

    LL
     
  6. summer

    summer Active Member

    HAve to agree with Lisfranc. Often times this problem goes undiagnosed or misdiagnosed. If she has a sag of the medial column, it is likely she won't respond to orthotics, and the medial Lisfrancs fusion might be the way to go. I recently had a 70+ year old patient with similar symptoms. The fusion worked beautifully, and she "ditched" the cane in favor of ballroom dancing with her husband. By the way she had been to other practitioners with a bagful of orthotics that she couldn't or wouldn't use.
     
  7. Try this....make a Reverse Morton's Extension modification to the orthotic and make sure there is a V-Wedge cut-out...That's it! Keep it simple works for me. I use this for all my 1st MTp symptomatic patients... works great for sesmoiditis / hallux limitus / rigidus and plantarflexed 1st rays!! Do not try a Morton's extension as I found this raises the 1st ray so there is binding on the dorsal aspect of the 1st MTP.
     
  8. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Footman (repeated)

    In case you werent paying attention to the name of this thread, the problem is base of 1st MT/cun pain, not 1st MTP joint pain...

    I don't know that your suggestion will provide much control over a symptomatic 1st MT/cun jt. :confused:

    If it can, I'd be delighted to hear how.

    LL
     
  9. Atlas

    Atlas Well-Known Member

    Plantarflexing, dorsiflexing or stabilizing the first met does impact on the 1st met/cun joint. For instance, dorsiflexing the first met does increase compressive forces in the dorsal aspect of the 1st met/cun joint.

    My guess was that footman was paying attention.
     
  10. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    ...although his comments seem to all relate to 1st MTPJ facilitation.

    Any orthosis that "splints" or "stabilises" the 1st MT-cun joint will probably help the pain. I would agree that, in the absence of significant hindfoot valgus and medial column breach, there's a chance that a 1st ray cutout (or variation of the same effect), will possibly help - it just depends on the aetiology of this parituclar case (an x-ray would be helpful).

    Then again, stick just about anything short of bubblegum in the shoe and you might get an equivalent result.

    Point taken. :)
     
  11. David Smith

    David Smith Well-Known Member

    Mark

    Do you think there could be Deep peroneal nerve involvement in this case which, may require surgery to resolve.
    ref;
    Dorsal Foot Pain Due to Compression
    of the Deep Peroneal Nerve by Exostosis
    of the Metatarsocuneiform Joint
    Robert G. Parker, DPM*
    Journal of the American Podiatric Medical Association • Vol 95 • No 5 • September/October 2005

    Cheers Dave Smith
     
  12. efuller

    efuller MVP

    cause and effect??

    I'll agree that there is a correlation between 1stMC arthritis and instability of the joint. Which comes first? I'll also concede that this may be related to the history of trauma. However, if the trauma was not the immediate cause then we could approach this from the tissue stress perspective. High load sub 1 creates a dorsiflexion stress on the first ray. The first ray/windlass can have pathology anywhere within the system, including the first met cuneiform joint. This load can cause the faulting. Therefore, any treatment that would decrease the dorsiflexion stress on the first met ray would help both 1st MPJ and 1st MC pathology.

    The old lisfranc injury point is a good one.
     
  13. Freeman

    Freeman Active Member

    Pedorthist view here....If orthotics are helpful/well tolerated and the patient is wearing laced oxfords or athletic shoes, make sure the lacing does NOT cross diagonally over that painful area. I will typically take the lace out. Beginning to relace with the shoe on the foot I will almost always skip the bottom lace holes on an athletic shoe when there is any kind of forefoot/midfoot pain becuse I do not wish for the lace, which is gernerally tied too tight, to act as a hindrance to 1st ray plantarflexion and dorsiflexion. Then I will go vertically up the side of the upper and then go back to diagonal lacing above the painful area. It is quite amazing what simple lacing techniques can do for some of these problems.
    Freeman
     
  14. Lee

    Lee Active Member

    In addition to the previously proposed possible pathologies, have you checked the DP radiograph for a sesamoid in the tendon of tibialis anterior? Could be chondromalacia. I presume your patient's healthy. Might be worth going down the 'further diagnostic investigations' route.
     
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