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Help with forefoot pain in patient

Discussion in 'Biomechanics, Sports and Foot orthoses' started by muretti, Jan 4, 2007.

  1. muretti

    muretti Welcome New Poster

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    Dear collegues,This is the first time I'm loggig into this forum. I'm a young Italian podiatrist who's starting to learn about biomechanics. Unfortunately, this techinique is not very common in Italy, so i hope to find someone amongst you who can give me some advice.
    I will submit to you the case of one of my patients in the hopes that someone help me.
    My patient is a woman aged 60 of medium weight. She has a pèain in her forefoot during the prpulsion phase.Here's a short summary of her medical history: she had a lot of pain in her metatarsus in 2004-2005 and before this had ruptured her achilles tendon I am attacching an interesting x-ray regarding the structure of my patient's tslus bone.
    If someone could be so kind as suggest what type of soles would best work for this pathology I would be most grateful.
    I hope to receive an answer soon

    Cordially yours,
  2. Re: Sorry,we can help me?


    Welcome to Podiatry Arena. Your patient's talus appears normal on these non-weightbearing radiographs. It would be most helpful if you could describe exactly which anatomical structure(s) are most tender or symptomatic on your patient's foot since there are many possible sources of pain in the forefoot. Also, to rule out osseous pathology, dorso-plantar and medial-oblique radiographs of the foot would be most helpful (you have only supplied lateral radiographs). A description of what activities make the pain better or worse, how shoes affect the pain, if the patient has any abnormal medical history, and what treatment has already been tried will also be very important for us to better diagnose and help suggest treatment for your patient.

    Good luck.
  3. Podiatry777

    Podiatry777 Active Member

    Very briefly,

    You are assuming biomechanics are the cause. may I suggest localised study of the area for 1. morton's neuroma ( I often find Large forefoot varus-rubbing of metatarsals from foot slap). 2. fatty pad deterioration (poor shoe cushioning) 3. freiberg's fracture 4. Sesamoiditis 5. Hallux Limitus, etc. I would follow Kevin Kirby's advice in careful ordering of X-Rays as he specified. I would only add "take all X-Rays in patient weightbearing position" .
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Podiatry 777

    A few questions and points:

    * Isn't the pathophysiology of Morton's neuroma biomechanical?
    * Forefoot varus is very *rare*, and is not specifically associated with neuroma development as far as I know.
    * The common digital nerve/Mortons neuroma sits plantar and distal to the metatarsals - so "rubbing" has no anatomical basis
    * Is fat pad deterioration really associated with poor shoe cushioning?
    * Frieberg's "infarction" - no "fracture" - two very different types of pathology

    Welcome to the politically correct and evidence-based world of Podiatry Arena ;)

  5. Podiatry777

    Podiatry777 Active Member


    Right, lets be more accurate. I rushed to hand out pointers in this one, and rightfully you commented.

    * Yes, I'm incorrect to star one.
    * If I place a foot in neutral non weight bearing and ensure 1st MPJ has not dropped but follows other met heads- i CALL THIS f.fOOT VARUS and see heaps of it. My personal observations are M. neuroma if often present in such cases and when I'm old I'll do the study:)
    * I'll have to get the anatomy books out, but my old perception was foot nerves run between metatarsal bones and even though they may be plantar, a forefoot anomally causes the drop of these bones with each step (huge number over time) and enough forces reactionery or otherwise could force the soft tissues between the 'jarring' bones to rub-ie Friction is the correct term? Stil too many non technical terms, I know.
    Also common in Interdigital spaces 4-5, I'd say forces during gait cycle shift from 5th met area fast to toe off at hallux causing compression of soft tissue in question Interdigitally.
    There could be some forward forces in this case also. I think we need a live gait analysis with an ultrasound on this one- maybe a neonatal ultrasound type probe used to screen on the feet in motionlooking for live tissue movements? I think grab this idea and run, as someone will pinch it soon enough, hence I made the 1st prediction, perhaps??
    * Unless fat pad shifts forward all that repetitive trauma could deteriorate the fat pad-Hypothesis? Perhaps one of possible causes.
    * I'm incorrect again on the last point, thus point taken:)

    Thanks Again.
  6. DaVinci

    DaVinci Well-Known Member

    Forefoot varus is rare. I assume you mean forefoot supinatus.
  7. Atlas

    Atlas Well-Known Member

    Ciao bella.

    Tu fortunato, perche questa femina fa male e propulsion.

    Che gira fa male?

    Mi dispiace molto. Non scrit e parle italiano bene.

    With basic biomechanical knowlege, we should be cautious about giving over detailed biomechanical solutions.

    Option A: Stabilise the ankle, and twist the forefoot passively. You might find that twisting the forefoot into supination (with the heel/ankle steady) might bring on the patient's pain. Otherwise try forefoot pronation. The answer to this will guide your next move.

    Option B: Otherwise, you are lucky that this lady does not like propulsion. In your clinic room get her to tip toe. This should be uncomfortable for her. If so, you can then try several interventions to change this test. One possible intervention may be taping the forefoot to increase the (antiquated) transverse arch. Then with the tape on, get her to tip toe again. If it is better then you have found the starting line.


    Last edited: Jan 15, 2007
  8. Paul B

    Paul B Active Member


    Just a few quick tips. 2 of your 3 xrays demonstrate the mid, not FF??
    Soft tissue pathology (a common cause of problems) is best explored using high definiotion ultra sound. this can produce 10-15 good differential Dx.

    identification of Anatomical structure is the key. If you can't do that, all else is speculation.


  9. mahtay2000

    mahtay2000 Banya Bagus Makan Man

    Which part of the forefoot exactly is in pain, is it 2,3,4; 1 and 5; 2 only? This can give you a closer idea of the problem.

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