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Help with patient with forefoot pain

Discussion in 'General Issues and Discussion Forum' started by Mathew Vaughan, Feb 16, 2009.

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    First post so please go easy on me if I haven’t set info out correctly.

    55 year old male attended my clinic complaining of pain of 5 weeks duration in ball of foot, he had fallen and hyper extended his left 2-4 toes and now was experiencing pain when walking. The patient has a slow growing terminal brain tumour which affects his balance.

    Clinical assessment revealed tenderness at the plantar aspect of Left 2-4 Met heads, and on palpation of left 2-4 metatarsals. Left 3rd toe was swollen and seemed fixed at the proximal IPJ. His foot was tender but there was not any areas which when palpated caused significant pain.

    I issued the patient a very simply 2mm EVA insoles with valgus pad extended distally into a 2-4 met bar to deflect pressure from painful areas, recommended icing and NSAIDs. I did not want to issue anything too complicated as to further alter his balance. I recommended that the patient have an x-ray to see if there were any fractures.

    The patient has now called after a week and said that the insoles really helped but he has fallen again and damaged the toes again and is concerned that the insoles are not working so well.

    The patient has very mobile/ loose feet, although he does not show overall body hyper mobility and I was wondering if I should consider issuing some prescription orthoses to control his foot motion and toaid his balance or would this be contraindicated. The patient has a relatively normal foot profile (no pes planus or cavus).

    Mathew Vaughan
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: 1st Post


    Welcome to Podiatry Arena.

    My advice to you is simple. Establish a diagnosis.

    Once you know what the problem is, then treatment is usually relatively easy. Dont jump into prescribing orthotics and insoles until you know what it is that you are treating.

    At this time, we know your patient has apparently suffered an acute trauma to the forefoot, possibly affecting the lesser MTP joints and toes. We know some areas in particular are tender to palpation. We know he has a tumour which is affecting his vestibular system.

    It is helpful then to establish if cutaneus, vascular and neurological structures are normal, before moving to orthopaedic assessment. If there is a CNS deficit, it would be useful to know if there is any loss of motor or sensory status in the foot.

    Most acute foot and ankle injuries respond well to immobilisation (eg walking brace/ CAM walker, taping) in the immediate phase, whilst awaiting the outcomes of initial investigations (ie x-ray to exclude #). This provides comfort and reduces additional tissue stress, along with buying some time.

    It is possible your patient may have done an acute soft tissue injury such as a plantar plate tear or attenuation, which may be difficult to assess clinically whilst tissues are acutely inflamed.

    Perhaps providing the outcome of the initial x-ray and posting the films would be useful to us.

    Kind regards,

  3. Peter

    Peter Well-Known Member

    Re: 1st Post


    LL is right on the money, and esp with respect to plantar plate pathology. If you want to keep it simple to begin with, recommend to your pt a stiff soled laced shoe with a good toe-spring eg a walking boot from an outdoor pursuits shop/Reebok Classics.
  4. Re: 1st Post

    Firstly a warm welcome and a hearty well done for taking the plunge. In the Words of Old Ben Kenobi "you have taken your first steps towards a larger world".

    I would concur with my colleagues summation. You need to know exactly what the problem is to treat optimally.


    This can be hard to do depending on the condition / location / experience of the clinician. And confidently stating "it is thus" does not make it so.

    There are the obvious "usual suspects" you should exclude by clinical test or imaging (stress #, etc). If you hit lucky here then that will inform your treatment.

    If, however, there is no obvious diagnosis, there is some value to treating palliatively and even sometimes diagnostically (always IMO).

    The following is based only on the information at hand (IE no definitive diagnosis).

    You have told us your patient has balance issues. This would lead me to use a full contact casted device (little or no arch fill, cast perhaps a little below neutral to avoid arch irritation) to increase the weight bearing area of the foot and thus increase the total exteroceptive data available to the CNS. I might also make this insole with a higher heel cup and flanges than usual to provide transverse plane feedback also. Much would depend on the nature of the brain damage. If the patient has poor balance because of poor proprioceptive feedback improving exteroceptive feedback might help...

    For the painful area, again barring a clear DX, i would seek to offload impulse (time * Pressure). A device with a pre met rocker would decrease forefoot load time. A pre met dome might elevate 234 met by applying pressure proximal to the met heads. A cavity pad with a soft plug would reduce peak pressure under the bony areas.

    Hope this helps.

  5. Graham

    Graham RIP

    Using 2-4 silicone toe prop/splint will often relieve pain in the toes in these acute cases. Gives the toes something to grip without moving the ipjs

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