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Metatarsal pads and metatarsalgia

Discussion in 'General Issues and Discussion Forum' started by NewsBot, Feb 7, 2007.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

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    Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study.
    Kang JH, Chen MD, Chen SC, Hsi WL.
    BMC Musculoskelet Disord. 2006 Dec 5;7:95.
    Full text
     
  2. Excellent study. Should have been done 10-15 years ago by the podiatry profession, however. Oh well, at least somebody finally gave us some evidence of how metatarsal pads work.
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. John Spina

    John Spina Active Member

    Logically we knew that they worked,we just were not sure of the mechanism.
     
  5. Cameron

    Cameron Well-Known Member

    Netizens

    Still a very small study to draw too many conclusions from, despite overwhelming anidotal evidence to support it. Similar work was published in the Chiropodist (UK) in the early 80s. Work conducted by Ken Robertson (if memory serves) with preliminary work on the pedobaragraph He compared position of met pads and peak pressure and found the positon of the metatarsal pad on the foot had significant little bearing on the peak pressures recorded. All appeared to reduce peak pressures but no attempt was made to record pain as his subjects were all normals. Over the last two decades there has been work done by physical therapists and physiotherapists relating to metatarsal pads and their effects. Some studies were pretty dubious but others rather interesting with one examining the effects of water content in callus.

    It would seem prudent to accept pressure alone would not account for metatarsalgia but likely to contribute as a variable.

    What say you?

    Cameron
     
  6. Scorpio622

    Scorpio622 Active Member

    Along this topic...I've often wondered about the effects of mortons neuroma pads. I was taught in school to place the apex of this small dome pad (they are smaller than metatarsal pads) between the metatarsal necks of the affected interspace- with the hope of spreading the metatarsals having a reverse Mulders effect. I doubt this happens, and any positive effect is probably from the mechanisms discussed in this paper. Any thoughts??? Is it widely believed that a neuroma pad is designed to separate metatarsals???

    Nick
     
  7. It seems reasonable to assume that a metatarsal pad or "neuroma pad" if placed correctly may tend to cause a small separation of the metatarsals that may, in turn, cause a reduction in compression force on the neuroma. However, I tell my patients that this will only work if their shoes are loose enough in the forefoot to allow the metatarsals to spread apart. I use small metatarsal pads routinely in patients with neuromas, mostly with good success, and I place them so that their apex is at the level of the metatarsal neck, +/- a few mm distal or proximal depending on perceived patient comfort. I feel the metatarsal pads work much better if placed on or within a custom foot orthosis for treatment of neuromas.
     
  8. Cameron

    Cameron Well-Known Member

    Netizens

    As I understand the etiology of neuroma, there appears to be compression and stretching of the nerve fibres which are cited as co-requisites. The idea metatarsal heads rubbing together is unlikely and physically separating them with soft padding on the sole of the foot, improbable. But I do share Kevin's experience with the benefit of stratigically placed pads. I always thought the critical increased bulk over the lateral aspect of the fourth met shaft may in some way reduce peak pressure as the foot goes into propulsion. This may 'rest the nerve', and break the pain cycle. I have also used silicone props to similar effect.

    Cameron
     
  9. This is quite an interesting concept and one that I have not given much recent thought to. Mechanical modelling of the effects of the metatarsal pad would show, as in the study listed above, that GRF for the forefoot has not only been shifted more posteriorly towards the distal 3rd and 4th metatarsal shafts but also has been redirected away from the 3rd and 4th metatarsal heads. Another critical part of this modelling would be that the more narrow shape of the metatarsal necks versus the metatarsal heads would cause the intermetatarsal distance to be much greater at the metatarsal neck level than at the metatarsal head level.

    Now, if a fairly pinpoint GRF (e.g. from a metatarsal pad) focuses a substantial plantar force more between the metatarsal necks rather than directly plantar to the metatarsal heads, there would be an increase in 4th metatarsal abduction moment (relative to the 3rd metatarsal) especially at late midstance and early propulsion. This increased magnitude of 4th ray abduction moment would tend to increase the distance between the 3rd and 4th metatarsals and would also probably significantly reduce the magnitude of pressure on the intermetatarsal nerve during late midstance and early propulsion.

    The mechanism here is similar to the mechanism that occurs when a splitting wedge/maul is swung onto the end of a round of wood Macho Man Splitting Wood. A relatively concentrated, pinpoint force between the grain of the piece of wood will easily split most wood rounds. A given kinetic energy, E, applied with a correctly shaped splitting maul into the wood grain on the round would result in the round being easily split. However, the same applied energy, E, from a blunt sledge-hammer, would distribute the weight to compress the multiple grains of wood on end which would only compress the wood face and would cause a dent to be formed in the end of the round from the impact.

    It seems quite likely that a metatarsal pad not only significantly increases the 4th ray abduction moment relative to the 3rd metatarsal and significantly decreases the pressure on the intermetatarsal nerve, but also slightly separates the metatarsal necks due to increased 4th ray abduction moment that causes increased tensile force on the deep transverse ligament (and other intermetatarsal soft tissue structures). This "splitting wedge" effect would be most prominent during late midstance and early propulsion when the GRF plantar to the forefoot is of the greatest magnitude.
     
  10. Cameron

    Cameron Well-Known Member

    Kevin

    I would concur the most likely explanation does involve change in direction of GRFs but could be less sceptical if a rigid shaft was used (as in shoe modification). I am amazed all the more because of the very low resistance to compression within foams and felt and that these would offer sufficient lever to change in direction of GRFs. If indeed this is so then it may be even a short experience (matter of hours) can have long term effects.

    Obviously conditons apply

    Cheers
    Cameron
     
  11. pretschko

    pretschko Member

    Dear All,
    I have issue with the very low density of MP's used by many pods - there is no mention of the density of the polyurethane pads used in the afore-quoted study.
    I have had some success with 'hapad' products as they can be half adhered and moved to ensure the most accurate placement after trial.
    Has any attention been paid to MP densities?
    Regards PR
     
  12. Cameron

    Cameron Well-Known Member

    pretschko

    >Has any attention been paid to MP densities?

    To the best of my knowledge MP are usually made of standard (medium) density foams /polyurethans or semi compressed, as in felts. Orthotists will often dent the foot plate of BKFO to give the equivolent effect of a hard density MP. I am not aware of any evaluations to review the efficacy of the traditional modification.

    Cameron
     
  13. LuckyLisfranc

    LuckyLisfranc Well-Known Member

     
  14. Dantastic

    Dantastic Active Member

    Not long ago I was experiencing intermetatarsal pain between 3-4 on my left foot. I found the greatest relief when walking would be to flex my toes - as if trying to grab something with my foot. I also found that in stance, a met pad would provide most relief when placed directly under the metatarsal heads. HOWEVER, this would be most uncomfortable during the propulsive phase of walking.

    I also found that by placing a met pad too far proximally, it would irritate the tight plantar fascia, resulting in aching pain as well as the sharp intermetatarsal pain.
     
  15. LL:

    I use the same process as you do and have made the same observations regarding patient comfort. For placement of metatarsal pads on foot orthoses, I generally have the lab add the metatarsal pad to the device so that metatarsal pad protrudes 15 mm distal to the anterior edge of the orthosis. Over the years this has worked out very well for my patients as a good standard location of metatarsal pad placement on their orthoses.
     
  16. Richard Chasen

    Richard Chasen Active Member

    Hi Paul,

    As far as I've observed, there is no uniformity amongst the pod community regarding the types of pads used (or, for that matter Cameron, amongst orthotists using them via cast modifications, since I've never done them that way and many of my colleagues are the same) as it usually depends on whether the individual pod is actually manufacturing the orthoses themselves and if so, where they buy their pads.

    I have noticed frequent differences in placement position however, with a great many pods locating the apex beneath the MTPJs as they would do for a felt PMP that's adhered to the foot, rather than more proximally to load the shafts and decrease pressure on the met heads.

    Been a while.

    Rich
     
  17. Richard Chasen

    Richard Chasen Active Member

    PS, again, that was a generalisation, as amongst the pods I know who manufacture their own orthoses, there is comparatively little uniformity.
     
  18. Richard Chasen

    Richard Chasen Active Member

    LL, just reading your post, I find the best area of placement to be when the apex is immediately proximal to the heads. I usually warn patients that this will feel too far back initially, but anything more distal will actually increase pressure beneath the MTPJs as the foot heads towards toe off, not doing the neuroma any favours. If it's blended into the device adequately at the posterior section, it shouldn't cause too much irritation to the plantar fascia slips
     
  19. For what it's worth i usually place mine with the leading edge across the middle of the met heads (ie under half the wb area). I tend to find this works better with soft pads than having them more proximal. I also find they work much better on a casted device than on their own.

    Robert
     
  20. Richard Chasen

    Richard Chasen Active Member

    Robert, it sounds like we're doing the same thing. I think the main difference is whether the devices are made from a cast or a direct mould, such as one of those rubber footboards.

    Richard
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effect of metatarsal pad placement on plantar pressure in people with diabetes mellitus and peripheral neuropathy.
    Hastings MK, Mueller MJ, Pilgram TK, Lott DJ, Commean PK, Johnson JE.
    Foot Ankle Int. 2007 Jan;28(1):84-8
     
  22. NewsBot

    NewsBot The Admin that posts the news.

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    Clinical Biomechanics (Articles in Press)
     
  23. scfitzner

    scfitzner Member

    Wow, my lab doesn't place them even close to this. I appreciate your insight and sharing this. I will have to give this a try.
    Does anyone find there are times when they have more success with a metatarsal bar?
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effect of a Metatarsal Pad on the Forefoot During Gait
    Koen L. M. Koenraadt, Niki M. Stolwijk, Dorine van den Wildenberg, Jaak Duysens, Noël L. W. Keijsers
    JAPMA January/February 2012 vol. 102 no. 1 18-24

     
  25. NewsBot

    NewsBot The Admin that posts the news.

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    Pei Y Lee, Karl B Landorf, Daniel R Bonanno and Hylton B Menz
    Journal of Foot and Ankle Research 2014, 7:18 doi:10.1186/1757-1146-7-18
     
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    NewsBot The Admin that posts the news.

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    Effect of the application of a metatarsal bar on pressure in the metatarsal bones of the foot
    Se Won Yoon
    Journal of Physical Therapy Science
    Vol. 27 (2015) No. 7 July p. 2143-2146

     
  27. NewsBot

    NewsBot The Admin that posts the news.

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    Changes in Plantar Pressure Distribution in Response to Different Metatarsal Pad Designs and Placements during Walking - a Dynamic Finite Element Analysis
    Chih-Kuang Chen et al
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  28. NewsBot

    NewsBot The Admin that posts the news.

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    The Effects of Metatarsal Pad on Plantar Pressure of the Forefoot in Individuals
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    Mohammad Jafarpisheh et al
    source
     
  29. NewsBot

    NewsBot The Admin that posts the news.

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    The effect of foot orthoses with forefoot cushioning or metatarsal pad on forefoot peak plantar pressure in running
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  30. NewsBot

    NewsBot The Admin that posts the news.

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    Effects of Metatarsal Pad length on Plantar Pressure and pressure time integral in diabetic foot
    Mohammad Taghipourdarzinaghibi, Ebrahim Abdi & Mansour Eslami
    Endocrine Abstracts (2016) 43 OC26 | DOI:10.1530/endoabs.43.OC26
     
  31. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    NewsBot The Admin that posts the news.

    Articles:
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    The Effect of Metatarsal Padding on Pain and Functional Ability in Metatarsalgia
    K. Männikkö, J. Sahlman
    Scandinavian Journal of Surgery March 1, 2017
     
  33. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Forefoot relief with shoe inserts : Effects of different construction strategies
    Baur H et al
    Z Rheumatol. 2017 Jul 7. doi: 10.1007/s00393-017-0347-8
     
  34. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Effect of Metatarsal Padding on Pain and Functional Ability in Metatarsalgia.
    Männikkö K, Sahlman J.
    Scand J Surg. 2017 Mar 1:1457496916683090. doi: 10.1177/1457496916683090.
     
  35. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    The Influence of Insole
    with Metatarsal Retro-Capital on Posture,
    Plantar Pressure and Body Segments Positions
    in Runners.

    Vermand, S., Duc,
    S., Janin, M., Ferrari, F.-J., Vermand, M.
    and Joly, P.
    International Journal of Clinical Medicine, 10, 326-335.
     
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