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Hi Everyone,

This is a patient I'm presenting for assessment, I thought I had worked everything out till I took some weight bearing pics on a podoscope.

This patient is a 39 year old male tennis player with bilateral achilles tendinosis, plantar fasciosis and RPMA2 capsualitis.

Biomechanical assessment shows STJ and MTJ are WNL, AJ equinus at 0deg knee ext and 5deg knee flexed. Jacks test positive, high supiation resistance, genu valgum, 1st MPJ 65deg bilaterally, no LLD, FF-RF neutral with neutral 1st ray position.

All this said, his right 1st ray and hallux do not WB when in STJ neutral. With his above biomechanical results I do not understand why this is.

My guess was a navicular-cuneiform coalition which raises the first ray with STJ is forced into NCSP.

Any Suggestions is much appreciated as I will definately be quizzed on this :)

Thanks
Bec

 

Possibly he has a degree of forefoot supinatus with midfoot pronation.
There fore when put in to STJ neutral, the forefoot is in a varus position. If flexible, the 1st ray should be able to be passively planterflexed to the ground.

By the way what is RPMA2?

 

or rearfoot varus?

 

There are few reasons why the first MPJ won't bear much weight. As already mentioned, a rearfoot varus foot (or a forefoot varus) can run out of range of motion before the medial forefoot bears significant weight. Do a Coleman block test to see if there is more eversion of the rearfoot available.

Another reason is that a foot with a more laterally positioned STJ axis may need very little pressure under the medial forefoot to put the center of pressure under the axis so the foot is balanced there. This foot will usually have an easy Jack's test (in stance the examiner's attemmpt to dorsiflex the patient's hallux will have little resistance.) However, you do need to watch for contraction of the peroneal and posterior tibial muscles when you do this, because the test may cause balance issues that the patient will respond to. I'm not sure what you mean by a positive Jack's test.

Another reason you may see that pressure distribution is a painful area sub 1st met head. The patient would contract their posterior tibial muscle constantly to decrease force sub 1. I can't see the tendon in the pictures, so this seems unlikely.

Regards,

Eric Fuller

 

If your clinical examination leads you to a Dx of a tarsal coalition, then the obvious question is "where are the X-rays!"

Steve

 

In the non weight bearing examination is the first ray fixed in dorsiflexion or is it hypermobile?

regards

 

Please define a "hypermobile" first ray.

 

Simon,

More flexible than average, floppy, with little or no resistance.

I came out of the closet and added my surname. Just for you Simon:drinks

Regards

 

That's that sorted then :rolleyes: I already knew your surname.

k =?????????