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Orthotics Prescription Help - pain under central met heads

Discussion in 'Biomechanics, Sports and Foot orthoses' started by zenjudo, Sep 1, 2011.

  1. zenjudo

    zenjudo Active Member

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    Hi guys,

    I'm prescribing orthotics for this lady who has chronic sore ball of feet. She's had bad experience with wearing orthotics before (unfortunately she threw them out so I'm not sure about previous prescription), she is also having trouble with L anterior knee pain, and L hip pain + clicking, core instability, and lower back pain.

    Her main issue is pain under 2-4 metatarsal heads after prolonged use of feet. She's a keen tramper but always get sore from midpoint of the tramp and find it frustrating.

    She has had met dome put on shoe insole but it actually hurt the ball of feet more, and toe prop made for her rigid mallet lesser toes that actually made the pain worse as well.

    I'm prescribing new orthotics for her and given she's a bit of complex case, I came here to get some confirmation/help.

    Below is my clinical findings:
    Non WB:
    - short 1st ray, slight hypermobile
    - collapsed metatarsal arch (callous under 2nd-4th met heads)
    - moderate bunion defomity on L. neutral on R
    - Callous plantar-medial L hallux IPJ (none on the R)
    - slight plantarflexed forefoot to rearfoot
    - whole body hypermobile
    - normal subtalar joint axis
    - weaker L leg overall.
    - tight gastroc-soleus complex on both, L slightly tighter

    - flexible cavus foot (high medial and lateral arches that collapsed a little upon weight bearing)
    - mild genu valgum, L more
    - large Q angle
    - easy supination resistance test on both
    - normal easy windlass
    - arch height did not change at all during small knee bend

    - abductory twist on both
    - R more abducted angle of gait
    - late stance pronation

    Proposed Orthotics prescription:
    - low density polypropylene with reinforcement
    - metatarsal dome/pad/cookie (or whatever you want to call it).
    - neutral rearfoot post/stabilizer
    - plantar cover with 2nd-4th cut-out
    - slight heel lift
    - medial and lateral arch pad
    - morton's extension

    My concern is:
    - given she's had trouble with met dome before, is she likely to tolerate this time?
    - should I try to correct late stance pronation with morton's pad or forefoot varus pad at all? or correct it much early on using rearfoot varus posting.

    Any help or advice or guidance are much appreciated.

  2. Griff

    Griff Moderator

  3. efuller

    efuller MVP

    On non weight bearing, when you attempt to dorsiflex the forefoot on the rearfoot, how much range of motion is there? I'm not sure if others mean the same thing as I do when I say flexible cavus. There are some fairly rare feet that have a significant amount of range of motion in the sagittal plane and they tend to "rest" with the forefoot plantar flexed on the rearfoot. These folks appear to plantar flex their forefoot in swing phase of gait and when the forefoot finally loads the forefoot will dorsiflex to a normal arch height. I believe they get metatarsal pain because the forefoot has to slide on the inside of the shoe to dorsiflex. Casting these people non weight bearing is a problem because you will create a much higher arched device than they will tolerate.

    Of course, ignore this your observation of flexible cavus is different than I described.

    A rigid cavus does well with a device that increases load in the mid foot. A rigid cavus may have a wet foot print that does not show any load under the styloid. So, increasing the load in the midfoot will reduce the load on the metatarsals. I have described two different types of cavus feet, one will want a higher arch than you would expect and one will want a lower arch than you might expect. I can't tell from your description which one it is.

  4. RobinP

    RobinP Well-Known Member

    The thread to which Ian has put a link is quite valuable. Well, as the OP, it was to me

    I would, however, pick up on one thing that you mentioned which may be important. Although you assessed there to be a normal sub talar joint axis, the easy supination resistance and normal easy windlass might be suggesting some lat deviation of the STJ axis in gait and the late stance phase pronation may be to reduce lateral instability at this point in the gait cycle.

    That is, that the patient is "actively pronating" to avoid lateral instability. The resulting abductory twist can greatly increase friction in the 2nd MPJ and subsequent pain. The dorsiflexion of the medial column as a result of the pronation may also increase the load on the 2nd MPJ.

    I'm sure Eric will have much more succinct comment upon this than I but I find managing 2nd MPJ pain in people like this really tricky as there are many factors to consider.

    Pt pronates = arch support and medial wedge is not always the way when other factors are involved such as "active pronation"

    Tricky one

  5. zenjudo

    zenjudo Active Member

    Hi Robin,

    Ya, it is a tricky one innit?

    That's why I want to see what everyone thinks before I secure the orthotic prescription.

    Like you suggested, I also suspect she has a slight lateral deviation of the STJ axis and she had easy supination resistance test and good windlass.

    I think what's contributed to the late pronation was the short and dorsiflexed 1st ray, I think I'll use a stiffer morton pad to take up the ligament laxity to offload the lesser MTPJs.

    This lady did have slight flexible cavus foot - slight plantarflexed forefoot could be dorsiflexed somewhat over the rearfoot.

    Thanks for all the input.


  6. Lorcan

    Lorcan Active Member


    Does this lady have a forefoot varus or forefoot valgus perhaps due to plantarflexed
    1st ray? If she has a forefoot valgus I would be sure to post/wedge this possible by more than she presents with, I find this can help. You could try this with some
    7mm semicompressed felt on her foot first.

  7. mgrig

    mgrig Active Member

    Maybe not throw the kitchen sink at it straight away? A lot of the variables can be added after an initial trial and error of a more simple device. It might make for better compliance, comfort and fit a greater variety of shoes. It will also provide an feedback as to which are most effective variables for this particular case.

    I would look at the location of the previous met pad...perhaps too far distal? or too dense or thick?

    Could this pt have a FnHL? or Decreased dorsiflexion stiffness of the 1st ray? in which case, i would question the mortons ext...maybe a cluffy wedge instead?
  8. PodAus

    PodAus Active Member

    Any diagnostics / imaging?

    What's the diagnosis???

    Good idea prior to formulation of treatment protocol
  9. davidh

    davidh Podiatry Arena Veteran

    I go along with this.

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