Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Pain 1st Metatarsophalangeal joint- interesting case

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Simon Spooner, Jan 11, 2010.

  1. Members do not see these Ads. Sign Up.
    Interesting recent case, I'd like to share for our educative pleasure:

    47 year old male with congenital foot deformity (see images- how many abnormalities can you spot?) and limb length discrepancy. The left leg is a good inch shorter and the foot is some 4 shoes sizes smaller and cavoid (he wears shoes that are fitted to his larger foot and hence way too long for his left foot). Despite this he used to compete at triathlon wearing standard footwear without orthotics.

    Some five years ago he was given a wedge shaped heel lift (1.5cm) and shortly after while playing hockey felt and heard a crack in the region of the first metatarsal, since then he has experienced pain, exacerbated by dorsiflexion at his 1st MTPJ.

    He had previously been given 3/4 length EVA orthoses (weightbearing cast) which had not really made any difference to his pain. His formal footwear has a heel lift and forefoot rocker / lift- this helps. However, he wishes to run.

    Pain on palpation of sesamoids and on weightbearing dorsiflexion / tip-toe rise.

    Your thoughts....

    Attached Files:

  2. I not sure if you can start a post with this but...............

    Thats really f...king cool. Amazing.

    I guess the tibial seasamoid is fractured or is it bipartial ? Also the fibular looks subluxed. But can you off load the 1st without crazy pain developing in the area of the 5th and 4th ?

    Do you have a photos of the foot ?

    Can someone run in a Rocker sole ?
  3. Good question- how do you tell the difference between a fracture and a bipartite?

    What's wrong elsewhere?
  5. Is he missing a cuneform as well ? The DP view I count only 2 cuneforms the MO view its a bit hard to confirm but it still looks like only 2 cuneforms. Back to the x-rays for another look. Throw out the texts book and research papers on Biomex for this guy.
  6. 1. Talo-navicular synostosis
    2. Rounded ankle joint shape in frontal plane due to #1
    3. Bipartite medial sesamoid vs sesamoid fracture
    4. 4th and 5th metatarsal anomaly
  7. drsarbes

    drsarbes Well-Known Member

    Hi Simon:
    Thanks for sharing this, what we call a FUF deformity ( I'll let you figure out what that stands for)!!!
    I'd say the ankle remodeling due to lack of STJ motion.
    Any other abnormalities? Hands OK?

  8. Everything else normal. So is the sesamoid fractured or bi-partite? How do you tell?
  9. blinda

    blinda MVP

    I plump for Bipartite sesamoid.

    These have smooth margins, with narrow and distinct regular edges. Whereas, a fractured sesamoid has irregular edges. As has been mentioned before, is this also shown on the contralateral foot?

    However if there is pain i.e. marked tenderness to pressure over the tibial sesamoid, that could indicate fracture....maybe:confused:
    Last edited: Jan 11, 2010
  10. Graham

    Graham RIP

    The medial sesamoid seems to be bipartate as edges appear organised. Could be an old fracture. The sesamoids appear to be displaced laterally. This may put excessive load on the medial sesamoid hence the pain. - Perhaps
  11. Do you have the right foot x-ray. If he has a bi-partite sesamoid on the right side then I would say more likely Bi-partite. If not I´m not sure you can tell. But I guess it does not change your treatment plan that much does it ? Tissue stress wise that Is. What do you have planned Simon ?
  12. I only have x-rays of the left foot as these were taken prior to him coming to me via orthopaedics. I have already made him a set of full length EVA devices (right foot neutral shell) left foot has the following modifications: deep heel cup, first ray cut out, reverse Morton's extension and 10mm lift straight through. I also demonstrated flask strapping (which he seemed to like) and advised NSAIDS. I have also suggested that it may be helpful to buy two pairs of running shoes: one to fit the right foot and one to fit the length of the left foot. Currently the running shoe he wears on his left foot is 4 sizes too big, this means that the design features of the shoe are completely out of place. I dispensed the devices on Saturday (which is when he showed me the x-rays for the first time). So we'll see...

    I don't have static stance photo's but I do have video of walking and running gaits, I'll try to upload these to You-tube if I find the time.
  13. blinda

    blinda MVP

    I`d be very interested to hear how he gets on with the devices you recently issued.

    Whilst I appreciate that your tx plan does not significanlty vary whether its a fracture or bi, which would you say it is and why?

  14. Bel,

    My initial thoughts were that it was a bi-partite, but I'm honestly not sure which is why I put it to the collective wisdom. There are guys and girls here who have looked at far more x-rays than I. The problem is that of duration from the time of the injury- the edges would have remodelled if it was a fracture making it difficult... I guess I'm wondering if a sesamoidectomy might be the way to go?
  15. blinda

    blinda MVP

    Simon, thanks for the reply.


    I cant claim to have had much experience with examining x-rays of bi-partite sesamoids, however I did come across a pt, when i worked for the NHS, who underwent a sesamoidectomy. As a result his FHB was was compromised and his HAV worsened post surgery, and the pain remained unchanged. But as you say, let those who have had dealings with similar cases comment.

  16. Indeed, last resort plan- I'm just trying to think of all the possibilities
  17. Thanks for putting this one up Simon. Pretty intersting. If you had of seen the
    x-rays before would you have changed anything with the treatment plan? or did you get pretty good info from the patient ?

    Would be great to see the films if you get time.
  18. I've uploaded a running gait here: http://www.youtube.com/watch?v=F1yefdofvu4

    It's full speed (sorry) and I've had to convert from .mov to mp4 so the quality has been lost.

    Walking barefoot here: http://www.youtube.com/watch?v=NuL_r-vzlOU

    I'm not sure the x-rays would have changed my treatment plan as I'd elicited good information from the patient during history and physical. But it's always nice to see it- just in case.
  19. He moves pretty well compaired to the picture I had in my mine from the x-rays.

    I was asking about if the xrays would have changed your tx plan more from an interst in the fact that the STJ and MTJ would function completely differently from a ´normal´STJ and MTJ.

    Thanks again Simon.
  20. I'd already performed a physical! These X-rays don't tell us much about movement ;)
  21. Point taken, typing to fast for the brain again............ good to know the reason for the movement different though. Craig should make a smilie with the person slapping it´s forehead and saying duh I could use that now. :D
  22. Absolutely. The patient has been through the system and so was able to describe in simple terms much of what was inside, for example, he told me that he had a "ball and socket" ankle joint.

    Palpation is a wonderful thing -seeing it is even better though.

    Conservatively, I needed to start somewhere.......
    We'll see how he gets on. Anyone had any experience of these kind of feet before?
  23. efuller

    efuller MVP

    The question on the x-rays is almost what's right. It's quite amazing that he does triathlons and wants to run.

    It does make you think. In addition to Kevin's mention of X-ray abnormalities:
    Short first metatarsal
    Thickened cortices of 2nd and third metatrssals.
    Abnormal metatarsal parabola
    Cavus, medial and lateral.

    The video and x-ray really raise some questions:
    Does the talo navicular synostosis limit STJ motion. Normally fusion of the TN joint will limit talo calcaneal motion. The ball and socket ankle could be a result of a lack of talo calcaneal motion. There is a physical exam question.

    What is the frontal plane range of motion of the calcaneus relative to the leg? From the video of running there is very little frontal plane motion. Is this because there is little frontal plane motion in the ball and socket ankle and the STJ combined or do the muscles stabilize the frontal plane position of the heel?

    Finally, where are the calluses? If this guy is running, at 47, with that amount of cavus, with that metatarsal parabola, there has to be callus somewhere on the left foot. Is the first ray plantar flexed enough to compensate for its relative shortness.

    Most of the above is academic. If the pain occurs at the sesamoids with hallux dorsiflexion, then treat that regardless of what the x-ray looks like. Although putting some pressure under the arch to decrease the pressure under the 1st MPJ is something that can be learned from the x-ray. So reduce the force going through the first ray. From your description of the orhtotic that you dispensed, it sounds like this is what you are doing.

  24. Simon:

    Great case. Thanks for sharing with everyone.:drinks

    This individual has a "ball-and-socket" ankle joint probably because he never possessed normal subtalar joint motion at any time within his lifetime due to his talo-navicular synostosis. I have seen a few of these patients over the years and seeing this shape of the ankle mortice on the frontal plane always reminds me of the great potential for bone and joint remodelling that may occur over time during the younger years of an individual when abnormal forces and moments are placed across the joints of the foot and lower extremity.

    External rearfoot inversion-eversion moments, that occur during every weightbearing activity that we perform, never produced significant eversion of the calcaneus on the talus in this individual once his talo-navicular synostosis ossified. As a result of this lack of normal subtalar joint motion, the necessary frontal plane rearfoot motion had to occur at the only other joint that would allow frontal plane motion of the calcaneus relative to the tibia in response to the external rearfoot inversion-eversion moments: the ankle joint. As a result, this individual has now developed permanent rounding of the normally angular planes of the ankle joint mortice due to abnormal magnitudes of eversion-inversion moments that occurred with every step at the ankle joint during this individual's life .

    This a very graphic example of Wolff's Law.

    Maybe those individuals who think we should not treat children's flatfoot deformity with foot orthoses could learn an important lesson from this case as to how powerful bone remodelling can be when growing bones are subjected to abnormal internal forces and moments during normal weightbearing activities.
  25. Eric, thanks for your response, the STJ mobility was restricted, however this was clearly compensated by the increased frontal plane ankle mobility- resulting in a rearfoot complex that was actually highly mobile non-weightbearing. I didn't take goniometric measures so cannot tell you in degrees what they were exactly.
    Very slight callus sub 5th MTPJ- remember he hasn't done much running in the last 5 years.

    P.S. nobody has mentioned the accessory ossicles yet clear in the top image so I'll add that to the list!
  26. efuller

    efuller MVP

    I remember this explanation very vividly from my instructors in podiatry college. However, it is a story that I have never looked for a reference for. I certainly don't have a better story, but this is one where I would love to have someone followed from birth with limited range of motion to see if the ball and socket. So, take the story with a small grain of salt.

  27. Agreed, we do not know whether the ball and socket ankle and talo-navicuar synostosis were both congenital or if the ball and socket developed as a result of the synostosis.

    BTW what's the consensus on that sesamoid- bipartite or fracture?
  28. Simon and Eric:

    We don't know a lot of things in this world of ours.

    What would be the best explanation for the "ball and socket ankle" which is quite rare and only seems to occur, in my experience, when there is a congenital tarsal coalition that limits subtalar joint range of motion? Do you truly think it is likely that this ball and socket ankle is a congenital occurrence and that this somehow caused a tarsal coalition? Certainly, the theoretical explanation that I proposed earlier makes very good mechanical sense to me. However, I am open to any better theoretical explanations as to why Simon's patient just happened to have not only a talonavicular synostosis but also a very rare shape to his ankle joint mortice.

    Has anyone ever seen this "ball and socket" shape of the ankle in anyone that did not have a preexisting tarsal coalition?
  29. Easy, Tiger. I was just philosophising.;)
  30. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    No. I concur, it seems to only occur due to tarsal coaltion or iatrogenic fusion.

    Probably seen about a dozen or so over the years.

  31. So do I. Out of interest: how many of the cases you have seen also had the conjoined 4th / 5th metatarsals as in this case?
  32. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Probably none from memory.

    I can only remember one foot that had a tarsal coalition and some form of brachymetatarsia...but was too juvenile to have had adaptive change at the ankle joint by then.

    Good case...might use it in my radiology lectures!

  33. efuller

    efuller MVP

    Hi Kevin,

    That JBJS article is along the lines of what I was asking for. Point taken. However, many valuable neurons are used up memorizing "facts" that are based on conjecture. For example the STJ is more stable in neutrual position. Yes, students should think about ball and socket ankle when they see a synostosis. However, once you got the problem, from a congenital cause, knowing the cause doesn't help you much in treatment. Thanks for taking the time to look up the articles.

  34. bob

    bob Active Member

    OK, there's a lot going on with this foot, but your patient's complaining of pain at the plantar aspect of the 1st MTPJ. Looking at the x-rays, the patient does have signs of a bipartite medial sesamoid, but I also think they may have a fracture of the proximal section of this bipartite bone. Looking on the DP, you can see the well defined, rounded cortical margins of the two sections of the sesamoid - at the most medial and distal section there is a sclerosed area which is unclear. If you look at the same area on your oblique there appears to be a fracture line. Now, this could be an x-ray artifact so my next step would be a CT scan. If you don't have access to this or don't agree, you could try an injection to the area to see if it settles the pain. Before doing this, I'd be interested to know how recently the trauma occured to the area and whether you've had them non-weightbear or immobilised the joint? Like I said though, I'd get a CT and chat to my radiology department about it.

    Local pathology for LOCAL people!
  35. Thanks Bob. The injury occurred 5 years ago. He first attended my clinic approx 1 month ago.
  36. bob

    bob Active Member

    It'd be a bit unusual to wait 5 years if the pain was down to a fracture, so I'd go with imaging first. Have a chat to your local radiology unit about it and take it from there.

    How long have you had them in orthoses? Have they responded to any treatment so far? I think Belinda mentioned that there is a risk of hallux valgus following excision of the sesamoid and I would agree with this, so it's definately worth trying everything else and coming up with a firm diagnosis prior to offering this.
  37. bob

    bob Active Member

    Sorry Simon,
    I just re-read my original reply. Where I said the most 'medial and distal section' I was referring to the proximal part of the bipartite tibial sesamoid. Also, this potential fracture line may be visible on the lateral. Looking at the views again, there could also be some OA changes around the fibular sesamoid. On clinical examination (compression of the sesamoid into the metatarsal head whilst dorsiflexing the toe) does either one of the sesamoids hurt more than the other?
  38. Pain in both really, perhaps more so on the tibial- he didn't wait five years- he's been going through the NHS mill...
    I agree re" your observations on the x-rays. On the viewer programme that came with the x-rays, I can zoom and change contrast etc. I did think there was something going on with the fibula sesamoid too.
  39. Eric and Simon:

    I suppose that the reason I feel this observation of an association between the ball and socket ankle joint and tarsal coalition is so important to podiatric medicine is that it, more than any other radiographic observation I can think of, very graphically represents how powerful abnormal internal joint moments can be in literally reshaping the bones and joints of the young, growing foot. Seeing this rounded ankle joint shape, along with reading the papers I posted on this subject, further impressed me that the changes we can make in the mechanics of the foot of a child within the first 7 years of their life has likely more potential to effect permanent change in their adult osseous pedal morphology than likely what we do with their foot from the ages of 7 to 25.

    Many of our our medical colleagues, and also otherwise respected members of our profession, are happy to simply observe children with flat feet without offering even the simplest of treatments for this condition, even though permanent osseous structural abnormalities may be occurring within these young feet due to their lack of treatment. I feel that our current state of biomechanical knowledge demands that our profession more seriously consider that non-treatment of these children's feet with signficant flatfoot deformity likely will relegate these individuals, as adults, to permanent foot deformity and dysfunction.

Share This Page