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Painful LF 1st MTPJ arthritis - help needed

Discussion in 'General Issues and Discussion Forum' started by ajs604, May 28, 2010.

  1. ajs604

    ajs604 Active Member

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    I have a question I am a recent graduate and work as a sole practitioner so just want to clarify something. I had a patient today referred to be by their GP for arthritis in their 1st MTPJ. On examination there was limited dorsi and plantarflexion of the 1st ray. The patient reports pain of approx 18mth duration and on a scale of 1-10 announces the pain as a 3 so not too bad. I have orderd a pair of off-the-shelf orthotics as not currently doing custom ones - was thinking a 1st ray cut out and maybe some correction as the patient pronates considerably on their left foot.

    Any suggestions would be appreciated.

    Many thanks
  2. Jeff Root

    Jeff Root Well-Known Member

    Why do they pronate more on their left foot? Hallux limitus (functional or structural in this case?) or hallux rigidus can be the cause or the result of stj pronation. You should ideally not only treat their symptoms (just putting the patient in an otc device might do this) but you should make a diagnosis and attempt to treat the cause of their symptoms. Do you believe you have done an adequate workup on this patient? If so, you should probably be able to identify the cause of their excessive pronation.

    A 1st ray cutout, a reverse Morton's extension and a number of other orthotic modifications might be in order, but they should be based on something more than the limited information you have provided us.

  3. Jeff Root

    Jeff Root Well-Known Member

    I should have said, why do they only have symptoms on their left foot. Do they pronate more on their left foot? I got ahead of myself in my posting above!
  4. RobinP

    RobinP Well-Known Member


    Can I suggest you read this thread.


    It is a good way of getting your thinking straight and for everyone on the arena to have a more clear picture of the case you are presenting. This will ensure you get maximium /applicable feedback

    As Jeff said, you need to make some type of diagnosis. You need to be able to justify your usage of the prescription you mention by relating it to a diagnosis. I find it easiest to consider all the differential diagnoses and discard according to my findings. Thus, creating a treatment plan becomes more logical.

    Look forward to trying to help out. Good luck

  5. Footoomsh

    Footoomsh Active Member

    I was wondering how old your patient is and what activities etc they participate in? Is the ROM very small and painful in OKC? This may change the most appropriate course of action.
    All the best.
  6. David Smith

    David Smith Well-Known Member



    Back to your clinical problem- The important stuff Jeff et al have said not withstanding then; If the 1st MPJ is restricted because of oseous lipping or some other arthrosis then a shoe with a rocker sole is very useful to reduce moments about the 1st mpj and reduce the functional RoM required for the hallux.

    Cheers Dave Smith
  7. Alex Adam

    Alex Adam Active Member

    Asymetric pronation is often a result from compensatory mechanisms due to proprioceptive response to Leg Length or scoliosis. In the former case the hip that is high, in this case the left, will see an increased pronation of the foot to allow the lowering of the talus and we would note an increase of supination through to mid stance on the other. If you measure the LLD and they are the same then suspect a thorasic/lumber scoliosis.
    If it is a scoliosis be aware that the device should not fully control the foot, this would remove the compensatory motion needed for scoliosis. If you over control you are likely to 'shunt' the problem into the spine.
    Shunting reflex is a term used in the treatment of CP patients.

    You could also check for nerve entrapment of the first digital nerve as it passes the medial sesmoid.

    Remember 'Arthritis' is an over inflamatory response to normal wear and tear. Identify the mechanism and this will allow you to formulate a sound treatment regime.

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