Long standing HD and back pain

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Im posting this thread today as i dont know what do with my patient next.

here is his history.
He is 43 years old, suffered a nasty fracture to L1 following a RTA in 1996, he needed lots of rehab at the time and now suffers with some disc problems and general back pain.
He has been attending our podiatry clinics for years with problems of long standing HD's mainly under both 4th plantar MTPJ's. He finds these vwery painful and was having debridement every 4 weeks a few years ago he had the right HD removed surgically, but this has now returned and is probably worse with the involvement of scar tissue.

I have tried many things from simple padding and insoles to more accomodative and semi functional orthoses. Some orthoses have helped these Hd s in the past but aggravate his back terribly. he has a very high pain threshold and is willing to try anything and also appreciates any thing we try.

I recently referred him back to our podiatric surgeon for another opnion. He diagnosed some mid foot and forfoot OA with dropped metatarsals (pts words) they were considering operating after talking to the back specialist. They have now decided that operating is a bad idea due to lack of skin/soft tissue(again pts words!!).

This chap is now back with me for monthly debridement but he is at the end of his tether really and im frustrated as i cant use any orthoses due to his back.

Does anyone have any suggestions?

Thanks

 

Maybe have a crack at footwear modifications - rockers soles with carefull assessment of the correct compensatory heel elevation .
It maybe that to ensure that the footwear does not effect lumbar lordosis etc, that the heel raises are made of shock attenuating materials or ground off (Reverse grind off/Striker heel mods).
My approach is usually to look globally at the effect of the mods then start to tweak - trying always not to make the back worse.

I would also want to know why the HD are so prominent - osseous, neural or shear mechanisms.

Cheers

Phil

 

Baypod

There's not a lot of info to go on but I would gues that your pt has an ankle that is non compliant to GRF, Func hallux limitus, and tends to have early heel lift and at pushes off / propulsive phase the CoP goes from medial to lateral and so the pt spends more time on the lateral lesser met heads. Perhaps the 4th ray is stiff to GRF also.

Try mobilising the ankle and the met rays, then use a orthosis with no medial heel post or heel lift but add a lateral f/foot post and 1st met / ray cut out.

My reasoning is this; Medial rearfoot post and heel lift can tend to increase lumbar lordosis, depending on the nature of his resting posture, which maybe your pt cannot tolerate. I have had some patients that get a severe increase in back pain with only one or two mil of heel lift increase.

Enabling the function of the 1st ray and windlass allows improved saggital plane progression and add a f/foot lateral post will reduce pressure on the 1st mpj ad encourage improvement of this action. It may appear that adding a lateral f/foot post will increase pressure sub lateral fore foot, this is not necessarily the case. Since you will improve saggital plane p[rogression with mobs and 1st ray c/o the heel lift off can be later and therefore GRF is attenuated on the f/foot. This can equal reduced peak pressure and decreased time at peak pressure. Give stretching exercises to keep the ankle RoM compliant to GRF. Perhaps add a balance cut out sub 4th to this and you may be sucessful. Shoe gear is important to consider as Phil suggested.

I might get shot down in flames for this suggestion but it is a solution that I have succesfully used in the past. Bearing in mind that I don't know much aboout your Pt's biomechanics.

Cheers Dave Smith

 

Forget the clever stuff, I'd start with a flat 3-4mm eva insole with a hole in it were the lesion is. We demonstratred the effectiveness of this and highlighted some of the potential limitations of debridement in a small trial published in the British Journal of Podiatry 2005; 8(2):53-59 and reprinted in the Australasian Journal of Podiatric Medicine 2005; Vol 39, No.2 : 33-40. Abstract here:
http://www.apodc.com.au/AJPM/Contents/Full text/Vol39/abstracts/Vol 39_2_33-40abstract.pdf

A simple solution, without the risk of knackering his back any further. Lot's of success with this- sometimes gets rid of the lesions, but wouldn't bank on it, but will reduce pain and frequency of return. No good in private practice as too cheap a solution
P.S. My pound says he's smoker or has been. Never read it anywhere that I can recall, but have noticed this type of HD in smokers over the years- I know my mate Javier Pascual has noted this too. One of these days I'll do a proper lit search and write it up.

 

I agree that simple measures usually work best here. I have found otoform-K full length toe props to work well in such cases of stubborn forefoot pressure lesions.

Would be worth a try. I don't have the references at hand but there has been some work done indicating a reduction in foreoot plantar pressure when using such devices.

Cheers
Steve

 

Thanks for all your suggestions, i will try all, most simple first.

He is off to see the orthotist this week so i will forward on the footwear suggestions.

David you were correct with my pts biomechanics, sorry i wasnt more detailed.

My pt is not a smoker and im not aware of him ever being a smoker, but he is an ex drinker and 'borderline diabetic'. He is also very tall and overweight, but hes trying hard and recently lost a stone.

Thanks for your help, i ll keep you opsted if anything helps

Baypod

 

Thanks for all your suggestions. I will try all starting with the most simple. He is off to see he orthotist this week, so i will forward the ideas on footwear.

David you were correct with his biomechanics. sorry i wasnt more detailed.

And Simon, my pt isnt a smoker but possibly an ex smoker, I will find out. But he is an ex drinker and 'borderline' diabetic. He is a very tall chap he needs to lose some weight, he has recently lost a stone and purely sees this as a way to help his feet which it hasnt so he is dissapointed. I continue to encourage him.

I ll keep you posted if anything helps.

Baypod

 

Baypod

I assumed you have tried the simple methods and traditional methods and were looking for a new angle. However a simple method I have found very effective is to make adhesive met pads with cut out and issue about six to the patient to change as necessary until the next visit, Then repeat ad infinitum. It has been very sucessful where patients are compliant and orthoses were not an option, not wanted or did not work. Sometimes I believe that an insole/orthosis with cut out still allows shear forces to act on the lesion as the foot slides around in the shoe over the top of the insole, this can't happen with adhesive pads.

Cheers Dave

 

Thanks David, i have tried simple methods, but some time ago. I will try again. Ive never tried much with adhesive pads as im not a lover of them. But i will try anything now.

Thanks again

Baypod

 

I have had some success plugging HD with otoform K in the past - might be worth a try.
Russ.

 

Not a big fan of this approach as it tends to increase dorsiflexion stiffness in the underlying mets. Just my opinion.

 

To this i would add that if you can find a shoe / trainer with a reasonably deep lattice or solid forfoot sole you might be able to remove the soft liner and use a finger grinder to drill out a further 4 or 5 mm from the under the lesion.

Regards
Robert

 

This thread begs the question: Why do orthoses cause back pain, and how can orthoses help back pain?

 

I have a female patient with three nasty plantar met head corns, one is neurovascular. I have not been getting anywhere with these corns with fortnightly treatment over some months. After reading your post RussAgg, I filled the neurovascular HD with Otoform K. On review 2 weeks later, the patient reported that the corn was much less painful and enucleation was tolerated far more.

How on earth does this work?

Rebecca

 

I'm guessing that by occluding the skin it softens it so when you debride you don't cause as much trauma. I've had similar results stuffing it full of jellonet. I've also been known to put a 5 mm cavity pad on, fill the corn and the cavity with flexitol, blenderm on top to keep it all in and send the patient away for a few hours then get them back to debride.

Regards
Robert

 

but if someone is in terrible pain and cannot tolerate an orthotic etc then surely this is a welcome compromise?

besides, is there any evidence that this will cause dorsiflexion stiffness to the underlying mets and if so what are the likely outcomes of such stiffness? please elaborate.

 

Dear Rebecca,

I agree with Robert's explanation of how otoform K might work. I first heard of it when it appeared in a small study in an old podiatry mag, probably about 15-20 years ago. Unfortunately, despite looking for it, I can't seem to put my hands on it.

Cheers, Russ.

 

Hi just plug in oto k into a google search and take your pick of suppliers. How long do you apply for on the planter surface, Im wondering if it would be worthwhile trying on a RA or neurovascular situation.

 

Hi Leigh
I meant the study not the actual otoform! (got plenty of that).
Cheers, Russ.