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Pressure lesions at apex of lesser toes form running

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podtiger, Mar 2, 2010.

  1. podtiger

    podtiger Active Member

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    I have a problem with a patient who was initially getting pain on the medial aspect of both ankles and subtalar join region. It extended basically along where the tibialis posterior muscle runs and inserts into the navicular. After a bimechanical assessment I prescribed a quick fix in the form of 3/4 vasyli orthoses to help prevent abnormal pronation and to support the midtarsal joint. I explained to the patient that eventually she may need more custom made orthoses. The patient is a 35 yr old recreational runner who is now doing up to 35 km per week.
    This helped the patient right away. She also found the vasyli orthoses quite comfortable.
    Now, however, there is a problem with the B/2/3/4 apices getting pressure lesions fairly close to the nail area of these toes. I am thinking the foot may have moved forward slightly due to less room in the shoe.
    My problem is how to fix this for the patient? I am also aware that she is running more kms now.


  2. Easy....get a bigger shoe......
  3. Mark_M

    Mark_M Active Member

    First thing to check is the lacing, ensure the laces tight distal to proximal and then lace lock. This usually prevents any forward motion that could be occuring in the shoe.

    Also a 3/4 orthotic on top of an innersole will take up room in the shoe, Try removing the innersole and replacing with a full length orthotic.
  4. efuller

    efuller MVP

    I agree with the other posters that a longer shoe or keeping the foot back in the shoe is probably the answer. You could look at the toe impression in the sock liner to see how close they are to the end of the shoe.

    Another possibility is that there is increased use of flexor digitorum longus. This muscle is a close 2nd to the posterior tibial muscle in creating supination moment at the STJ. If the original problem was posterior tibial tendonitis, a patient could learn to use a different muscle instead.

  5. podtiger

    podtiger Active Member

    Thanks for your replies. It's funny checking the shoe it felt like there was still enough room for the toes while the patient was standing with orthotics in runners. I will check again and try the lacing advice.

    thank you
  6. stevewells

    stevewells Active Member

    Have you checked that the orthoses fit well back into the heel counter of the shoe - if the shape is slightly different or the fit is tight they can pop forward especially if you have them on top of the existing sockliner - just a thought.

  7. David Smith

    David Smith Well-Known Member


    You could try a silicon toe prop mould or:

    Assuming that it is not a problem related to the shoe itself; First, did you establish the diagnosis? i.e was it posterior tibialis pain? If it was and you decided it was because of the stress caused by resisting pronation moments then did you decide how this action came about. E.G. was it a medial STJ axis? a supinatus forefoot? a compensation for a saggital plane progression perturbation (SPPP) like FncHL or equinus ankle /forefoot? was the first ray compliant to GRF and therefore the dorsiflexion deflection increased tension in the PL and increased pronation moments that way?

    For instance it may be the case the in a compensation for (SPPP) plus a very medial STJ axis the compensation may have been to increase the toe out foot placement to reduce the ankle dorsiflexion lever arm. In this case the foot may have pronated more due to increased horizontal GRF relative to the STJ. This may have lead to the lateral aspect of the foot being off the ground and the toe clawing to stabilise the foot but not actually beinbg able to get much purchase.

    When you fitted the orthoses but did not address the ankle equinus for instance, the toes may still have the clawed attitude but can now have more purchase on the ground since the foot in more supinated and the ankle dosiflexion moments have increased in stance phase.

    This is just one scenario, which may not apply at all to your patient but gives you an idea about how you might think about the intervention process.

    OK I'm willing toi be shot down in flames now:boxing:

    Cheers Dave

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