Dear all.
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I need some help on the following case.
Goalkeeper, with high arch profile on both.Supinates during the whole of stance phase, maybe comes up to neutral during "foot flat". Last year he presented with no symptoms to me, but he insested that the Dr. of his team recommended some orthoses since he is a pes cavus foot type.So i gave him some EVA prefab with an arch support and nothing else, so that he could have some more support during the gait cycle. However he wore the orthoses only in his every day shoes and not in his football boots and he found them great. After a years time he told me he injured his foot during beach soccer and now he gets some pain under the "ball of the right foot". The pain starts during activity but disappears after the warm up!!!???. However it is aggravated when he puts all the weight on the right foot,for example when he needs to pass the ball (he is left footed) or when he swings to the right and all the weight is forced on the right foot. Clinically the 1st MPjt does not look inflammed and the x-ray does not show a fracture. The range of motion on the 1st MPjt is normal, neither the patient feels any discomfort when i dorsi or plantarflex the hallux.
Please give me some thoughts about diagnosis and treatment.
Thank you in advance
p.s. Excuse my English, I am Greek.
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Plantar pressure with and without custom insoles in patients with common foot complaints
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oh no, not plantar fasciitis again
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Have a go at the Jone SCS technique:
Jones Counterstrain Technique for sesamoiditis -
I would like to understand more about this condition too. The paradox is, that the more ideal we correct/facilitate in biomechanical terms, the greater the load on the sesamoids. Plantar-flexion of the 1st ray would drive the sessamoids into the ground!
Do we use 2-5 met bars? Do we incorporate plantar wing covers? Do we go easy with PF 1st ray and move the peak of the arch distally?
As for Dx, I would have thought palpation was quite reliable. -
Apart from the above, if the gastroc / soleus complex is tight, there is more and earlier loading of the forefoot, therefore gastroc and soleus stretches required.
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If there is a fracture, Wilson's cast as before and review for non-union after removal. Bone scan is preferred as sometimes stress fractures will not be obvious on xray. With non union or avascular necrosis, sesamoidectomy should be performedas soon as possible. -
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I agree with Craig in that there are a number of differential diagnoses; Perlman (1994) suggested ten -
Vascular claudication
Acute disruption of sesamoid ligaments
Avascular necrosis osteochondritis
Stress Fracture
Neoplasm of bone and soft tissue.
Tendonitis of FHL or adductor hallucis
Osteitis or inflamatory bone disease
Chondromalacia
Normally occurring bipartite sesamoid
Sesamoid gout
I would be interested to hear of any experiences, particularly where there has been disruption of the inter-sesamoid ligament. Is surgical repair possible? -
Nick -
Sesamoid problems generally are relieved by a combination of an orthosis/insole that causes a rearfoot supination moment and increases the GRF plantar to the 2nd-5th metatarsal heads and decreases the GRF plantar to the sesamoids. However, I may also inject cortisone, use icing therapy, or use a cam-walker type brace. I may even surgically excise the sesamoid or perform a dorsiflexing osteotomy of the first ray if the patient is resistant to conservative care. Careful examination combined with appropriate x-rays (sesamoid axial views are critical), bone scans and MRI scans are often necessary to pin down a diagnosis. -
It is a corrective Total Contact Cast (TCC) in this case modified with a depression over the 1st MTPJ and the ankle & hallux held in 10 degree plantarflexion.
Cheers
Mark -
Kinematically, she is quite pronated at terminal stance although curiously she has a laterally deviated STJ axis and actively pronates at midstance. My plan is to shift the centre of pressure laterally at terminal stance in order to facilitate 1st ray plantarflexion. Doing so, I would hope that there is less propulsion off the medial aspect of the hallux and 1st MPJ, which is where the nerve resides. I have also advised icing the area to reduce any potential inflammation. I was going to provide a silicone bunion protector just to reduce the nerve irritation.
Am I doing the right thing? I would appreciate any guidance. Once again Kevin, thanks for pointing out another pathology that I would otherwise have failed to diagnose.
Kind regards,
Robin -
Pay close attention to the late midstance pronation. This needs to be resolved with the foot orthosis. Generally the best way to get rid of the late midstance pronation is to use a nicely fitting orthosis in the medial longitudinal arch, no medial heel skive, and then use also a 3 mm korex reverse Morton's extension to the sulcus. Ice therapy, 20 minutes, twice daily, also helps. -
So, if there is a laterally deviated STJ axis, it's ok to add a lateral skive and intrinsic forefoot valgus post. Just don't try to evert the foot farther than it can go.
Eric -
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Gents, many thanks for your considered responses.
Regards,
Robin
<
Plantar pressure with and without custom insoles in patients with common foot complaints
|
oh no, not plantar fasciitis again
>
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