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Hi all
I have a 48year old female patient who has a physical job and chronic pain in both feet. Her foot shape is pes planus and she has very little fibrofatty padding covering her metatarsal joints. Both feet 1st IPJ and both 1st and 5th MTPJ callus and HDs.

She has been attending for over 5 years and has gradually come back more frequently for treatment.

Have tried accomadative insoles, corrective insoles to correct pronation at calcaneum and mid tarsal area.

She has seen a number of podiatrists over the years and has a vast array of orthotics with no benefit.

she has also seen a orthopaedic surgeon who, under general anaesthesia tried a manual external achilles lengthening, apparently he told her he had "given her legs a good tug and to go home and try calf stretches and wear MBTs"

At a loss what to do, not confident with biomechanics but determined to learn so guidance much appreciated.

Regards Kylie

 

to give you some more info;
she stopped smoking two years ago.
my issue with knowing what to do next is that i have tried accomodative insoles, no success and not sure how far to go with corrective orthoses. if surgery were to be considered, what type of procedures? I personally thought the orthopaedic surgeon would have done an achilles lengthening and metatarsal head reduction but he has said he doesnt want to operate again (although the previous op was actually a manipulation rather than an incision)

Thanks

 

I've seen patients with a pile of orthotics that did not address the problem. If her problem is excessive force sub 1st and 5th mets then she needs an extension that will increase the force on mets 2-4. Was this done? Just because you make an accomodative device, does not mean that it will reduce stress on the affected structures. If you don't tell a lab to offweight a specific area they may make a device that will tend to make an even weight distribution. I personally would operate on he pile of orthotics before I would have a surgical procedure for excessive force on 1st and 5th met heads.

Eric

 

I would strongly agree with Eric. Accommodative doesn't always mean pressure redistribution. Load everywhere but the affected areas as much as the patient can tolerate and leave voids for the highest pressure areas.

Also, don't forget that there will almost certainly be a shear force component and this may require addressing to give the most effective treatment

Can you pad the feet with SCF to an extent that the high pressure areas are relieved?

If you can, then you should be able to have a fair stab at some orthoses that do a similar job. It may require some changes in footwear but needs must.....

Robin

 

Good morrow (at least for you) Robin, my query today is "SCF"?
And would you and Mr Fuller adhere a Poron / PPT / P-lite 'plug' beneath the 1st and 5th metatarsal heads as well as the 2-4 firmer met. pad; and would it be better still, if possible, to cut apertures in the sock lining and plug with the 'Poron' plug so as to avoid the heel to forefoot (2-4 met heads) differential, cheers, mark

 

I think the key is the firmer material sub 2-4. The problem is too much weight on 1 and 5 and not enough weight on 2-4. Adding anything sub 1 and 5, even soft stuff, is going to relatively increase the pressure there. Putting a hole sub 1 and 5 is simpler than putting in a plug.

Eric

 

Hi Mark,

It depends....

Most effective is clearly having nothing acting as a plug. However, there are plenty of patients who do not like the edge of the aperture. I reduce this by using a material such as poron 92 (red) which is incredibly low density (open cell) and when used to acurately fill the aperture, negates the feeling of an edge, especially with a top cover such as 1.6mm neosorb(spenco) Also gives less offloading but it is very much patient specific as to who will tolerate non infilled apertures.

I'm sure there was a bit of reearch that showed that an aperture was more effective than a "sink"(a localised dell in the orthosis) when it came to reducing static pressure under mets. Combo of padding the non problematic areas and offloading the problematic areas is likely to give the greatest success

SCF is semi compressed felt - sorry, my bad