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Titanium Plates - mid foot OA

Discussion in 'General Issues and Discussion Forum' started by MelbPod, Feb 14, 2009.

  1. MelbPod

    MelbPod Active Member

    Members do not see these Ads. Sign Up.
    I had a patient in recently as I'll outline below, and I suppose what I'm after is any further insight to the management and treatment methods she had previously been offered by an orthotists. I am not one to critisise until I have a full understanding of justification, so anybody with experince or insight please fill me in:

    - 60 year old female, nurse, wears flat lace-ups.

    - Presented for opinion of severe midfoot pain on right localised to 2nd met-cuneiform jt. had recent x-rays showing OA of jt with NO jt space.

    -Significant HAV on both feet. No pain of 1st MTPJ, but instability of medial column.

    - Foot pain began ~12months ago can remember around time of begining boxing-type classes (now seized)

    - History of bilateral hip replacement, and knee replacement on Right.

    PREVIOUS tx:

    - an orthopaed Sx had advised her 10 months ago to steer clear of surgery due to the 'traumatic recovery time and pain associated'. but diagnosed the OA and referred to an orthotist.

    - ORTHOTIST provided EVA full length supportive mid foot orthotics. Provided some releif but found to take up alot of room in shoes, increase 1st MTPJ pressure, limit footwear etc.

    - On further advice, the orthotist prescribed full-length TITANIUM PLATES (flat) to be worn in all footwear. The patient send on review these were to be stiched to base of court shoe?

    Now being a fairly fresh pod, I would value more experienced pods opinions but in my understanding of foot function, I understand that any movement of the mid-foot is going to be creating pain,

    However, as the body moves over the foot when propulsion takes place, the foot needs to move somewhere. By creating such a stiff, flat shoe... I picture the foot abducting and increasing deformity of the 1 MTPJ....inturn weight transfer to 2nd met.......

    I have advised on footwear wit a rollbar, midfoot supporting carbonfibre orthotics and information to consider surgery in future.

    Appreciate your Opinion,


  2. efuller

    efuller MVP

    There is a condition, that I have not seen written about much, in which the 2nd cuneiform subluxes dorsally. I didn't put much belief into manipulations untill I had my own cuneiform become uncomfortable and have it manipulated.

    The symptoms are a vague midfoot (at 2nd cuneiform) pain worse with propulsion phase of gait and non weight bearing plantarflexion of the forefoot on the rearfoot. Dorsiflexion and plantar flexion of the 2nd metatarsal will repoduce the symptoms upon examination. As you palpate up the shaft of the 2nd metatarsal and reach the cunieform, there is often a palpable bump greater than the contralateral side.

    On the x-ray diagnosis of arthritis at the cuneiform: The joints around the cuneiform are very hard to visualize on x-ray because they are not usually angled parallel to the x-ray beam.

    Manipulation technique. Put the middle finger of one hand over the cuneiform, place the other hand on top, then place both thumbs on the plantar surface of the foot close to the metatarsal heads. Patient seated in the chair with feet pointed toward you. Then a quick forcefull movement with the force downward at the 2nd cunieform and an upward force with thumbs at the metatarsal heads. With a light patient and a slippery chair the patient should slide toward you a bit. When successful there is a click. Sometimes it takes more than one click to fully reduce the subluxation. Sometimes distraction of the metatarsal before the manipulation is helpful.

    Of course, if it really is arthritis, then the above would hurt for nothing.

    I recently popped my sister's 2nd cunieform with good results. Once, when I was traveling, I had to teach my wife how to pop my cuneiform. Now, I've got a patient who has a 2nd cunieform that you can see sticking up dorsally from across the room. I was not able to reduce it. Unfortunately, she has some CRPS like symptoms that seem to be related to it. I'm still trying to figure out what to do with her. She might have to go to surgery.

    Oh, the shoe stiffeners might help.


    Eric Fuller
  3. David Wedemeyer

    David Wedemeyer Well-Known Member


    I feel there are obviously cases where manipulation will reduce a subluxed cuneiform (and many other bones of the feet). This is one of those subjects that typically arouses a remarkable response depending on the type of practitioner that is asked, so I am sure more comments will follow.

    What is your opinion of manipulating a primary 2nd met elevatus, or with HAV? Personally I would like to see more inter-disciplinary RCT's on extremity manipulation and its indications (and contraindications). The paucity of good RCT's on this subject considering its wide usage astounds me.

  4. MelbPod

    MelbPod Active Member

    Thanks for the advise. I will reassess and keep you posted.
  5. efuller

    efuller MVP

    I have no opinion on those manipulations as I have not seen them. Could you describe what is done and what your trying to treat.

    There is another pesky one that I've been trying to figure out. It's pesky because my wife is the patient, but I have seen it in a couple of other people. It's a 4th met cuboid subluxation. The 4th met base seems plantarly dislocated to the cuboid. Palpable from dorsally. It seems to pop back into place with distraction of the met and a dosiflexory moment applied to the met. Sometimes a dorsal to plantar push from the plantar surface below the met helps. I really have no idea what I'm doing with this, but it sometimes helps. That is one thing that bothers me about manipulations is that a lot of people are so sure they help, but there is often no measurement of the subluxation. Is it placebo, or is there some movement of bone. That is one question that will make manipulation very hard to study.

    Maybe no one else will comment because they will never find a manipulation thread under the heading of titanium plates.


  6. TedJed

    TedJed Active Member

    Oh crikey, no wonder manipulation comes in for some bad press. Using terms like 'pop, click & snap' to describe manual techniques does nothing to clarify what is actually happening. Let alone, a practitioner who is trying to make sense of what 'manipulators' are saying and doing.

    It reminds me of a chiropractic seminar I snuck into where the presenter was talking about getting patients in to "snap 'em & crack 'em" and he was SERIOUS!

    The idea that manipulation can put a bone back 'in' that was 'out' is just not possible unless it was an acute subluxation. In my experience, most subluxations are maintained by connective tissue adaptations which require time and persistence, to release. That is, after all, how they formed.

    MUA (manipulation under anesthesia) does change bone positions immediately, but the associated tearing/damage of the connective tissue necessitates the use of anesthesia and a prolonged healing time.

    Patients often report a 'good result' (symptomatic relief) when a practitioner induces a cavitation release (a.k.a.snap, crack, pop, click) but this is due to a release of the hydraulic pressure of the synovial fluid, not a bone shifting x mm. The practitioner will also observe improved range and quality of motion but should not be deceived in thinking a measurable shift in the joint/bones position has taken place with one manipulation.

    The joints within the Mid Tarsus have a very small range of movement normally, so the slightest release of hydraulic pressure can have a significant sensory change (i.e. feels lots better).

    In my view, measurable changes can and do take place with manipulation over a period of time, but this has to be associated with connective tissue changes too.

    Your desire David, to see RCTs providing this evidence is a common desire by all practitioners who perform Foot Mobilisation/Manipulation Techniques (FMT) to justify what we see clinically on a daily basis. While I routinely use pre and post w/bearing x-rays to record treatment results, there are several limitations that prevent them from being rigorously valid and reliable.

  7. TedJed

    TedJed Active Member

  8. David Wedemeyer

    David Wedemeyer Well-Known Member

    Hello Ted,

    You really won't get any argument from me on what you have written here. The reason that I inquired of Eric what his feelings are on manipulation of the foot joints is because I value Eric's opinion as a clinician and educator with many years of experience. Perhaps I need to amend my question to Eric because apparently he does not understand what I had asked him.

    The spinal joints and the foot joints are dramatically different animals in architecture, function and range of motion. I think that we would all agree to that. Personally, over the years I too have attended continuing education seminars where some 'expert' on the lower extremity is touting manipulation of the foot and ankle as being a routine practice and efficacious for myriad conditions. Since I do provide spinal manipulation (I do not refer to it as "pop, snap or crack" and the audible achieved in most spinal manipulations while dramatic is not my baseline for the success of the maneuver) I am always fascinated at the number of my colleagues who perform these extremity 'adjustments' and the claims that they make of their efficacy. I have become even more in awe of the number of allied professions performing the same procedures, especially podiatrists.

    I rarely manipulate the joints of the feet (and ankles). I do come across certain displacements that I feel can be reduced when there is aberrant motion in those joints, that joint displacement below subluxation can and does occur and that patients often do report relief of symptoms when these joints are manipulated. There is also a change in function from these procedures. Because I am a CPed as well and possibly because I may have slightly more knowledge of the indications, design and implementation of foot orthoses than many of my colleagues, I always look at supporting those manipulations with the appropriate orthosis and footwear to maintain the correction (Dr. Dananberg seems to support this idea). I agree that cavitation of many of the foot joints may not provide long-term benefit unless there is prophylactic follow-up with orthoses.

    But you're correct, many chiropractors are merely focused on one dimension, the snap, crackle and pop you have referred to. So again I would ask how beneficial is manipulation of the foot joints for specific conditions and where is the research to support these procedures?
  9. MelbPod

    MelbPod Active Member

    Thanks for your input TedJed, however I find that pic of 'corrective bunion manipulation' on your link very misleading to patients and practitioners.
    The foot seems to be in completely different position between the 2 shot, with the full 3rd metatarsal in the 2nd picture?

    I agree that manipulations of the foot have there place and some conditions can be releived with such treatment (cuboid subluxation..)
    However are measurements taken from x-rays not quite subjective?

    Do your patients have accurate expected outcomes from treatment?

    What is the long-term management of these patients?

    I am fairly green to manipulations, so maybe I dont fully understand all the concepts. It just doesnt seem to fit with conditions such as bunions.

    If you could provide any feedback for me, I would be interested to find out more about this practice.
  10. David Wedemeyer

    David Wedemeyer Well-Known Member

    Sally are the plates removable? I would consider carbon fiber as a shank material as it is more forgiving and maybe a Thomas heel shoe or a medial heel wedge. This would eliminate the medial to lateral roll significantly. Possibly a toe rocker. I would also assess the fit of the EVA orthoses and their relationship to the shoe itself and grind as necessary to ensure the proper fit.

    Given OA, midfoot instability and lack of real pain in the MTP joint I would not want to rush to improve this patient's biomechanics but merely to offload the MTP to avoid further damage and progression while improving medial column stability. Very conservative and very inexpensive as a first run.

    You expressed to Eric what I intended to ask him which was does he place much faith in mobilization/manipulation of the Hallux with HAV present or elevatus of the 2nd due to this. I may have been coy because I personally feel that it can be a very bad idea. If I am wrong I don;t mind being corrected because I do advocate manipulation of the foot joints many other circumstances.

  11. TedJed

    TedJed Active Member

    Hope this helps,
  12. MelbPod

    MelbPod Active Member

    Thanks for your feedback Ted
  13. efuller

    efuller MVP

    I think I understand what you are asking now. Are you asking about the concept of manipulation. My level of experience and thought on this is fairly low. I will say that I have seen bones out of place. And I have seen bones popped back into place. (I have no problem with that terminology as I have no emotional attachment to the words involved. Perhaps manipulation would be better. eh?) That said the thought process should involve why the bones pop out of place. If you believe in physics, there must be a force from somewhere to move something. I once was wondering about what could possibly cause a cuneiform to dorsally sublux in front of some students and one suggested compression from the peroneus longus tendon. At this point, I don't have a better theory, so I'll stick with it until a better one comes along. So certainly if you follow this theory in the presence of a dorsally subluxed cuneiform you should add something to the orthotic to prevent the need for high tension in the peroneus longus tendon. (Decrease force under first met head and decrease high supination moments.)

    Now to the 1st mpj. My paper on the Windlass mechanism describes how reverse buckling (described much earlier by McGlamry) creates the forces that cause the first met to rotate away from the 2nd met. There are x-ray studies to show that at least some of this movement is at the 1st met cuneiform joint. So, manipulation/mobilization should address that joint. If you look at xrays and note that the sesamoids are no longer under the met head, you have explain what happened to the sesamoidal suspensory apparatus. (I might have just made that term up.) Specifically there is a ligament/ joint capsule that goes from the medial met head to the sesamoids. This ligament has to elongate to allow the sesamoids to stay in the same place and the Metatarsal to rotate in the transverse plane. I don't know how you are going to manipulate some bones to make this ligament shorter.

    After manipulation of the 1st MPJ you also have to find a way to keep it there. There are people when standing, when you attempt to dorsiflex their hallux, who will show significant increase in the medial promenence of the first met head. (This simple action causes the 1st metarsal to rotate away from the second.) The forces that attempt to cause dorsiflexion of the hallux during gait are very high in relation to the forces produced by muscles that thave the cross sectional area of the intrinsic foot muscles. So it will be very hard to train muscles to hold the manipulation in place.

    I also rarely manipulate joints. It is an art that should have more written about it and should have more science applied to it.


  14. David Wedemeyer

    David Wedemeyer Well-Known Member

    Eric I have seen as an example numerous cases of a presentation of Carpal Tunnel like symptoms where there is also marked activity of the extensor forearm muscles and concomitant Lateral Epicondylitis (Tennis Elbow) on exam. The extensor forearm musculature does have a greater cross-sectional area than the foot intrinsics and resultant ability to generate forces on the carpals and I find these people have resultant pain and dysfunction in the wrist carpal area as well. This is parallel to your student’s suggestion of peroneus longus compression, via the common flexor/extensor retinaculum and its attachements at the wrist.

    I always treat the forearm and give specific attention to the lateral epicondyle (electrical stim, ultrasound, myofascial release, Mill's manipulation etc). They typically improve in a few weeks and then I manipulate the carpals if warranted. In my experience manipulation of the carpals only does not produce any discernible benefit for this type of displacement.

    The point being that I agree that muscles can exert strong forces (moments) on their bony attachments and sublux carpals, tarsals, even spinal vertebrae. The problem, as you describe is how to keep the gain from manipulation in the joints of the feet when their architecture is so dramatically different from the spine. The spinal joints are actually termed the ‘triple joint complex’ consisting of a spinal disc and the zygapophyseal facet joints in unison. The facets are true synovial joints while the spinal disc is not. The spinal disc is the factor that allows a beneficial change in position to occur with spinal manipulation that I don't see as remarkable in the peripheral joints. At least not without some form of prophylactic support such as orthoses.

    The disc does allow greater degree of freedom of movement at these segments and is not a characteristic of any joint of the feet. Manipulating a spinal joint has a far different feel and result to say a subluxed cuboid (which is a saddle joint) and although they can be manipulated, as you point out the soft-tissue restraining mechanism cannot be shortened or tightened by manipulation alone. Once ligaments and tendons are stretched beyond their elastic barriers they are doomed typically.

    I met with one of your colleagues at the PFOLA in 2007 in San Diego. We were discussing and sharing methods for manipulation of the foot and I found that podiatric techniques were similar to what I was taught in college actually. I have also seen techniques that frighten my sensibilities from both professions. I agree that much more research and a more standardized approach to manipulation of the extremities would be beneficial. It is an art that demands more science and more attention.


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