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What is with all the first met head elevations on foot orthotics?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Oct 29, 2011.

  1. Craig Payne

    Craig Payne Moderator


    Members do not see these Ads. Sign Up.
    For those who have been to one of the Boot Camps know how I try hard to be consistent with the evidence. Models gets proposed on the how and why of foot orthotics that is consistent with all the available evidence (for eg, the model on how foot orthotics might work in PFPS that is consistent with all the apparent conflictory claims and research) in order to do it better.

    One key element of foot function that I consider extremely important is allowing the foot to establish the windlass mechanism, so the foot/arch are capable of supporting itself. We incorporate design features into foot orthotics (eg first ray cut outs; forefoot valgus posts) to facilitate this. Howard Dananberg introduced the kinetic wedge to help achieve this. James Clough popularized the Cluffy Wedge to do this as well. Ed Glaser, as part of his MASS theory approach is very adamant about getting the first ray down to the ground during the foam box casting to achieve this. Dennis Shavelson in some of his writings on Functional Foot Typing talks about a forefoot vault enhancement, which is the same as plantarflexing the first ray.

    All of this, to me, is biologically consistent, with all the evidence that we have on the windlass mechanism as well as being consistent with the coherent theoretical approaches surrounding facilitating the windlass mechanism.

    HOWEVER, on the other side we have a number of approaches that are doing the opposite of this, ie from where I sit, they jam up the first ray (ir mortons extension) and should interfere with the windlass mechanism and should be detrimental to foot function. The most obvious is the approach advocated by Brian Rothbart that advocates the use of his PCI insole to elevate the first ray and that the mechanism is via proprioceptive. Also, there is Burton Schular who has a book promoting the use of mortons extension to treat almost everyone (Dudley Mortons Toe (and love of money) the root of all Evil; No 1 Best seller); along with claims that Podiatrists can cure fibromyalgia; at the recent Spain conference following my presentation on foot orthotics in PFPS,I was approached and through an interpreter was told they disagreed with everything I said as they just use a 1-2mm thick pad under the first met head for them all. There are many more examples of this.

    What I do not get is why do these approaches that are so contradictory to the prevailing coherent theory and the available scientific evidence claimed by the proponents of them to be so effective?

    What say you?
  2. Craig Payne

    Craig Payne Moderator

    Maybe I should rephrase it:
    One group of approaches are saying get the first ray down and the other group of approaches are saying lift the first ray up. How can they both be right?

    Obviously, I believe the first group of approaches to get the first ray down is more biologically plausible and theoretically coherent and is more consistent with the evidence than the second group of approaches. But why to proponents of the second group claim so much clinical success?
    ie, its:
  3. Because:

    a) 1st ray function is not the be all and end all and the body has in-built redundancy and cat skinning abilities
    b) The modifications don't effect 1st ray function how we think they should
    c) The "success" being claimed has little to do with the modifications being estolled by their supporters
  4. I also wonder if there is some " pain" avoidance as well , ie putting some hardish under the 1st Met head the sesamoids will have greater GRF at the area and the body will avoid the irritation by increasing the internal supination moments.
  5. RobinP

    RobinP Well-Known Member

    Does raising the 1st metatarsal head necessarily interfere with "correct" Windlass function?

    With most things, is it not a continuum? For a given individual, there will be a force on the 1st MPJ that will give the optimal Windlass function(if that is indeed what is actually desired, bearing in mind that it might not be)

    Is it not OK to think that for certain pathologies/presentations that one or other is correct in different situations?
  6. David Smith

    David Smith Well-Known Member


    I often use 1st ray / mpj cut out to help avoid FncHL. However this is only when there is the possibilty of FncHL but not when there is no possibility. If the 1st ray is elevated relative to the lesser rays during stance phase then I would often add a post to accommodate this. I also would often then add a drop of below the hallux, which I believe will reduce tension in the PF and allow the windlass to operate without excessive force sub hallux.

    FncHL is not an absolute state but rather a matter of degree. I.E. at some point the tension in the PF reaches a point that will significantly impede saggital plane progression as it plantarflexes the hallux and so some compensation must be made to facilitate saggital plane progression and avoid pathology that would occur as the stress in the PF increases.

    Therefore horses for course, a 1st mpj cut out is one way of reducing the GRF sub hallux but posting the elevated 1st ray and cutting out under the hallux also works.

    Cutting out under an elevated 1st ray will not increase plantarflexing forces acting on the 1st ray will it? There is nothing extra to push the 1st ray down is there except gravity which is very weak and insignificant in this example.

    That's my explanation anyway:eek:

    Regards Dave Smith
  7. Certainly there is considerable variation from one foot to another and what works best for one patient will not necessarily work well for another patient. This is also true for using varus and valgus forefoot wedges and Morton's extensions and Reverse Morton's extensions.

    Over the past few decades, it has been my belief that this idea that a Morton's extension or varus forefoot extension will somehow "jam-up" the first ray and prevent hallux dorsiflexion in all patients is far too simplistic of a notion to be true. My own observations over the past quarter century is that placing a Morton's extension or varus forefoot extension may in fact cause increased subtalar joint supination in some patients and may cause increased subtalar joint pronation in other patients. Much of what we see in gait as a result of these forefoot wedges/extensions probably depends on their direct mechanical effect versus their neuromotor effects. The ultimate kinetic/kinematic response will also depend on what is being done with the orthosis shape and stiffness proximal to these metatarsal head pads. The dorsiflexion stiffnesses of the medial and lateral longitudinal arches also probably have a signficant effect on how these forefoot extensions/wedges affect the kinetics and kinematics of gait.

    Therefore, in summary, I wouldn't be so sure that we are so knowledgeable that we shouldn't be experimenting with different patterns of forefoot extensions to find out what makes the patient function the best during gait and helps relieve their symptoms the most effectively.
  8. Craig Payne

    Craig Payne Moderator

    The point of this thread and what I am trying to get to the bottom of is why do so many use 'mortons extenions" or "pad under the first met head" or "whatever you call them" and claim such remarkable clinical success.

    For eg:
    He claims his "research" is the 30 000 patients he has used them on. He has written a book on it and regularly puts out press releases extolling the virtues of a mortons extension.

    Why is he allegedly getting so much clinical success with this?
  9. Craig Payne

    Craig Payne Moderator

  10. Because, ready, wait for it, drum roll..... He hasn't performed a controlled trial and he is selling something.
  11. Craig:

    How are the claims of Burton Schuler any different than the claims of Ed Glaser, Dennis Shavelson and Brian Rothbart? I agree with Simon....they are all selling something.
  12. Craig Payne

    Craig Payne Moderator

    The difference is the specific claims related to this topic (Ed's plantarflexing the first ray during casting and Dennis's comments on forefoot vault enhancement) are consistent with the evidence and prevailing biologically plausible theory on the topic (other parts of there claims/theories may be problematic). The claims by Schuler and Rothbart are not consistent with the evidence and prevailing biologically plausible theory on the topic.

    There are many others who routinely use first met elevations/mortons extensions that have no product to sell (eg the person at the Spain conference I mentioned above - they disagreed with everything I said and only use a 5mm "mortons extension" without an actual orthotic for PFPS!).

    I just trying to get to the bottom of why they are getting the clinical results that they claim that they are getting.
  13. Craig:

    I also routinely use varus forefoot extensions on my orthoses for runners with patello-femoral pain syndrome and medial tibial stress syndrome. However, I wouldn't do the same for walkers. When we talk about the benefits of varus forefoot extensions, we must be careful if we are talking about orthoses for walking or orthoses for running.

    Here's what I say: use varus forefoot extensions routinely in runners, but use them sparingly in walkers.
  14. Craig Payne

    Craig Payne Moderator

    I not specifically talking about runners; I talking about those who use a mortons extension like modification for pretty much every patient.

    If we ignore the "commerical" side of what Burtin Schuler is claiming (he is not the only one), see the "toe pad" that he uses: http://whyyoureallyhurt.com/ ... why is he getting the apparent clinical success that he is claiming to get?

    I take Simon's point:
    I not for one minute am agreeing with the claims, as they are not consistent with the available evidence, prevailing theory and my own clinical experiences.
  15. My own clinical experience tells me that both kinetic wedges and Mortons extensions can relieve 1st MTPJ pain, sometimes in the same patient= skinning the same cat via a different approach.
  16. Craig Payne

    Craig Payne Moderator

    Agreed. A morton extension will restrict first MPJ dorsiflexion an can help symptoms in the joint, but what about the long list on Schuler's site that a 'toe pad' can fix:
  17. efuller

    efuller MVP

    I think that there is sort of a Hightower effect. We are changing something. I remember a patient I had as a student. If I remember correctly the patient was a personal friend of Ron Valmassey and he was the clinician. Anyway, horrible hallux limitus/ rigidus. First, an orthotic, it got better for a week or two. Then it started to hurt again. Add a reverse Morton's, same story. Then, he tells me to add a Morton's extension. I'm thinking no way this works. It felt better for a while... and then it started to hurt again.

    One theory that I have is that a Morton's extension, that is just under the met head, will create sort of a rocker effect. With the extension, you will be able to lift the heel and there will be some range of motion before there is a need to dorsiflex the hallux against a tight plantar fascia.

  18. I await the data... In the meantime he's probably counting his money from book and orthotic sales. Who's the bigger fool? Me or the fella that sold his soul to satan and the boys from marketing?

    "if you're in marketing, kill yourself"- Hicks
  19. Craig Payne

    Craig Payne Moderator

    Simon, I not disagreeing with you and Kevin ... I just trying to understand what there are so many extraordinary claims (not just by Schuler) about the clinical effectiveness of this approach.
    I suspect part of the answer rests in this topic:
  20. Possible Answers:

    1. Maybe Eric is right.....possibly these treatments are helping one problem and causing another problem.....

    2. The people saying these things aren't really paying good attention to the symptoms being created elsewhere and the abnormal gait function that these types of modifications create.

    3. These people are financially motivated to say whatever they need to believe to keep making money on these insoles.

    4. Another possibility is that they are right and all the rest of us are wrong....or, in other words..... Brian Rothbart was right after all!

    On second thought, eliminate #4 as a possibility.:rolleyes:
  21. Craig you added a Rev Mortons extension a few months go to your device if I remember correctly.

    Take it off and add a Mortons extension see what happens - N = 1 but still.

    Edit check that it was a Cluffy wedge I´m pretty sure now -
  22. David Smith

    David Smith Well-Known Member

    Hey guys, have you ever had that experience where you've been at a bar and the bar tender serves everyone and anyone but you? You feel like you must be invisible huh? Seems to happen a lot just lately: is this a representativness heuristic, should I start taking the Olanzipne again or do I just write cr-p (rubbish) nowadays?:dizzy:
  23. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    This doesn't seem like a particularly complex of contentious issue. The reason they can both be "right" is that one approach believes the 1st MTPJ can still 'work', and the other says it is time to 'give up'.

    The analogy is no different in foot surgery for the 1st MTPJ.

    A cheilectomy, Youngwick decompression procedure, even a Kellers, etc is aimed a restoring or allowing 1st MTPJ motion to persist. A fusion is obviously the opposite - game up - too much degenerative joint disease. As others, including Kevin, have repeatedly stated - runners and most individuals can happily return to quite active pursuits after fusion.

    The important issue is to acknowledge and respect the continuum which exists in progressive osteoarthritis of the 1st MTP joint. As the joint deteriorates, the head goes up, the fascial slip and short flexor contract, sesamoids elongate and begin to ghost, and the IP joint becomes the main weight bearing contact point for the medial column.

    Because of this I routinely try to facilitate 1st MTPJ function/windlass in the early stages of the disease, and then eventually progress to 'bringing the ground up to meet the head' in the later part of the disease (read FF varus extension etc).

    I think the rule that should be applied is that where relatively pain free ROM exists, facilitate motion - and when joint disease is late stage 2 or 3/4 - block and elevate.

    This is the general philosophy I have seen most foot surgeons use.

  24. David Smith

    David Smith Well-Known Member


    Simon has said it already in not so many (big ) words I thought I said it (but perhaps not) and LL definetely said it:

    Representative Heuristic and Confirmation bias (Robert, you should be all over this like a rash ;)

    We classify things and events by their similarity and frequency and then we conveniently only remember or log the similar things or concomitant events that confirm that assumption. Most of us don't have the time, inclination or money to do quality research that gives absolute definition even if it were possible (and its probably not in so much of the work we do) and so we use the convenience of cognitive assumption

    Cognitive assumption
    "There exists a circular relationship between learning, meaning and memory. What is learned is affected by its meaningfulness, and the meaning is determined by what is remembered, and the memory is affected by what we learn. Basis for cognitive theories."

    Refgads Dave
  25. Phil Wells

    Phil Wells Active Member


    I think it may be due to specific tissue stress reduction verse improved function.
    The best analogy is if we break our arm we splint it (In some form or another) to reduce tissue stress that causes pain.
    When this force is no longer needed, we remove the splinting and carefully start using it again to re-instate function.
    It 'may' be possible that by elevating the 1st met the foot is splinted - pain avoidance mechanics, improved lever arms etc etc - and the pain reduces.
    The patient then feels better and removes the insoles and lives happily ever after OR develops the symptoms again, wears the insole until better and repeat etc.

    However this would only work in very simple pathomechanical cases (which may be the majority of the people attracted to the 1st met elevating group) and where we are dealing with multifactorial causes, then a good clinician who uses mobs and manips, orthoses, rehab may uses the function enhancing approaches -e.g. 1st met enhancement.

    Just a thought.

  26. Ben

    Ben Member

    I think leg shape has a lot to do with why a varus extension will work along with what Kevin said in regards to the proximal construction and stiffness of the device. I do use these successfully with runners and PTTD, but not sure would for general walking and definitely not for any lateral movement/court sport activities.
  27. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Over the past few years I have been publishing on my research and findings. Unfortunately, there appears to be a misunderstanding on what I am proposing. The Metatarsus Primus Supinatus foot structure (AKA Rothbarts Foot) is an abnormal inherited foot structure in which the first metatarsal (only) is structurally (not positionally) in supinatus (structurally inverted and elevated) relative to the embryological lateral column of the foot (this includes metatarsals 2 - 5).

    Even in this thread, the intervention for treating Rothbarts Foot is presented as elevating the first metatarsal. This is not the case. The therapy is placing a proprioceptive signal underneath the first metatarsal which is in supinatus (when the STJ is placed in joint congruity, the supinatus of the first metatarsal becomes evident).

    If a (Rothbart) proprioceptive insole was placed underneath a foot other than the Rothbarts Foot or the PreClinical Clubfoot Deformity, you would jam the first MPJ, that is, you would jam the articular facet of the proximal phalanx against the superior aspect of the head of the 1st metatarsal.

    All this is explained in detail on my research website. You can read in detail about the Rothbarts Foot and the PreClinical Clubfoot Deformity

    Craig, regarding how proprioceptive insoles function, I published a paper earlier this year in Podiatry Review where I presented a theoretical model that I believe explains how proprioceptive insoles work. Obviously more research needs to be done. However, this paper is a starting point.

    Kevin, just to correct one of your misassumptions. I am not connected in anyway with the company that sells PCIs. Over 15 years ago I designed this insole. However, since then I have made many changes, none of which are incorporated in the PCIs currently being sold. Bottom line, I make no profit from the sale of PCIs.

  28. AppleCake

    AppleCake Welcome New Poster

    Hello my first comment on P Arena
    I come from the mists of time and awoke in 2009 to find a whole new world. Once called hallux valgus and rotation of the two phalanges I have found can cause the nail plate to act as a knife at the final stage of weight bearing ooch! An extension to the INSOLE (get up those in shock its only a word will I be struck off for using it?) beneath the first MP Joint can mean the other foot has reached the ground before the force is exerted on the nail sulcus. Make do and mend is sometimes appropriate.
  29. :welcome:

    and What ?
  30. HansMassage

    HansMassage Active Member

    I got slapped for bringing this up in another thread. I am glad to see it get a logical discussion.
    In practice in the chiropractor's office if the client could not get the first met to the floor without ankle distortion we brought the floor up to the first met. as their posture improved we removed the pad. If they truly had a Morton's foot then it was the same as those with a short bone in the leg or thigh, it is an adaptive orthotic that allows normal motion.
    At a conference where we were discussing leg length discrepancy, a lady was referred to me that had severe Morton's foot. she was wearing the only foot wear she had ever found that was comfortable. It was a pair of thongs where the thong had been glued between the sole plate and the top plate under the head of the first met.
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
  31. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Hi Hans,

    When I talked to Janet Travell (nearly 15 years ago), we discussed the short first metatarsal vs a first metatarsal in supinatus (structurally elevated and inverted). I suggested that the reason the extension pad underneath the first metatarsal worked so well, was not because it was functionally extending the first metatarsal, but because it was applying a proprioceptive signal underneath the metatarsal (by virtue of the thickness of the pad).

    She found my research thought provoking and just before she died, wrote me a letter saying that I may have well discovered the third dimension of Morton's Foot (the elevatus).

    Since then, my studies on the embryological development of the foot has led me to the conclusion that the Primus Metatarsus Supinatus (AKA Rothbarts) foot is much more common than Morton's Foot.

    Prof Brian

    Rothbart BA 2009. Morton's Foot vs Rothbart's Foot. Are They the Same? Podiatry Review, Vol 66(3):6-9.
  32. User7

    User7 Active Member

    Dear Brian,

    Primus Metatarsus Supinatus (PMS) is an interesting idea. I've looked at the two references you provided above about this morphological variation. But in both articles I only see digital art showing the supinatus of the talar neck that defines PMS. Are there any references (primary ones, preferably) you can refer me to that show radiological evidence of PMS?

    I would need to see clear x-rays or CT scans comparing normal and PMS feet of adults before I could accept PMS as a real morphological variation. Without such evidence, it's too easy to conclude that an inverted forefoot relative to the reafoot is either an acquired deformity (forefoot supinatus) or Root's (much less fashionable) forefoot varus.

    If such comparative images have not been published previously, would you consider posting them here?

  33. User7

    User7 Active Member

    Craig, does this "Spanish school" have any published work we can refer to that would explain their perspective? Did they explain to you why they thought a Morton's extension trumped your approach?
  34. Craig Payne

    Craig Payne Moderator

  35. Dananberg

    Dananberg Active Member

    To answer Craig’s question about how different forms of care which are 180 degrees opposed to the other can possibly work. I have asked this question of myself many times. My sense of all this is as follows.

    Locking of the 1st MTP joint whether functional or structural, results in a compensatory type gait style in which the forefoot inverts. This has become known as the Locke Maneuver which Ray Locke described over 40 years ago to describe the inverted type gait exhibited by subjects with hallux rigidus. The foot can “use” this whenever the ground, for what ever reason, prevents 1st MTP joint dorsiflexion from occurring during its normally timed sequence. Weight is shifted laterally on the foot and the 1st joint is successfully avoided.
    When using a Morton’s extension and/or 1-5 varus post, the natural compensatory inverted foot position is supported. Over time, however, it has been my experience that these need increasing amounts of “control”, as the supported position becomes insufficient over time and more is necessary to create the same effect.

    So, the difference is that one method attempts to permit normal 1st MTP joint ROM, while the other supports the compensatory mechanism with shorter term success.


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