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orthotic considerations for patient following First MTPJ Fusion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by spike2260, Sep 9, 2010.

  1. spike2260

    spike2260 Member


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    hello all,

    Recently I recieved a referral from an orthopaedic surgeon to consider some form of orthotic therapy for a patient of his, i would like to add before i go on, the following surgical procedure was not completed by him.

    58 year old female with metarsalgia and a dorsiflexed hallux following an unsuccesful fusion of 1st MTPJ of the left foot. Patients history is quite remarkable, pateint is not taking any medication and suffers from no systemic conditions apart osteoarthritis. She had 1st MTPJ fusion one year ago and has, ever since had nothing but problems, not only is the hallux dorsiflexed she still continues to experience pain within the joint and suffers from metatarsalgia in that foot respectively.

    My quesiton is, would anybody consider there to be an appropriate orthotic to help manage this pain? as she is not keen to undergo any further surgery to rectify the problem, she said she has been left rather dispondant following the surgery and wishes she had never gone through with it.

    Would the course of action be to try to deal with the metarsalgia with met bar etc? During examination hallux is rigid and in a fixed dorsiflexed position.

    Any advice would be very much welcomed
     
  2. Spike,

    Maybe the best bet would not to look to orthotics 1st, but to look at shoes.

    A rocker bottom shoe with a stiff sole that will reduce the dorsiflexion forces on the 1st from Ground reaction forces.

    I would also suggest that metarsalgia is a bit like shin splints and more specific diagnosis may help with more specific treatment plans, but I would look at shoes.

    Hope that helps
     
  3. spike2260

    spike2260 Member

    Many thanks, i was wondering whether any orthotics would be appropriate and was consdiering whether a rocker bottom sole would be more benefical,

    Thank you for your input
     
  4. Jeff Root

    Jeff Root Well-Known Member


    I would need more biomechanical information to give you better advice. However, as a rule, a rigid hallux is compensated for by increased stj pronation. An orthosis that increases the propulsive nature of her gait (i.e. resists pronation) might exacerbate her 1st mpj symptoms because it will increase dorsiflexion moments of the hallux. One option is to use a pronated cast and make a polypropylene orthosis that has an anterior projection of the shell under the hallux. The shell will resist some of the dorsiflexion forces. If the extension is not well tolerated or proves to be too stiff, you can always cut it off and try just the pronated shell. I would also not use an extrinsic rearfoot post in order to allow more pronation. Additional information that might help would include the relative position of the 1st met. Is the 1st dorsiflexed relative to the second? If so, the metatarsalgia might be related to overload of the second, and the orthosis might help with that. What is her chief complaint, metatarsalgia or 1st mpj pain? How much rom is there in the 1st ray? What is her ff to rf relationship like? Any other description of foot type or functional observations would be helpful.
     
  5. Spike:

    Before we can help you and your patient, you will need to provide us with specific anatomic information as to where the symptoms are located exactly in the foot. The term "metatarsalgia" could include over 20 different anatomical structures.

    The following link may help:
    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144
     
  6. spike2260

    spike2260 Member

    Hi Guys,

    My Apologies for being so vague, I was in a rush this morning,examination revealed no rearfoot to forefoot abnormalities, and rigid fixed hallux with equal amonuts of Df to Pf of the frist ray bi-laterally, 1st met head is inline with lesser met heads so no plantarfelexed first ray etc, The metatarsalgis she experiences is overlying the 2nd and 3rd met heads Respectively. She had recieved a corticosteriod injection from which she claims to have been pain free since, ( this lead me to believe there maybe a possible intermetarsal bursitis present) pain is experienced in the great toe during ambulation particularly toe off.

    I hope that helps if i have missed anything please do let me know
     
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