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Young Boxer's metatarsalgia

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Oct 22, 2008.

  1. David Smith

    David Smith Well-Known Member


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    Dear all

    I was wondering if you might be able to give some advice with the problem outlined below?

    I have a customer who is a young boxer 17rs old (No1 junior in GB) who has very painful metatarsalgia both feet. He has very low plantarflexed but compliant 1st ray/mpj but this quickly becomes very stiff as the hallux is dorsiflexed because the plantar fascia is short and stiff and very prominent under a cavus compliant arch. The pain is sub 1st 2nd met heads but more diffuse than just sesamoiditis but is more painful on the 1st met head.

    The problem is that everything is fine during normal walking and running it is only when boxing training that the pain becomes, as he describes, unbearable. In the dynamic boxing stance, only the very distal forefoot is on the ground (no heel or mid foot contact) and there is constant lateral and torsional shear as he moves back and forward and internally rotates the front foot to induce power thru the hip and shoulder to make an effective jab. The rearfoor internally rotates in a simmilar fashion to develop power for the cross.

    He has had valgus forefoot extensions fitted to the soles of his boxing boots by the NHS, which did not reduce pain but increased time till pain. He had other various pads and orthoses made but these made no difference since they were typical manufacturing design (eg root) and he does not make use of any rear or midfoot accomodation or control since he never has contact with them in training and fighting.

    I had thought of 6mm silicon with nylon backing ( as suggested by Robert Isaacs)as a simple insole to reduce shear forces, also Vasyli make a new insole called the Armstrong, which reduces shear forces by using a teflon sheet sandwiched between layers of shock attenuating material. (in conjunction with the modified boots)

    Anything more accomodative or custom should not tend to dorsiflex the hallux more than is neccessary since this stiffens the 1st ray dorsiflexion signifcantly and early.

    Do you have any ideas? have you come across this problem before?

    I have a videos if you would like to view them but each one is about 40mb so might go over the download limit.


    All the best Dave Smith
     
  2. efuller

    efuller MVP

    I think you have the answer in the valgus wedge. In boxing, he's up on his toes. With the geometry of the foot (lateral mets shorter) the longer mets, 1&2, will bear the weight. (symptoms only when boxing) Bring the ground up to the lesser mets. It may be a very big wedge. Bigger than he, or you, would like for other activities. Have him stand and then lift the heel off of the ground and look at the distance between ground and fifth met head. Before that, try assess STJ position in "boxing" stance. He may tend to keep his foot in a more pronated position and that will increase the tendency to bear weight on 1 & 2.

    The only other option is to find a way to supinate his STJ when he is up on the ball of his foot. This may make him too laterally unstable.

    This another example of thinking in the tissue stress approach. If it hurts in a certain position, analyze that position and reduce the stress in that position.

    Cheers,

    Eric
     
    Last edited: Oct 22, 2008
  3. Scholl Party feet, designed for disco dancing in high heels. Sometimes simple solutions work well.
     
  4. Prefer something like Maxacaine. Much, much more shearing capacity. Not sure an insole is the way to go though. Perhaps a flat base with a renewable 6mm forefoot gel segment so he can replace it when it shears through which it will do pretty quickly.

    Try him with it and if it works sell him a whole sheet of the stuff (you can buy it from algeos) so he can do it himself would be my advice. The eternal dilemma. Softer = wears out quicker. Doubly true of gels.

    Sent you a sample of Maxacaine 6mm BTW dave. Did you spot that in your last package? Personally i love the stuff even though it does not last very well.

    Regards
    Robert
     
  5. What are the adhesive properties like?
     
  6. David Smith

    David Smith Well-Known Member

    Robert

    Yes I got that thanks although the envelope sat on my desk with the Footprints for a couple of days before I realised that it was in there.

    Cheers dave
     
  7. Depends. The Gel itself is stabilised between a layer of lycra and a flexible impermeable layer. Either both or neither can be removed. If i'm sticking it in a shoe i usually use double sided tape on the white side and leave the lycra on. If i'm taping it to a foot i usually use the 3mm version and remove the white layer so the gel is in direct contact with the foot (really good on very fragile skin and stretching over prominant HAV).

    If you pm me your snail mail i'll send you a sample, probably easier than describing it!

    Kind regards

    Robert
     
  8. Graham

    Graham RIP

    Robert,

    When throwing a punch the foot on the side which throws the punch goes though an rapid adductory twist followed by an immediate abbuctory twist to return the foot to it's base position.

    Try a reverse mortons extension and cut out the first ray. This will allow some purchase through the first mtpj and spread the load a little.

    Regards
     
  9. Yeah, I have played with gels before and commonly they do not adhere well to other materials. The reason I asked was because you said:

    Just wondered how you adhered the gel to the "flat base" - double sided tape?

    P.S. any potential downsides to standing atop a wobbly jelly when boxing?
     
  10. vontabago

    vontabago Member

    Hi I am a pod student.

    I was wondering what type of forefoot valgus he has? Is compensation taking place at the mpj a flexible forefoot vagus, or is it a rigid forefoot valgus, where compensation is taking place at the subtalor joint. Also if this is the case then peroneus longus has the mechanical advantage of planter flexing the 1st ray hence the hallux planter flexed position. The main reason I am metioning this is because I have been taught, if its flexable forefoot valgus use a lateral control posting, and if its rigid use cut outs with possible rear foot control. But none of these have been applied?
     
  11. efuller

    efuller MVP

    Hi Von,

    A couple of points
    It might be helpful for you to think about forefoot valgus in terms of STJ axis position. When the axis is lateral to the first met head force on the first met head will cause STJ supination. And when the axis is medial to the first met head, ground reaction force will cause pronation of the STJ. I find this a much better explanation of why there is a "rigid" and a "flexible: forefoot valgus.

    In the case of the boxer the wedge isn't really treating a forefoot valgus. It's treating foot geometry. The first and second mets are longer than the other mets so when the ankle is plantarflexed more weight will be on the longer mets as opposed to the shorter mets. The boxer is up on his toes, so the ankle is plantar flexed. Yes, it would probably be possible to supinate the STJ to get weight on the shorter mets, but there would be an increased chance of ankle sprains. Watch some people walk barefoot. You will often see the 5th met head off of the ground a significant amount of time before the medial forefoot is off of the ground.

    Regards,

    Eric Fuller
     
  12. Phil Wells

    Phil Wells Active Member

    Dave

    Have you thought about modifying the boxing boots?
    It may be possible to add everted posting with a variable geometry - we do this regularly with rocker sole mods - to apply a very specific load. Within these mods it is also possible to add varying degrees of material compliance to load/off weight the foot.
    Also if you need to reduce shear forces, there is a material called Shearban that it a self adhesive teflon sheet - used with AFO's for CPalsy.

    Hope this helps


    Phil
     
  13. David Smith

    David Smith Well-Known Member

    Phil

    He had one pair of boot with an externaly added valgus post on the forefoot - Tell me more

    Dave
     
  14. Phil Wells

    Phil Wells Active Member

    Dave

    Rather than trying to apply a force via wedging alone, it is possible to try and change the COP via adding lower density, compressible material such as Poron to the opposing axis of the STj etc. (very similar to Craig's method of variable density heel raises) I would also look at shaping the lateral posting to mimic the angle of the Stj axis.
    How about surrounding the lateral forefoot wedging with poron and extending into the toes and back into the met shafts?
    This can all be done with a simple insole but once it is effective, then this can be incorporated into the sole of the boot. This always seems more effective as the 'lever' arm is larger as it is further away from the point of application.

    What do you think?

    Phil
     
  15. efuller

    efuller MVP

    Hi all,

    Not that I do much viewing of boxing, but doesn't a boxing shoe have minimal additional room for wedges? Is that why the wedge already added was added externally?

    Eric
     
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