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Archive for January, 2019

ICB Lower limb biomechanics

Metatarsalgia is a general term used to denote a painful foot condition in the metatarsal region of the foot, the area just before the toes, more commonly referred to as the ball of the foot. Thomas G. Morton ( I867) is credited with identifying the condition1. This is a common foot disorder that can affect the bones and joints at the ball of the foot. Metatarsalgia (ball of foot pain) is often located under the 2nd, 3rd and 4th metatarsal heads, or more isolated at the first metatarsal head (near the big toe). Differential diagnosis of Metatarsalgia is Morton’s Neuroma which exhibits localised pain than Metatarsalgia.

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This as often it affects the sufferer’s quality of life. Metatarsalgia restricts the distances patients can walk, and causes extreme pain and discomfort. It is a simple condition to treat effectively, however left untreated, this condition can be debilitating to its sufferers.

Typically the patient will present with an ‘all over burning or stone bruise feeling’, often the foot will feel swollen.

There are many contributing causes for the condition, the main one being excessive pronation. Other issues such as diabetes, Rheumatoid Arthritis, gout and excess fluid build up can all provide the environment to promote the development of increased stress on the ball of the foot resulting in Metatarsalgia.

Most articles written about the condition appear to combine Metatarsalgia and Morton’s Neuroma, whereas there are two distinct conditions, one a generalised all over pain or feeling of discomfort and the other (Morton’s neuroma) a specific localised pain usually presenting between either the 2nd and 3rd or 3rd and 4th meta-tarsal joints.

The more common and certainly the easier condition to address is Metatarsalgia in which excessive pronation appears as the main underlying causative factor. General podiatric opinion appears to credit the cause as ‘a forced change of the dynamics of the foot’ as outlined by ACFAOM (American college of Foot Orthopedics & Medicine). Increased obesity is often a ‘trigger’ as it places additional stress on the foot structure.

Excessive pronation for any length of time can cause weakening of the soft tissue structures and as a result ligamentous laxity and muscle wastage will occur. As this occurs in the forefoot, the metatarsals plantar flex and rotation takes places resulting in the loss of the transverse arch.

These shearing forces on the forefoot structures causing pressure and pain.

Long term damage to the nerves may be caused and callosities will be exhibited in the patient. With this condition one or more of the metatarsal heads become painful and/or inflamed, usually due to excessive pressure over a long period of time. It is common to experience acute, recurrent, or chronic pain with Metatarsalgia. Also, as we get older, the fat pad in our foot tends to thin, making us much more susceptible to pain in the ball of the foot (Cailliet, 1983; Lorimer et al, 1997).

Treatment

Research has indicated that nonsurgical management is usually sufficient to achieve satisfactory results2 when dealing with Metatarsalgia. We should be encouraged to pursue conservative treatments as a first approach after establishing the underlying causative factors such as mechanics, foot anatomy, and foot and ankle deformity.

1. Identify if the feet are pronating or supinating.

2. If pronation exists then place the foot into the ideal or subtalar neutral position, and identify the amount of pronation, i.e. slight, moderate or severe. This will help you identify the appropriate ICB Orthotic type to heat mould – then mould the orthotic to the subtalar neutral joint position(STJ). It is considered that mild pronation needs less support, whilst severe pronation requires firmer orthotic support.

3. Don’t forget to consider the patient’s body weight also – light weight patients need less control than overweight patients.

If the patient has been excessively pronating for a long time, not only will they have lost the longitudinal arch but they may have also lost the transverse arch.

This situation will require that the practitioner heat moulds to the patient’s neutral calcaneal stance position, and will then apply a metatarsal dome to restore the transverse arch.

The size of the dome will depend on the width of the foot – i.e. a narrow foot will only require a small metatarsal dome, a wide foot, a larger dome. The function of the metatarsal dome is to promote the transverse arch and separate the metatarsal heads to prevent nerve impingement and entrapment.

If the foot is supinating or the patient has a high Pes Cavus foot type this allows increased pressure on the metatarsal heads and callous formation. Always check for a forefoot valgus deformity greater than 10˚. A plantarflexed 1st ray (metatarsal) can also elicit a lateral shift as compensational repositioning of the foot and may present with a forefoot valgus anomaly together with a pes cavus foot type and often clawed toes will be present.

If you identify a forefoot valgus larger than 10˚, place a Forefoot Valgus addition (approximately half the size of the valgus to start with), and heat mould the ICB Orthotics with the Forefoot Valgus attached.


NOTE: The Addition should be attached prior to moulding, otherwise the orthotic may become unstable in the shoe.

If the patient presents with a plantarflexed 1st ray, the practitioner will need to cut a deflection around the 1st MTPJ to allow the 1st metatarsal head to drop down, and the lesser metatarsal heads will then be supported by the orthotic.

For patients with both a forefoot valgus and a plantarflexed 1st ray, a metatarsal dome needs to be added to the dorsal surface of the orthotic (AFTER heat moulding), to lift and separate the metatarsal heads and reduce the clawing effect on the digits.

Often an orthotic alone is not enough and the practitioner may need to incorporate additional treatment modalities, such as:

•  Appropriate shoe with wide and deep toe box

•  Foot Mobilisation Techniques

•  Sports taping to provide short term relief by mimicking the role of foot orthotics.

Weight reduction can assist to reduce gravitational pressures.

In more severe cases non-steroidal anti-inflammatory medications or simple painkillers.

Elevate and rest after periods of standing and walking. This will take pressure off the ball of the foot, and allow it to recover.

Ice pack at the site of the pain for 20 minutes on, 20 minutes off, may provide additional relief.

A combination of orthotic therapy and other such treatment methods will undoubtedly be beneficial to long-term treatment success.

 

REFERENCES
1. K. I. Nissen, Plantar Digital Neuritis – Morton ‘s Metatarsal-gia JBJS, Oct 1946 p84
2. Norman Espinosa, MD, James W. Brodsky, MD Ernesto Maceira, MD Metatarsalgia J Am Acad Orthop Surg August 2010 vol. 18 no. 8 474-485
General references
CAILLIET, R. (1983) Foot and Ankle Pain, Philadelphia: FA Davis Com-pany
LORIMER, D., FRENCH, GWEN, & WEST, S. (1997) Neales Common Foot Disorders: Diagnosis and Management, 5th Edition, Melbourne: Churchill Livingstone

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Bunions: Hallux Abducto Valgus is a deformity characterised by lateral deviation of the great toe, hence the most commonly used medical terms associated with a bunion anomaly are the terms ‘hallux valgus’ or ‘hallux abducto-valgus’ and ‘HAV’. The term hallux refers to the great toe or the ‘big toe’ and “valgus” refers to the abnormal angulation of the great toe which is commonly associated with bunion anomalies. This video shows the 3 stages of bunion deformity.


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The use of the terminology abductus and abducto identifies that the direction of the hallux is away from the mid line of the body and approaches the second toe.

In the later stages of the bunion develop-mental progression the deformity can typically result in dislocation of the hallux from the metatarsal head1.

The answer to the question of ‘what causes a bunion’ is quite complex. A patient’s biomechanics is the main contributing factor behind the development of a bunion, however, tight fitting shoes can often aggravate the condition during its development.2

Excessive pronation will cause forces to be applied to the forefoot, with increased load on the 1st metatarsal head in an adducted direction. This will allow rotation of the shaft and in turn the hallux (big toe) will compensate by abducting.

A short 1st metatarsal or hyper mobile feet are considerably more susceptible, in this situation, the patient’s biomechanics is hereditary. As the 1st metatarsal adducts, rotates and drops to the ground to provide stability for the structure, a short 1st metatarsal shaft is a major contributing factor in the adduct-ing of the shaft to the midline of the body . When combined with pronation this caus-es the hallux to abduct, hence the term ‘Hallux Abducto Valgus’. (Lorimer et al, 1997; Selner et al, 1992; De Valentine, 1992).

In addition to the common HAV there is an alternate bunion known as a ‘Tailor’s bunion’, which is also described as a ‘bunionette’, a condition caused as a result of inflammation of the fifth metatarsal bone at the base of the 5th phalange or little toe.3

Similar foot mechanics issues appear to be the underlying causative factor being a shorter 5th metatarsal shaft which deviates or abducts away from the midline to gain ground control or stability , in turn the 5th digit adducts toward the midline of the body.

Three Stages of Bunion Development

Orthotic therapy at each stage can reduce the incident of the bunion progressing to the next stage.

1.Primary Stage: usually occurs from adolescents up to the age of 25 years. A primary stage bunion presents as a slight bump See Fig 2

2. Secondary Stage; occurs generally at between the ages of 25 and 55 years. The 1st metatarsal head adducts and the hallux abducts causing pressure on the 2nd digit. Callosity may develop on the medial side of the 1st Metatarso Phalan-geal Joint and medial hallux. See fig 3

As the foot continues to pronate over several years the ground reaction forces en-courage the hallux into abduction and the extensor hallucis longus also becomes tight and pulls the hallux further across in a ‘bow’ like effect.

3. Tertiary Stage: If this situation is not controlled with orthotic therapy at the sec-ondary stage to prevent the condition from progressing further, the bunion will eventually move into the Tertiary Stage (or the 3rd stage– Fig 4). In the tertiary stage of Hallux Abducto Valgus an overlap-ping of the hallux occurs either above or below the 2nd digit. See fig 4 As this takes place the patient’s shoes become difficult to wear, and find it hard to find shoes to accommodate, as most shoes will aggravate the 1st MTPJ on the medial side (Thordarson, 2004).

This stage is very difficult to treat, the patient may be in extreme pain and often find it hard to find footwear that can accommodate for the deviated hallux. Patients may need to consult an orthopedic surgeon to surgically correct the bunion deformity. Following surgery, the patient will need to have orthotic prescribed to treat the underlying biomechanical condition. Orthotics are essential to give the foot realignment and support, and prevent the reoccurrence of the Hallux Abducto Valgus (bunion).

Treatment

Night splints do not appear to be very successful in the correction of the HAV but may be of assistance to properly prescribed orthotic devices which will are designed to realign and control the patient’s excessive pronation thus reducing the development of the bunion. The night splint and alternatively bunion strapping may be of assistance during the first stage of bunion development, however the benefits may be undone when the patient engages in weight bearing activity without foundational correction

Prescribe an orthotic to realign and control the patient’s excessive pronation. Heat and mould the orthotic with the foot in the Neutral Calcaneal Stance Position (NCSP). Following heat moulding, monitor the patient, ensuring the orthotic is adequately controlling the excessive pronation – thus preventing further development of the bunion.

When treating hallux abducto valgus with orthotic therapy, it is important to explain not only the causes of bunion development but also the 3 stages. By doing so the patient will understand why they need to wear orthotics and that by doing so they will prevent the bunion from progressing to the next stage.

Treating Hallux Abducto Valgus with orthotic therapy will realign the foot, limit calcaneal eversion, thus controlling excessive pronation and taking pressure off the 1st MTPJ. However, monitor the bunion closely, if it worsens or continues to be painful, review the prescribed orthotic – make sure the orthotic is providing enough control, and check if the patient is continuing to excessively pronate through the orthotic. If the patient is continuing to excessively pronate it may be necessary to pre-scribe a firmer density orthotic such as the ICB Firm Green Orthotics, to ensure correction and control is being achieved.

If the patient presents with a short 1st metatarsal shaft, the practitioner can create a Morton’s Extension on the orthotic. To do so place a Forefoot Orthotic Addition under the hallux (attach using double sided tape) – this treatment is only successful in the first stage.


References:
1. Thomas .C. Michaud Foot orthoses and other forms of conservative foot care 1997 P72
2.Bunions (Hallux Abducto Valgus)”. Footphysicians.com. 2009-12-18. Infor-mation Retrieved 2011-03-20- Tailor’s Bunion”.
General References
DE VALENTINE, S.J. (Ed) (1992) Foot and Ankle Disorders in Children, New York: Churchill Livingstone
LORIMER, D., FRENCH, GWEN, & WEST, S. (1997) Neales Common Foot Disorders: Diagno-sis and Management, 5th Edition, Melbourne: Churchill Livingstone
SELNER, A. J., SENER, M.D., TUCKER, R.A., & EIRICH, G. (1992) Tricorrectional Bunionecto-my for Surgical Repair of Juvenile Hallux Valgus, JAPMA
THORDARSON , DAVID B. (2004) Foot & Ankle, Lippincott Williams & Wilkins

 

A common complaint amongst patient’s who have been prescribed foot orthotics is ‘pain in the arch’. This type of pain can be the result of 4 common issues:

1. Pain can be due calcification (similar to dupuytren’s contracture in the hand), a fibroma in the body of the Plantar Fascia, or a Ganglion cyst may be present.

TREATMENT: If there is calcification in the fascia, use manual therapy to break it down. For a fibroma or Ganglion cyst, a deflection will need to be heated into the orthotic to accommodate and relieve any pressure from this area.
Watch the video: Using heat to make a deflection in an ICB Orthotic.

2. Plantar fasciitis pain can be experienced at the attachment to the calcaneus.

TREATMENT: Control rearfoot pronation using orthotics with intrinsic rearfoot posting to realign the feet to the Subtalar Joint Neutral Position (STJN). If addi-tional inversion is required to control and achieve STJN, add extra rearfoot wedg-es (2° or 4°) to provide additional Calcaneal control1.

A medial arch infill can also be applied to the orthotic to provide increased arch support.

Watch the Video: Plantar fascial groove in a ICB orthotic. 

3. The Plantar fascia may be tight, and during gait (at mid stance to toe-off), compressing into the medial longitudinal arch of the orthotic causing discomfort and pain. To test for a tight fascia use the ‘Windlass Test’ see below.

Watch the video about the Plantar Fascial Groove.

TREATMENT: Create a plantar fascial ‘relief’ or ‘groove’ in the arch of the orthotic using heat or by grinding the orthotic. Place the groove 1cm from the medial edge through the arch contour.

 

4. The patient may exhibit unilateral excessive pronation as a possible compensation for a leg length discrepancy.

TREATMENT: Unilateral arch pain can be associated with a leg length difference2 due to long leg compensatory excessive pronation. If a structural leg length discrepancy is identified, a heel lift will need to applied to the orthotic on the shorter leg.

References:
1. FROWEN, P., O’DONNELL, M., LORIMER, D., BURROW, G. (2010) Neales Disorders of the Foot 8th Edition, p127 2. MICHAUD, T.C. (1997) Foot Orthoses and Other Forms of Conservative Foot Care, Sydney: William & Wilkins, p.114

One question that is often asked is ‘When should an orthotic be used in conjunction with the patients treatment program?

Many practitioners grapple with this issue and it can be confusing, especially if orthotic therapy is not used regularly in clinical practice.

One starting point is to examine the common conditions where orthotics are or have been recorded as being effective. The use of orthotics can be beneficial in many circumstances and so practitioners should be aware of the application and treatment. Doing this will make available to their patients treatment choices when attending to lower limb biomechanical conditions.

Practitioners should use their own modality in conjunction with orthotic therapy, or develop relationships with practitioners from other modalities, thus combining treatments to provide the patient with a holistic regime.
Orthotic therapy is not a definitive treat-ment, it should be regarded as just one part of the treatment protocol.

The common conditions that an orthotic can treat include:

  Bunions
usually caused by a short 1st metatarsal1 and aggravated by excessive pronation at  mid-stance to toe off 2.


  Ball of Foot Pain
collapsing and rotating of the metatarsals result-ing from excessive pronation.


  Plantar Fasciitis / Heel Spur
excessive pronation causes the fascia to elongate and tear from the calcaneal attachment. Spurs are a secondary compensation.


  Severs Disease
(children’s heel pain) – related to excessive pronation and growth spurts in children and affects sporting children more than sedentary ones.


  Achilles Pain
excessive pronation and supination creates a point of pain stress point.


  Shin Splints
lateral, medial, anterior – excessive pronation and supination are key contributing factors.


  Knee Pain
collateral ligament strain due to excessive pronation and supination factors.


  Osgood Schlatters Syndrome
occurs due to a combination of tibial tuberosity immaturity and quadriceps tightness3, growth spurts and tibial rotation factors.


  Hip Pain
due to structural or functional leg length and supination factors including tight external hip rotators.


  Low Back Pain
Unilateral and bilateral pronation, and structural and functional leg length causing stress on the lower back L1-L5.


  Leg Length Syndrome
when a structural leg length difference is evident the long leg may excessively pronate as compensation to level the pelvis.

A report by The American College of FOOT & ANKLE ORTHOPEDICS & MEDICINE entitled Prescription Custom Foot Orthoses – Practice Guidelines, December, 2006 names the following conditions as being treatable with orthotic therapy :

1. Proximal Lower Extremity Pathology A. Shin Splints B. Tendonitis (Tenosynovitis) C. Posterior Tibial Dysfunction D. Chondromalacia Patella (Runner’s Knee, Patellofemoral Syn-drome) E. Iliotibial Band Syndrome F. Limb Length Discrepancy

2. Arthritides A. Inflammatory Arthri-tis, B. Rheumatoid Arthritis, Psoriatic C. Arthritis, Other Inflamatory Ar-thritides D. Osteoarthritis

3. Mechanically Induced Pain and Deformities A. Pes Cavus, Haglund’s Deformity B. Hammer Digit Syndrome C. Functional Hallux Limitus, Hallux Limitus and Hallux Rigidus D. Plantar Fasciitis E. Equinus F. Sinus Tarsi Syn-drome G. Tailor’s Bunion (Bunionette) H. Hallux Abducto-Valgus (Hallux Val-gus, Bunion) I. Pes Planus J. Metatarsal-gia K. Sesamoiditis L. Morton’s Neuroma (Intermetatarsal Neuroma)

4. Pediatric Conditions A. Calcaneal Apophysitis B. Genu Varum and Genu Valgum C. Tarsal Coalition D. Metatarsus Adductus 5 . Sensory Neuropathies A. Peripheral Neuropathy B. Charcot Neuroarthropathy (Charcot Foot)C. Tarsal Tunnel Syndrome So what is the starting point? And when should I use orthotics? First ,establish if the patient presents with a condition that is recorded as, being able to be treated with orthotics.

Check for pronation or supination. If the patient pronates, this will often be an underlying factor to many of the conditions mentioned above, treatment with orthotics to realign and control the rearfoot and support the longitudinal arch should be undertaken.

Identifying Lower limb biomechanical anomalies and foot mechanics issues relating to both pronation and supination will be a key treatment to realigning and controlling the rearfoot with orthotics.

Identify the amount of excessive pronation or excessive supination by correcting the foot to neutral and then allowing the patient to rest and relax their feet (NCSP and RCSP)* this will allow you to identify whether the patient will require a corrective orthotic product.

Next, check structural leg length and if a heel lift is required attach to the orthotic for the short leg, start by using ½ the measured amount or a 4mm heel lift addition. The long leg may be excessively pronating as compensation and will need to be supported by the orthotic. Never use a single orthotic, always prescribe a pair as this will maintain correct foundational balance.

If the foot is supinating the patient will experience jarring in the foot and to the upper structure, and will often have a rigid high arched foot type. This type of foot commonly exhibits a forefoot valgus deformity. The pes cavus type foot is not that common – about 8 – 9% of the population may present with it.

In this case an orthotic is required to control the supination by maintaining the Ideal / Neutral Calcaneal Stance Position(NCSP), use a forefoot addition to treat the forefoot valgus, whilst providing the patient with comfortable support.

Prescribing an orthotic for your patient base is easy as: 1, 2, 3

1. Identify the RCSP (patients Resting position).

2. Observe the NCSP (Neutral or corrected position) to identify the correct position for heat moulding the orthotic, and to help identify the pronation effect,
i.e. NCSP – RCSP = Total Pronation
Observation of Rearfoot positioning and Anterior positioning using ICB Anterior Alignment Method ( ICBAAM) see youtube.com/icbmedical


3. Check the leg length (manually) for any structural differences.

4. The Palpation for Supine Medial Malleoli Asymmetry Technique is an easy method which has been reported as having both Intra-examiner and inter-examiner reliability. The technique was clinically trialled at RMIT University 2005 by Gary Fryer4.
By following these simple steps more than 80% of the Lower Limb Biomechanical conditions practitioners see in the clinic on a daily basis can be treated effectively with orthotic therapy.
Patient’s should be instructed to wear their orthotics for 1-2 hours per day, increasing gradually over 1-2 weeks until it is comfortable wearing them full time. If discomfort is experienced, the patient should take the orthotics out of their shoes, and give their feet a rest. Continue until it is comfortable wear-ing the orthotics all day.

“When should orthotic additions be attached to the orthotic?”
Orthotic additions can be added on the subsequent consultation.
Forefoot & Rearfoot additions can be attached to the orthotics on subsequent visits – if required.

If you need any further assistance or advice with patient assessment, or prescribing orthotics View DLT Facebook, contact DLT Podiatry
email: sales@dltpodiatry.co.uk, or go to the website: www.dltpodiatry.co.uk


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