Written by: Larry Huppin, DPM
9/14/2009 2:00 PM

Today we are going to look at a case study from my office – one that I find a bit disturbing in that two podiatrists wanted to perform surgical exploration on a problem that was easily handled with orthotic therapy. The patient is a 49 year old podiatrist (yes, a podiatrist) with a primarily CNC practice.

He has a 7 month history of pain at the plantar base of the 5th metatarsal. He reports a history of stepping on some glass about 8 months ago. A friend who is a physician removed a glass fragment, but since then he has had pain on the plantar foot near the 5th met/cuboid joint. He had both MRI and diagnostic ultrasound – both of which were negative for evidence of foreign body.

He has since seen two local podiatrists. Both of whom advised surgery to explore the area for foreign body.

His exam was significant for a cavus foot structure with a plantarly prominent styloid process right. Pain to palpation was present on the right foot at the plantar styloid process. No foreign body or mass was palpated On the left the styloid was prominent, but there was no pain.
Both heels were inverted moderately in gait and stance.

My diagnosis was a capsulitis / arthralgia of the 5th met / cuboid joint, secondary to increased pressure in this area caused by the large styloid and lateral column overload due to the inverted heel. The foreign body may have started the inflammatory process but there is simply so much pressure on this area that the inflammation never had a chance to resolve.

My thought was that we simply needed to reduce pressure on the painful area. The goal of treatment is to transfer force off of this painful area near the base of the 5th metatarsal. I recommended an orthosis with the following Rx:

• Vacuum Formed Polypropylene 4mm with EVA arch fill. We use the EVA fill so that in the event that the sweet spot is not deep enough, we can grind out the sweet spot and even grind through the polypropylene. With the EVA fill present, we do not end up with a hole in the poly.
• Deep heel cup
• Wide width. By making the device wider, we better transfer force off of the lateral column onto the medial column
• Cast Fill: Very minimum fill right, minimum fill left. Very minimum fill results in an orthosis that conforms very close to the medial arch of the foot. This will transfer force from the lateral column to the medial column.
• Sweet spot for styloid right
• Polypropylene rearfoot post. I want a firm post that will not compress laterally. This will result in faster pronation to reduce time (and force) on the lateral column.
• EVA cover to toes glue heel only. The cover is glued behind the sweet spot so that the sweet spot can be adjusted easily.
• Add 1.5mm poron to bottom of cover. This extra layer of cushion can help disperse pressure around the styloid
• Do not bevel post laterally on right. No lateral bevel will increase the velocity of pronation and decrease time spent on the lateral column.
   

Trackback Print

Location: Blogs Larry Huppin, DPM Case Studies

Your name:
Title:
Comment:
Security Code Enter the code shown above in the box below
Add Comment    Cancel