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Dec 1

Written by: Larry Huppin, DPM
12/1/2011 8:02 AM

I saw a patient this morning who presented with significant pain affecting the right foot, particularly in the area of the first metatarsophalangeal joint. Fourteen months ago, she had surgery to correct a bunion. It appears that she likely had a head procedure. She developed a nonunion, and then six months ago had a second procedure; a plate was added. She was nonweightbearing for a number of weeks and used a bone stimulator. The nonunion seems to have healed, but she is still having significant pain. She has been using Rocker soled shoes and she did receive a pair of orthotic devices.

She has continued to have significant pain affecting the right foot particularly in the area in the first MPJ and along the first metatarsal shaft.

The examination is most significant for pain with pressure at the first MPJ and along the first metatarsal shaft. She looked to have a short first ray.

Radiographs showed a significantly short first metatarsal.

In gait, she had significant pronation and had no purchase of the hallux on the right side.

She was wearing great shoes. They were stable with a Rocker sole. Her orthotics, however, were another story. She received a pair of carbon fiber orthosis. Unfortunately, the orthosis gapped significantly from her arch and were somewhat too long. An orthosis that does not conform closely to the arch often can cause an elevation of the first ray as the arch of the foot has to flatten just to let the foot reach the orthosis. Having the device too long also applies force directly under the first metatarsal head, further elevating the first ray. Sadly, this patient had spent a significant amount of money on an orthosis that was likely making her problem worse.

We should be able to relieve much of her pain by using an orthosis that conforms closely to the arch of the foot in order to transfer pressure off of the first metatarsal head. The device should also act to reduce excessive pronation and also help to encourage hallux purchase.

To evaluate my theory, I applied a low dye taping. Along with the tape, I added a piece of felt at the medial heel to act as a medial heel skive, felt under metatarsal heads 2-5 to act as a reverse Morton’s extension and also put some felt under the hallux in order to allow it to purchase. I had her wear this around for about 10 minutes and she reported that she had almost 100% relief of her symptoms and felt better since she had the surgery.

She is going to be returning to clinic for casting for orthotics. I will write another blog at that time and discuss the orthotic prescription in detail.

ProLab takes a scientific approach with our orthoses by integrating evidence-based medicine into orthotic therapy. Our team of Medical Consultants regularly evaluates the medical literature pertaining to orthotic therapy and biomechanics. ProLab clients are encouraged to contact a medical consultant whenever they have questions about an orthotic prescription.

For an easy way to stay up-to-date on evidence-based orthotic therapy, subscribe to our free E-Journal. Your will receive a monthly email synopsis of the research that impacts your practice.

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