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any advice appreciated, 24 y/o male blackbelt "someformof" karate full-time student (no money) has a hx of failed L/5th mpj fixation, non-union avulsion # at styloid process (or jones #)??? (not sure no imaging available) L/5 met. ...... 5xweek 1 1/2 hr karate lesson barefoot >> lots of pivoting on l/pma turning pelvis 90deg to left to enable a R/foot offensive kick ....... pain perceived only during pivot .... any ideas for pain relief measures (non-pharmacological) / referrals / anything, thanks, mark c

yep that's what i thought ... no ideas forthcoming ... i told him so ... i shouted (through a locked solid door) "mate, your stupid! your foot's buggered, try lawn-bowls!" ... as i'm checking my building insurance

Mark:

If you would write your clinical questions to us with fewer abbreviations, fewer acronyms, more significant clinical information and with an attempt at appropriate sentence structure and grammar, then probably more of us would actually perceive your posting to be a sincere and meaningful request for professional advice from a colleague. In turn, by you taking the extra effort to perform these commonly accepted protocols of professional courtesy, you would probably find that more of us would spend some of our valuable free time to give you advice. In addition, you may want to wait more than 24 hours for meaningful responses before you proclaim "yep that's what i thought ... no ideas forthcoming".

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

is that a "no" then kevin? i do appreciate your effort to
me a ticking off. Seems i'll have to send my son-in-law off to a podiatrist who uses more words in his sentences, mark c
PS as a biomechanical podiatrist i think you're exceptional!

I didn't quite get it from your explanantion, is the pain under the 5th MTPJ only or along the 5th ray? And only when he pivots on it during karate but does it hurt whilst walking/daily activities also? Why was the 5th MPJ fused for a styloid # anyway, I wonder?? yep, maybe lawn bowls is the answer...............

jos, as kevin quite rightly pointed out, i did an awful job of describing the hx / symptoms. the pain is concentrated at the head of the L/5th metatarsal and is only noticed when he trains, barefoot, and only when he pivots on the L/forefoot. he does compete at a national level so is keen to eliminate / ameliorate this distracting (and possibly detrimental) phenomena, thanks for reply, mark c

Mark:

I have found that the best way to deal with any injury of this nature (after over 20 years of dealing with nearly every imaginable injury to a foot), I first want to know a few basic things about the pain in the patient. First of all, I want to know about the quality of the pain. Is it a burning, tingling, numbing, aching, knife-like or throbbing pain? Second, I want to know when it occurs, what makes it better and what makes it worse. Third, I want to know when it first began to occur, and if it has been getting worse or better over the last few days/weeks/months. Fourth, I want to know the precise location of the most pain perceived by the patient and the precise location of the most tenderness that is determined by my exam. In other words, is it most painful/tender on the plantar, plantar-lateral, plantar-medial, lateral, dorsal-lateral, dorsal-medial, or dorsal aspect of the 5th metatarsal head? Fifth, does the patient have a biomechanical abnormaility that would tend to increase the ground reaction force plantar to the 5th metatarsal head that would be the most likely cause of an injury while barefoot? In other words, does he have a prominent plantar 5th metatarsal head, decreased 5th ray dorsiflexion stiffness, a metatarsus adductus, or does he have a "rigid forefoot valgus", a significant rearfoot varus or a partially compensated forefoot varus (using Root et al terminology)? In addition, does he have any plantar, lateral or dorsal 5th metatarsal head swelling, or areas of decreased skin sensation on the 5th digit?

My guess, from your limited history and physical description of this young athlete is that he should be icing the 5th metatarsal head area before he trains or competes for 10 minutes, after he trains or competes for 20 minutes and then one more time a day for 20 more minutes. If the fifth ray has a high degree of dorsiflexion stiffness or is exceptionally plantarly displaced, you may want to try showing him how to tape or adhere an 1/8" adhesive felt pad plantar to metatarsal heads 1-4 and proximal to the 5th metatarsal head while he trains so that when he does need to compete (assuming the pad won't be allowed on his foot during competitions) he will be less tender and symptomatic. If this does not work, an injection of cortisone solution into the symptomatic area would probably help greatly also.

And, Mark, I am glad to see you were a good sport about my earlier comments. Hope you didn't mind me using your posting to point out an obvious lesson to all of the readers of Podiatry Arena about the importance of being extra generous with useful information that everyone can understand (i.e. minimal abbreviations, minimal acronyms and written with exceptional clarity) when you are requesting one or more of us to share our professional expertise and experience with you.

Hope this helps your son-in-law continue to compete and excel in his sport of choice. Please let all of us know how he progresses.

Now onto my next 1,000 postings.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Yeah, i was going to suggest the ol' padding and strapping too- I would use a plantar pad with a "wing" for the 5th....maybe even a donut style pad if that first one doesn't work or feel comfy. Just had another thought....maybe try the reverse and pad over the area with something spongy (molefoam) to Increase cushioning and tape firmly...anything is worth a try! (although I guess it might spin off with all his pivoting! - tape well)

Thanks Kevin and Jos for your interest and advice.
When shod there is occasional throbbing. When barefoot a stabbing pain when he pivots on the forefoot and when he contacts uneven terrain which is elevated under the lateral forefoot eg corner of a mat

5 years hx with no known initiating factor, with a 'slight' improvement since the attempted 5th mpj fixation

Both symptomatic pain and elicited pain directly plantar to the 5th met head

Bilateral forefoot equinus, metatarsus adductus, increased 5th ray dorsiflexion stiffness

No swelling detected. Perceives light touch of cotton wool.

I have offered him your advice regarding icing and plantar pads and I will report his progress. Thanks again, mark c

Mark:

Thanks for this very thorough posting. :)

It is likely that his increased 5th ray dorsiflexion stiffness (which will increase the GRF plantar to the 5th metatarsal head as the lateral forefoot is loaded by GRF) along with his metatarsus adductus deformity (which will cause increased STJ supination moment due to the more medial position of the plantar forefoot relative to the STJ axis) are the most likely causes of the 5th metatarsal head symptoms. If you can show him how to place a pad on the plantar aspect of his lateral forefoot (plantar to the 5th metatarsal shaft to the 5th metatarsal neck) with 1/8" adhesive felt during training he will likely be a happy camper. The lateral forefoot wedging will serve the two-fold purpose of not only reducing the GRF plantar to the symptomatic 5th metatarsal head but will also increase the STJ pronation moments will will, in effect, "evert him off" the painful 5th metatarsal head.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I hope there is a plan B! Having suffered a large number of minor injuries to feet whilst performing angry Okinawan leaping and spinning the only thing i have ever persuaded to stick on the foot was zinc oxide tape and that only if it was wrapped all the way around the foot!

Might just be me as i tend to sweat like a pig in a sauna.

It's the price you pay. Lawn bowls is fun but does'nt teach you how to kick somebody so hard their kidneys fly out of their ears! (in a respectful, doing-it-to-learn-about-the-culture-and-acheive-inner-peace kind of a way)

Compound Benzoin might help a bit

Robert

Mark,

Barefoot dancers often use something called a "foot thong" to protect the plantar feet. Dancers obviously can do considerable amounts of spinning on the balls of the feet. They are designed to tie around the foot with padding at the PMA, and should stay in place better than most. A brief view of the internet shows that some come with extra padding. Although I have never had reason to use one, it looks as if extra padding could be adhered between pad and foot if necessary, to your prescription. Try typing "foot thong" into google.

Hope this helps,

Ian.

dear robertisaacs what a wonderful turn of phrase, you know how to "paint a pretty picture", may i quote you?, yep got the T.B.Co. ready....................and Ian thanks, will definitely have a look, thankyou gentlemen, mark c

Dear Mark - It sounds like he has a strained ligament around the 5th mpj, that is slightly loose in one direction and is only put on the stretch with rotation. As a practitioner of prolotherapy, I'd put about 0.2-0.5cc of lignocaine, preferably with some glucose as well, to the tender spot, trying to release a few cytokines and get a bit of new collagen being generated by the inflammatory cascade, in an attempt to repair the strain. Being incredibly fit and healthy he'd probably only need one or two treatments like this and the pain would go. Also, he wouldn't need to stop doing his training as the forces he generates in the ligament would encourage the new tissue to develop in the correct lines. If you only use lignocaine, leave the needle there for a few seconds until it is numb and tap the bone gently a few times as in the acupuncture technique, 'pecking the bone' to release a few cytokines from cells. I wish I could refer you to my website www.drmtaylor.com.au but it is temporarily out of action - but see Ross Hauser's website www.caringmedical.com/ for more details with a typical American flavour. I'm running 2 workshops in April (Brisbane and Adelaide) - if you're interested, email me taylorme@internode.on.net

Kevin, Jos, Robert and Ian, thanks again; this weekend my son-in-law won the heavyweight division at the Australian National Championships of Kyokyshin Karate and is off to Japan at the end of the year. I modified a flat insole with a 5mm deflective felt pad placed as Kevin described for all weight-bearing activities (he loves it ... in a manly sort-of-way) except for karate as they are not allowed in competition and he doesn't want to train in them as he feels he is balancing differently with and without them, he wants to train like he fights, all the best, mark c

Thanks for the update, Mark. By providing this type of update to your previous clinical question, thousands of podiatrists have now gained valuable clinical knowledge from your postings. Good job.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Markjohconley,

Sorry for my late entry into this thread. Trying to put all the information into an understanding of what is going on, I would say he has a tendonitis of the abductor digiti quinti. Due to a stretch injury, and he requires origin-insertion work, and reverse strain counter strain.

Sounds strange, but let me explain. He has a history of a fracture of the styloid area. There are 3 different mechanisms for this. Inversion-for the styloid (Dancer's fracture); Rotation with the heel off the ground-found more distally which can transverse to the fifth metatarsal-cuboid joint (Jones); and Dorsiflexion-found at the diaphyseal-metaphyseal junction (stress fracture).

Fractures are caused by a failure of the support system. This is not just the bone, but also muscles and periosteum that neutralize the forces. A simple example of this is the hip, where we see commonly a fracture in older people. Body weight on the femur’s head and neck is counterbalanced by abductors, and by the tension in the fascia lata.

In the case of a Jones fracture there is a rotation that has to be balanced that wants to adduct the fifth metatarsal (in the case of the left foot, rotation to the left). The muscle that is best suited to counterbalance this force is the abductor digiti minimi. For the fracture to occur, this muscle had to fail, and it had to be a stretch injury.

Treatment can be a taping to assist the muscle. (the lateral part of the Dye tape does this), or attend to the muscle. In the case of a stretch injury, you have to rub the origin and insertion away from the center of the muscle, about 10 firm strokes works, and then you put the muscle on stretch (dorsiflex and adduct the fifth toe) and pull the muscle fibers together (just a deep gentle pinch over the muscle belly). The chiropractors claim this resets the muscle spindle cells and golgi tendon organs. I also find that the periosteum gets damaged in fractures, so I find the damage and rub this to free it up (as you know the periosteum has a concentration of nerve supply, so it is my thinking that this is one of the sensors that triggers the muscle to fire).

I hope this explains why there is fifth metatarsal head pain after the proximal fracture. Also, the injuries are probably still there (especially the periosteum), so try these techniques and let me know what happens.

Regards,

Stanley

Makes me think "bursitis."

In addition to the taping and padding mentioned previously, how about trying ultrasound, iontophoresis, steroid injection, NSAIDS, or ASTYM?

Nat

Update > new injury.
At training he (son-in-law) was moving forward and his R/hallux was pulled back under his foot > +++ plantarflexion at met-phal and inter-phal joints methinks. Result is pain at d/s ipj when actively dorsiflexing the digit ; lack of active ipj plantarflexion??? rom; +++ pain when the ipj is quickly moved through limited rom.
Any Rx advice appreciated.

Update on his results at the karate (kyokushin) world championship (open class) in Japan. He was beaten in the first round (knock-out) by the competitor who eventually won the class (and was then taken to hospital with major injuries being fractures in jaw, l/hip and multiple in r/foot). My son-in-law's only obvious injury was a purple-black bruise (15cm diam.) on his l/lat thigh.
Lawn bowls/ karate alot in common eh?
All the best, Mark C

Ahhhh, a happy ending for all

And thanks to Kevin and all the others who so generously give of their time to post detailed and comprehensive responses to our questions.

mark,

Just aa thought, I'm a keen one for knowing whats going on in an area, have you ordered X-rays to image the area under teh R/5th MTPJ? Possibly include a forntal plane longitudinal to visulaise the plantar surface of the MTPJs (alla axial sesamoid view). You've had a few great suggestions, but what about an ossicle in the area, say in abductor digiti minumi tendon, or exostosis growth aroudn teh metatarsal head, especailly given that he has had surgery, bony scaring may be occuring. Possible deep scaring and entrapment of propper planter nerves also. When in doubt, back to anantomy and phyisiology. What is there and what can go wrong with it...?

Cheers!

__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?