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Now I have your attention, I was hoping someone out there may have come across what I am about to describe or has at least treated someone with a similar if not the same condition. So let’s start at the beginning.

Female, 42 years old, slight build and an avid runner. Complaining of Extensor tendonitis L/F with paresthesia radiating into 3rd digit L/F after running 20 mins, does not experience during normal ambulation. Runs 10 miles x3 weekly.

O/E.
Bi-lateral Genu valgum.
L/F @ End range of motion in NCSP excessively pronated in RCSP also. R/F Pronated in RCSP but not as marked as left and still plenty of motion still available at NCSP.
Bi-lateral HAV.
Bi -lateral FF equinus
Functional Hallux limitus
And posterior equinus with 0 degrees achieved upon passive dorsiflexion.
Heavy callous (as one would expect to all MTPJ) Both Feet.
During gait Low gear propulsion observed (patient completely fails to recruit 1st ray during any phase of gait) with early heel raise.


I hope that’s everything, there is quite a bit going on here with this lady so I hope I have described as best I can.

Now to the treatment as this is now symptomatic. I provided her with a 3/4 heel raise and met bar (Well I say met bar but it sits just proximal to the met heads) B/F. Patient returned after two weeks and stated that instead of getting pain 20 mins into her run this had now (after wearing the orthotics) not started happening until 30-40 mins in the run. Now me being clever dicky that I am thought o.k. I will c if we can begin to recruit the 1st ray into gait to 1) make it more efficient 2) stop this low gear propulsion which I feel is the cause to the met pain and extensor tendonitis, so I try a reverse mortons extension. Patient returns to say instead of just the digits dorsally and MTPJ`s hurting her whole foot now hurts?? And experiences some form paresthesia, I mean eh? What, I don’t get it. I am truly perplexed.

Know the question I pose is what do I do now? Do I revert back to the original orthotic I constructed and coupled with the extensive stretching program see how this works or do I look for another solution?

Please any help would be greatly appreciated.

Chris

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You come up with a diagnosis/ differential diagnosis for the original problem. What was this, before you started on your treatment plan? Why should extensor tendinitis give paresthesia to the 3rd digit? Why, following your intervention is she getting paresthesia to the whole foot? What causes paresthesia? Why is the time period to symptoms so predictable?

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Sounds like a lacing problem.

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Do you know what, I was thinking restricted blood flow/ compression too.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Hi simon, many thanks for your reply, i mean it seemed logical to me at first with excessive forefoot loading and the 3rd MTPJ bearing most of the pressure for that to being being painful into the run, and i was thinking extensor substition due to the forefoot equinus, but i cannot see how the raise is not benefical? and why after attempting to recruit the first ray it has now caused more of an issue than before its not as if there hallux rigidus present, or maybe one needs to address the issue from the rearfoot as opposed to the forefoot

Chris:

Try relacing the shoes to avoid shoe compression force on the EDL tendon. Generally the reduction in pain is noticed as soon as the shoe is relaced because the laces no longer generate compression force on the inflamed tendons and/or nerve. Icing twice a day is helpful also. Just saw a patient with this problem yesterday...relacing her shoes in the office allowed her run with no pain for the first time in three weeks.

Also, I wrote a newsletter on this relacing modification in March 2003 (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 181-182). 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 orginally thought this graham and advised her correct lacing techniques, and made a point of finding how she laced them in the begining but nothing seemed obvious

Dr Kirby,

Yes i have not asked her to relace the trainer so this is certainly an avenue i will explore, but what does one do regarding the excessive forefoot contact?

What is "excessive forefoot contact" when it's at home?

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Because the raise will increase pressure on the dorsum of the foot against the shoe upper. BTW paresthesia is not the same as pain.
http://en.wikipedia.org/wiki/Paresthesia

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

it appeared to me that in her case this is what was at least contributing to the porblem, but i can also see how incorrect lacing in this case may be the cause. I guess i overlooked the simple things and dived in there looking for the most complicated cause.

no no i know parathesia is not the same as pain, but her explanation of her symptoms vary everytime i see her and i think even she does not know what shes feeling at times. i appreciate the raise will increase the pressure on the dorsum, but the symptoms changed after the mortons extension??? when it was just the symptoms seemd to regress, how can this be mechanically?

But that doesn't answer my question: "what is excessive forefoot contact" - you use this term, either someone has taught you this, you have read it somewhere, or you have invented it- what do you mean by it?

More to the point you wrote to Graham:
Yet you wrote to Kevin:
So you advised her on the correct lacing technique, but you didn't ask her to alter her lacing????? What is the correct lacing technique. Oh Boy.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

sorry reverse mortons extension,

well i guess from uni we were taught too much forefoot contact i.e placing more pressure through the forefoot than rearfoot was not ideal in during gait, seeing as there was minimal contact during heel strike in gait and more forefoot loading coupled with heavy callous build up i assumed this was what was causing the issue.

In regard to the other question i asked how she laced her trainers before a run, and how it differed from when she wears her trainers during the day, seeing as this is the only time she experinces pain, she had not altered them since when she bought them but admitted to tying them too tight, so i advised her to loosen them, after this appointment seemed to be the time when some of the symptoms regresses.

I don't want to come over as the kill-joy here, but "excessive forefoot contact", is not a term that I would be using as it is meaningless. Forefoot contact time? Forefoot contact loading? So your lecturers told you that "more pressure on the forefoot than the rearfoot was not ideal during gait"- OK......

Piece of advice- Identify the tissues under stress, work out what factors might be stressing them, reduce the stress on the tissues that are complaining by whatever means you can, without causing problems elsewhere.

Anyway, back to the plot: she loosened her laces and the symptoms "regresses"? Hmmm. Think you might have the answer to your problem there.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

indeed, and i kick myself for not thinking that sooner, i was not sure whether it was the laces or the raise and met bar. i guess one way is to make sure she continues to not contrict the foot dorsally when wearing the trainers and if need be alter the lacing, if the laces being too tight where not the cause. then it would be more of a case of process elimination.

I appreciate your advice and time on this matter, i have only recently graduated and started in private practice so any support or advice is always very welcome.

Well done Graham.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Chris:

I learned a very valuable saying while in podiatry school that I think may help you with this case:

"When you hear hoof beats, think horses, not zebras."

__________________
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
**************************************************