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I have a patient with parkinsons getting pain in the metatarsal area and
not correctly walking heel to toe, typical of disease, shuffle walk, etc.
Is there anything I can do ?, would orthotics help ? or is it a postural
problem and requires specialist.
Involvement of foot:
Foot dystonia (sustained muscle contraction - twisting, repetitive patterned movement or an abnormal posture) triggered by walking and relieved by rest can occur in up to a third of those with PD. Stewart (1898) first described a dystonia in which the lessor toes of the foot flexed and the great toe hyperextends while walking in the early stages of some patients with PD. After standing still for a few minutes, it resolves. Dystonia of the lower limb is the presenting feature in up to 1-3% of those with PD – most of these involve the foot ; usually brought on with walking – may also get cramp like pains in arch. If not treated early - usually an equinovarus posture with an extended great toe (not to be confused with Babinski’s sign). In all patients who developed levodopa induced dystonia’s, the first site of initial involvement was the foot on the opposite side to which the Parkinsonism first developed. Dystonia’s seen in the ‘off’ period of levadopa dose cycle are usually painful and start in the foot, usually on side with initial or most severe forms of Parkinson's.
Plantar pressure changes have been described – mean heel force at contact reduced, increased loading in midfoot, decreased force during propulsion . Significant changes in plantar pressure patterns are also seen in those in mild to moderate disease, with a tendency to higher forefoot loading and a medial shift in the load, which may be related to strategies to reduce unsteadiness of gait .
Parkinsonism has been reported as appearing in one of the lower limbs in 30% as the initially presenting feature, either concurrently or preceding the upper limb features – which contradicts the common belief that most start in the upper limb. May present with unilateral onset of resting tremor or ‘dragging’ of one leg during walking. Younger patients may present with involuntary internal rotation of the foot when walking. They may be ignored in the lower limb as upper limb problems are easier to detect . Movements of the foot are more ‘simple’ than the hand, so subtle impairments in the foot/lower limb may not be detected.
A pseudo-rheumatoid type deformity of the feet (and hands) resembling Jaccoud’s arthropathy has been described in cases of Parkinsonism . Other typical features seen in the feet include clawing and flexion of the toes, inverted position of the foot during the festinating gait – assumed to due to rigidity of muscles.
Those with PD will have difficulty in foot self care due to tremors and other motor disturbances.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
I have treated two patients with Parkinson's, who have complained of met pain...on both occasions a neuroma was later diagnosed, using ultrasound. Not sure if this is typical of Parkinson's, tbh, perhaps more experienced practitioners might like to comment.
I have treated two patients with Parkinson's, who have complained of met pain...on both occasions a neuroma was later diagnosed, using ultrasound. Not sure if this is typical of Parkinson's, tbh, perhaps more experienced practitioners might like to comment.
I had the opposite - I started treated a lady for a neuroma and it just would not respond; she reported some unilateral leg weakness and increased fatigue ... turned out to eventually be multiple sclerosis
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
I would start with temporary felt padding to get a feel what will help before making any orthotic decisions.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
I would think Parkinson's patients can get neuromas, as well as neuroma patients developing Parkinsons.
I don't think you should take the leap to assume there is a cause and effect.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
I have found that shoes with a better arch support are helping at the present
time, however he is dragging his feet, which is typical of people with PD I have
been advised. So will have to bear in mind for the future orthotics or padding
first, as suggested, replies are very helpfull, please keep them coming.
I have a patient with parkinsons getting pain in the metatarsal area and
not correctly walking heel to toe, typical of disease, shuffle walk, etc.
Is there anything I can do ?, would orthotics help ? or is it a postural
problem and requires specialist.
Neil
Neil:
Since Parkinson's disease is a neurological disorder, then you should probably assume that the shuffling gait is neurological in origin. If the central nervous system can't generate the correct firing pattern for the lower extremity musculature due to disease, then no foot orthosis will be able to allow the central nervous system to perform that function for the patient.
An ankle-foot orthosis for more severe cases or a foot orthosis inside a high top hiking boot may work in less severe cases to allow a more normal heel to toe gait. A neurology consult is a must if the patient hasn't already had one. From your questions, it would probably be best if you asked your friendly orthotist for a consultation on types of braces that could be used by the patient to improve their gait function also. There are some excellent orthotists on Podiatry Arena who could surely help you out with this one.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I find a large ammount of the treatment should be done alongside a good physiotherapist by way of gait re-ed.
I find alot of the forefoot discomfort will be associated with the patient developing festination in which the patient will break into a run as their body posture leans forward and they have to keep up with their centre of mass which in turn tends to mean less effective swing and early forefoot strike.
Mark
Last edited by Cooking Pod : 13th February 2008 at 04:48 AM.
Reason: miss type
Parkinsons and forefoot pain
Re: Parkinsons and forefoot pain
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