forefoot

Question 1

what will make the metatarsal phalangeal joint more prominent?

Answer 1

dorsiflexing the toe

Question 2

what is metatarsalgia?

Answer 2

old term

broad term historically used to cover forefoot pain

Question 3

what are some examples of forefoot pain?

Answer 3

• plantar metatarsal head(s) pain (sesamoiditis, capsulitis/plantar plate tear/ plantar plate dysfunction, fat pad atrophy)
• 1st MTP pain on motion
• pain associated with toe deformities
• pain associated with hallux valgus
• mortons intermetatarsal neuroma
• stress fracture

Question 4

how does plantar metatarsal head(s) pain present?

Answer 4

typically presents with pain on the plantar aspect of the metatarsal head of the foot.

commonly due to increased stress placed on this area most commonly as a result of biomechanical overload of these joints.

trauma or inflammatory arthritis.

may be localised to one MTP joint or may be a few or all MTP joints.

Question 5

what is capsulitis?

Answer 5

surrpunding a joint are capsilar ligaments, which act to keep the two bones lined up together so that the joint can function within its optimal range.

when increased stress is placed on the joint capsule from either trauma, or more commonly biomechanical overload this can cause pain and inflammation to the joint capsule and the surrounding soft tissues.

Question 6

with what other condition is capsulitis common?

Answer 6

very common in inflammatory arthritis, such as rheumatoid arthritis (RA) & psoriatic arthritis)

a thorough patient history is essential to highlight other key rheumatoid red flags.

Question 7

what does metatarsal phalangeal joint squeeze test indicate?

Answer 7

a painful response may indicate full met head inflammation.

Question 8

when might clinicians suspect inflammatory arthritis?

Answer 8

if multiple painful swollen joints.

this may require a blood test to screen for inflammatory arthritis.

Question 9

what are some examples of increased overload from the GRF due to poor foot and ankle biomechanics?

Answer 9

• 1st ray dysfunction
• dorsiflexed 1st ray
• restricted 1st MTP ROM
• longer second metatarsal (or short 1st metatarsal)
• plantarflexed metatarsal(s)
• reduced ankle joint dorsiflexion or forefoot equinus
• prolonged use of high heel footwear
• excessive callous
• plantar flexed metatarsals
• excessive pronation moments
• structural deformity

Question 10

explain 1st ray hypermobility

Answer 10

• inability to stabilise the medial column as the GRF can move it with ease
• GRF transferred laterally overloading lesser met heads

Question 11

explain dorsiflexed 1st ray

Answer 11

• dorsiflexed 1st ray has an inability to accept plantar medial GRF loading as it sits higher then lesser met heads.
• lesser met heads are in more plantar weight bearing position
• GRF transferred laterally overloading lesser met heads.

Question 12

how is 1st ray hypermobility and dorsiflexed 1st ray different?

Answer 12

• their treatment is very different for foot orthosis design choice
• dorsiflexed 1st ray, you would typically want to increase the load on this part of the foot
• hypermobile 1st ray , you would typically want to reduce the load on this part of the foot (to facilitate 1st ray plantarflexion)

Question 13

what is the impact of restricted 1st MTP ROM?

Answer 13

if the 1st MTP joint does not extend as it should for normal propulsion during gait, pressure mapping software will show the GRF shifts laterally over the lesser met heads.

causing overloading on the lesser metatarsals.

often absent toe extension is seen during gait and the patient push off from all met heads rather than through the hallux.

Question 14

what is the impact of a long 2nd toe?

Answer 14

as the 2nd toe is longer this leads to excessive pressure on the 2nd and 3rd metatarsal head which can overload this area in the foot.

Question 15

what is the impact of plantarflexed metatarsals?

Answer 15

plantarflexed rays/ metatarsals have an increased ability to accept GRF loading which can overload the metatarsal(s).

Question 16

what is the impact of reduced ankle dorsiflexion?

Answer 16

external dorsiflexion moment acting on the ankle joint. so there is an internal plantarflexion moment happening on the ankle joint. through the gastroc soleus and achilles tendon.

Question 17

what are the causes of metatarsal fracture?

Answer 17

• trauma/ micro-trauma
• repetitive abnormal strain
• ankle sprain
• sagittal plane restriction

Question 18

what is wolfs law?

Answer 18

the principle that every change in the function of a bone leads to change in its internal architecture and its external form.

Question 19

where would there be pain in a metatarsal fracture?

Answer 19

• sudden sharp onset
• localised to metatarsal shaft (2/3 most common)
• pain on weightbearing.

Question 20

what is the role of the sesamoids?

Answer 20

the sesamoids are 2 circular shaped bones which absorb impact forces in the forefoot.

they form important attachment sites for ligaments and muscles.

they can become inflamed due to repetitive excessive plantar pressure/ loading on the plantar 1st MTP area.

Question 21

where will pain present on the sesamoids?

Answer 21

pain or tenderness presents typically on the plantar aspect of the 1st MTP joint of the foot.

by dorsiflexing the 1st MTP joint this will cause the 1st ray to plantar to the 1st MTP joint. this will enable easier palpation of the sesamoid bones.

pain on palpation suggests sesamoid irritation.

Question 22

what are the treatment options for forefoot pain?

Answer 22

• single or full MTP(s) recess/ cut out/ accommodations
• metatarsal ber/button
• high arch MLA designs
• soft cushioning full length top covers on foot orthoses
• enhance 1st ray function with specific design features (improve functional hallux limitus is present)
• may have to control increased pronation moments if present with medial wedge designs
• may have to accommodate dorsiflexion limitations (this may include referral for stretching protocol from physiotherapy)

or combination of the above

Question 23

what design of orthosis is used to enhance 1st ray function/ offload plantar 1st MTP?

Answer 23

reverse morton’s extension/ forefoot post.

1st MTP recess/ 1st MTP cut out.

Question 24

what are soft top covers used for?

Answer 24

cushioning

this will reduce compressive forces on the plantar aspect of the foot.

often very helpful on metatarsal head pain especially if there are exposed metatarsal heads or reduced fat pad on weight bearing areas of the foot.

Question 25

what is the use of a metatarsal button or bar?

Answer 25

offload by shifting GRF away from the met heads at a pint behind met heads = often called a deflective pad

Question 26

what are rocker soles used for?

Answer 26

used to reduce peak forefoot pressures by providing a new 3rd rocker adaption from the footwear (rather than the patients forefoot) at an area proximal to the metatarsal heads altering both motion and force distribution patterns.

Question 27

how much do rocker soles reduce pressure under the met heads by if designed correctly?

Answer 27

30-50%

Question 28

what does the rigid sole of rocker soles do?

Answer 28

limits movement at forefoot joints, particularly extension of the MTP joints. this also reduces movement of tissues across the plantar aspect of the foot and distributed forefoot loads better.

Question 29

what is the test for intermetatarsal neuromas?

Answer 29

Mulder's click test

Question 29

what is morton's intermetatarsal neuroma?

Answer 29

the distal medial plantar nerve divides at the level of the webspace and supplied the adjacent 2 toes. if increased pressures are acting on the nerve, fibrotic thickening can occur to the nerve in the metatarsal region of the foot. this may put increased pressures on the nerve to stimulate nerve pain.

Question 30

how do you carry out mulder's click test?

Answer 30

- identify the correct webspace - pinch webspace proximally, attempt to draw the neuroma forward towards the met head, with the other hand compress the met heads medially and laterally - feeling a click and painful response by the patient is a positive sign.

Question 31

what is the plantar plate?

Answer 31

plantar plate is a thin, slightly curved, fibrocartilaginous structure. it forms a soft tissue pocket around metatarsal heads.

Question 32

where do the plantar plates insert into?

Answer 32

it is the distal extension of the plantar fascia as it inserts into the bases of the proximal phalanx of the toes.

Question 33

what does increased tension in the plantar fascia do to the plantar plate?

Answer 33

increased tension in the plantar fascia increases the tension in the plantar plate and plantar flexes the proximal phalanx into the ground during weight bearing.

Question 34

what might injuries to the plantar plate cause the toes to do ?

Answer 34

injury to the plantar plate or plantar plate tears can reduce the plantarflexion moment applied to the proximal phalanx which can then cause the toe to extend over time as the digit plantarflexion moment. this can then continue to cause dorsal subluxation of the proximal phalanx on the metatarsal head giving raise to metatarsal phalangeal joint dorsiflexion/ extension deformities such as hammer toe or claw toes. this can also happen if the plantar plate suddenly ruptures due to trauma.

Question 35

what plantar plate areas are the most common areas which can be effected?

Answer 35

2nd and 3rd

Question 36

what can cause plantar plate injury?

Answer 36

- barefoot walking - walking on hard surfaces - running or jumping activities - prolonged use of high-heeled footwear

Question 37

what are some plantar plate symptoms?

Answer 37

- tenderness on palpation - pain in the area of the plantar plate (typically at the sulcus area of the foot) - swelling (may increase the pressures in this area and irradiate the nerves producing mortons neuroma symptoms)

Question 38

how do you carry out the plantar plate provocation test?

Answer 38

- dorsiflex toe 30° - apply dorsal force to distract toe away from metatarsal - apply downward force o the dorsal aspect of the base of the proximal phalanx - pain indicates a tear

Question 39

what is the lachman's drawer test?

Answer 39

- stabilise MTH - distract toe slightly - slide proximal phalanx superiorly - positive test results 50% upward movement of the proximal phalanx superiorly.

Question 40

what are the treatment options for plantar plate dysfunction?

Answer 40

treatment options that reduce forefoot pain. optimal offloading in the exact location is key.

Question 41

what are the 8 treatment options for forefoot pain?

Answer 41

- single or full MTP(s) recess/ cut out/ accommodations - metatarsal bar/button - high arch designs - soft cushioning full length top covers on foot orthosis - enhance 1st ray function with specific design features - may have to control pronation moments if occurring - may have to accommodate tight TA - rocker sole footwear adaptions (if severe pain on plantar plate - often not required)

Question 42

what is the role of plantar plate strapping?

Answer 42

this will plantar flex the proximal phalanx - external force provided by the tape will generate a digit plantar flexion moment. which is similar to the function that the plantar plate will produce naturally - which will reduce tension forces.