Adding Stiffness to the front of a Shoe: Help for Many Problems in the Front of Our Feet

     My retired partner, Dr Jane Denton, known world wide of the Denton Modification for over supination, continuously used this metatarsal stiffener. It is a 1/16 to 1/8 inch thickness of out sole material. All chronic pain in the area may be helped with this shoe modification. When patients tell you that they feel better as the shoe stiffness increases, this may be something that a shoe cobbler can add to a more flexible shoe. It should be done on both sides (even if the pain is on one side). It can always be removed if not helpful, or after the need for stiffness passes. 

1/8 inch Stiff Out Sole Material Applied to Add Stiffness for Painful Metatarsals

The Stiffness has to be created with 1/16 to 1/8 inch Material only. This increases someone's falling odds due to separating the ground from the foot, so has to be broken in to gradually. The patients that it works for are really pleased that they can wear some normal looking shoes. 

New Video: Mechanical Treatment of Painful 2nd and 3rd Metatarsals and Toes

     I am happy to give you a new video on the experimentation that some of my patients go through in relieving the mechanical sources of their metatarsal and digital pains around the 2nd and 3rd toe area. Always remember that relieving pain can need all 3 sources addressed: mechanics, inflammation, and nerve related.

https://youtu.be/2dGq6DKbL4U

Hike and Bike Shoes for Immobilization of the Bend at the Forefoot

I have been using Hike and Bike shoes to immobilize the foot while not having the negative impact of a removable cast in some patients. There is one used in a plantar fascial tear for the 3 months I normally cast the foot with a removable boot. If the patient especially has a back problem, the evenness of wearing a pair of shoes like these can be great. Remember you are not able to bend your foot in push off, or it will hurt you. Therefore, it immobilizes the pull of the plantar fascia. Any metatarsal  problem could be helped by this, even if it is only part of your treatment to vary the stresses 2-4 hours a day. Sesamoid problems, turf toe, metatarsalgia or stress fractures may be helped. 

http://www.fiveten.com/us/kestrel-lace-womens-shock-blue

Metatarsalgia: General Treatment Thoughts

Metatarsalgia: General Treatment Thoughts

    Metatarsalgia mean pain in the metatarsals. I use this general diagnosis for many forefoot problems around the 2nd through 5th metatarsals during the first through 3rd visits with a patient I am beginning to treat until a definitive diagnosis is made (if ever). At the first visit, I have to decide if an x ray is appropriate, and then start treating what I see in the examination. Here are the top 10 initial treatments for metatarsalgia:

1. Ice pack 2 times daily for 10 minutes, and contrast bathing if swelling is seen each evening the patient is home.

                              Try to find some proper basins for soaking!!

     2. Experiment with various shoes to find the most comfortable. Do heels bother you? Does the shoe need cushion, flexibility, stiffness etc to help? You may be surprised.

     3. Avoid barefoot around the house.

     4. Use activity modification principles to avoid irritations, but expect some minor soreness (Good Pain vs Bad Pain).

     5. If the pain came on suddenly with impact activities, assume a stress fracture. Stress Fractures do not show on x ray for 2-4 weeks after injury, and sometimes never. Start taking 1500 mg calcium and 1000 units Vit D3 (via diet, sun, or supplements).

     6. If you feel you need crutches, definitely see a doctor.

     7. If you feel that the pain is neurological with numbness, burning, electric shocks, tingling, etc, try gentle non painful massage, neural flossing, Neuro-Eze, and see a physiatrist/neurologist  to look into back or sciatic nerve issues.

     8. Purchase an Anklizer Removable boot through Amazon if pushing off hurts a lot.

     9. Begin to strengthen your foot immediately with an exercises that do not hurt. You can go to YouTube and type drblakeshealingsole Foot and Ankle Strengthening Playlist.

    10. See if Hapads or Sole OTC inserts are helpful at relieving some of the symptoms.

OOFOS sandals for maximal cushion

This sandal was just highly recommended by one of my patients today who has significant plantar foot pain due to loss of fat pad and metatarsalgia. Very cushioned on feel, but stable as I watched her walk. She uses it at home and limited shopping. 

http://store.oofos.com/

First Metatarsal Position: Important to Know with Metatarsal Problems

One important measurement that bio mechanic specialists evaluate is the relationship of the first metatarsal to the second metatarsal head. The foot should be centered under the ankle joint (therefore not pronated or supinated). One thumb on bottom and index finger on top grab the second metatarsal head and stabilize it. This will be the reference point. With the other hand, grab the first metatarsal head also from top and bottom. See where the first metatarsal head lies in relation to the second metatarsal head when the thumb fingernails are parallel. Then move the first metatarsal head up and down noting the overall motion and position. The motion is ideally 5 mm up and 5 mm down. In this patient, the left first metatarsal moved only 2 mm total (4 mm down and -2 mm up). This is called a stable plantar flexed first ray. Ideally the first and fifth metatarsal heads are lower than their adjacent metatarsals.

On this patient's right foot, the first metatarsal rested 3 mm above the second metatarsal. The overall motion with 6 mm (6 mm up and 0 mm down). This is called an elevated first ray or metatarsus primus elevatus (I love to talk like I am smart!!) This is an unstable first metatarsal that will not hold up the arch, and causes instability in the foot. It can be the cause of bunions or produced by the formation of a bunion. When recognized, orthotic modifications like the Cluffy Wedge or Morton's Extension  can be used, and if surgery is being done, corrections for the elevated bone can be done. With an elevated first metatarsal, the weight goes more to the second and sometimes third metatarsals leading to pain syndromes like metatarsalgia, capsulitis, neuromas, and hammertoes. 

Sketchers: A Modification for Stability

I love the concept behind Sketcher's roll bar. It can be very helpful for many different injuries like Hallux Rigidus/Limitus, metatarsalgia, plantar fasciitis, and others where limiting the bend at the ball of the foot (metatarsals) could be helpful. However, this shoe can produce medial instability, called over pronation as we roll forward. This can be easily treated for a little shoe doctoring. I take a scalpel, but a shoe repair store some other sharp instrument, and cut 1 to 1 and1/2 inches into the shoe from the big toe joint area. The length of the cut is 3 inches long as seen in the photos. The material used can be colored for cosmesis, and is beveled before applying. I use Barge Cement and Superglue or knockoff to secure into the shoe. As the patient rolls forward, the 1/4 inch forefoot varus wedge stops the foot from pronating and should subjectively to the patient feel that it holds the foot centered. I have never had a patient not feel more stable with this technique. 

Budin Splint Modifications for Sore Toes/Metatarsals

Hi Dr. Blake and I hope you are staying dry!

You asked that I email you with how I’m doing. We met on Tuesday, November 6^th regarding pain on my right foot at the base of the second toe.  You prescribed a pad with an elastic loop to wear around the second toe along with some stretching and icing.

It’s now been 11 days and I can’t say I’m felling much different. The pad is irritating to wear with sneakers or boots because when I slip my foot into the shoe, the elastic loop gets pulled down and irritates the skin at the base of the toe. Sometimes I have to take it off for a while.

 I find that when I wear my clogs with an open heel, however, it is much more comfortable.  I don’t usually wear clogs but it’s the only shoe that I can wear the pad pretty much all day without discomfort. I’ve been pretty religious about wearing the pad regardless.

I’ve been bad about the icing. I’ve only iced twice since seeing you.

I do the stretches but not daily.

So I haven’t been the perfect patient.

What do you suggest?

Thank you.

Dr Blake's Response: 

Hey Alicia (name change), Thanks for the update. Try getting a digital gel pad at the Sports Shop to put under the splint. It is a long finger looking structure, that you can cut into 3rds to place over the one toe. I have also attached the link to Silipos company that makes these things.  Then you can put the splint on tighter even. You can also use paper tape on the top of your foot to tape the splint down so it will move less. Attached is the note I wrote. Definitely ice twice daily, since the pain you are feeling is inflammation. Remember to stretch and perhaps buy some Yoga Toes so that we can begin to introduce them. Sure hope this helps. Rich PS If the icing does not bring down the inflammation along, then we can have you ice and go to PT. They would love to work on your foot. 

Budin Splint is a powerful stabilizer of the toe joints. When the elastic band is irritative, a digital gel pad can be used initially over the toe, or just tape to hold down the band and prevent it from moving. 

Alicia is a return patient I have not seen for about 4 years. Nancy has pain in her right foot and second toe area for about 6 months. Her pain level on a scale of 0 to 10 is about 4 or 5. She is taking some Advil for the pain. Has 2 pairs of orthotics which both have reverse Morton's extensions made by Dr. David Hannaford. She is a 59-year-old. She is 5 feet, 128 pounds. Her activities that she likes are West Coast Swing, water aerobics, Zumba and dance aerobics. She would like to enjoy them without discomfort are her main goals.

SHE HAS NO KNOWN DRUG ALLERGIES.

Medicines she takes a regular basis include
1. Valtrex.
2. Calcium.
3. Vitamin C.
4. Vitamin D.
5. DHA.

She has had no past hospitalizations or surgery. She is on no special diet.

On my examination, I found someone who had pain in the 2nd metatarsophalangeal joint plantarly. It is sore on maximum plantar flexion of the joint, not dorsiflexion. She has full range of motion. There is no evidence of instability. She has always had a short second toe and I think that short second toe may be raising up just a little bit or the 1st and 3rd toes may be going under it. In either case it would trap the second metatarsal head against the ground and cause irritation. If you couple that with her reverse Morton's or dancer's pad, that puts the weight off the first and onto the second, so as part of her treatment I reduced the padding under the 2nd metatarsal head.

Alicia's 2nd toe is much like this. When the toe is being held up in the air by being above other toes, and can not physically get down to it's normal level, pain develops under the metatarsal toe joint. The pressure at push off stays too long in the one place. The splint is designed to pull the toe down into more normal alignment. 

DIAGNOSES:
1. Capsulitis symptoms, right 2nd metatarsophalangeal joint, 726.90.
2. Right hammertoe deformity, 735.4.

PLAN: So today orthotic devices were evaluated and on the right side the area under the 2nd metatarsal head of the reverse Morton's extension was removed. I encouraged her to ice twice a day, encouraged her to stretch the toe in a plantigrade direction without pain. I may go to YogaToes once it is less painful. I gave her a prescription for 2 Budin splints and this will be designed to hold the toe down. She is advised that she can easily adjust the bottom if there is any pressure.

http://www.silipos.com/products/orthopedics/Digital-Care