Kevin and Stan;
I'd like to interject something into this conversation if I may. I"m
seeing the value of both of your arguments, and somehthing missing as well.
I would tend to agree that metatarsal spread contributes to neuroma
pain, but usually only if the patient wears a constrictive shoe of some
sort.
I think it is more of a stability issue over time, than just a
metatarsal spread issue. Just as I think that plantar fascitis is a force
vs. time problem, I think that if the foot moves or rolls as it should thru
the sagittal plane with little or no restrictions, i.e. metarsal spread,
dorsiflesion of the FF on the RF, etc., then you will have very little
chance of developing a neuroma.
Also, re: plantarflexion of the metatarsals, moments or otherwise, and
development of hammertoes. I very regularly see patients with FnHL
(functional hallux limitus) w/ contracted digits 2-5, or some combination
2-5. I have generally felt that these patients grip with their toes to
maintain stability lost by the FnHL at the 1st mpj. I've sucessfully
treated several athletes w/ isolated DIPJ or PIPJ pain 2-5 by using a
modified low dye, and then if that works, putting them into a CFO with a 1st
ray cutout. It seems that they do not have to grip to the same level
anymore and this relieves the pain completely.
I'd like to think that this is a primary contribution towards hammertoes
and metatarsalgia and neuroma as well.
Consider too, that the dorsiflexion of the lateral column and the medial
column often causes severe metatarsalgia or neuromas in this region 2-4
mpj's. Again it seems that loss of stability due to a combination of
pathologies (FnHL, medital STJ position, and MTJ pronation) can cause this
"inverted" forefoot deformity, as I've been calling it. What I"m saying is
that the 1st and 5th rays are dorsiflexed in respect to the rays 2-4, and
that often the 3rd ray will take the brunt of this force. I often see pain
on palpation of the plantar base of teh 3rd met and lateral cuneiform in
these patients. Those with more stable MTJ's tend not to have as much or
any tenderness in that area.
This idea of mine, with ample credit to Kevin Miller and others!, seems
to correlate well with Drs. Nester, Cocheba and Ward have discovered with
their dead man experiment. They have shown that on average the 4th and 5th
mets move as a unit, as does the medial column made up of the mets 1-3 and
the cuneiforms 1-3. It would make sense to me that, as Jeff Root said
recently in anothe post, the other bones of the foot can has obious effects
on the STJ position and MTJ as well.
Just a thought! ;-)
Happy Holidays!
Bruce Williams
----- Original Message -----
From: "Dr. Stanley Beekman" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, November 28, 2004 1:46 AM
Subject: Re: Measuring toe flexion strength
> Kevin,
>
>
> The motion occurs at Lis Franc's joint, The metatarsal will plantarflex
> with motion toward the 3rd metatarsal (and dorsiflexion with motion away
> from the third metatarsal). So plantarflexion will bring the metatarsals
> together.
>
> So in your scenario, the flexors plantarflex the forefoot (metatarsals),
> this would cause the metatarsal heads to squeeze together.
>
> In another scenario, the 3 groups of digital musculature are eccentrically
> firing utilizing the body's momentum. The effect of this is to control the
> plantarflexion of the metatarsal heads from the windlass effect, so the
> metatarsal heads do not impinge on the intermetatarsal nerves.
>
> Sincerely,
>
> Stanley
>
> At 11:04 PM 11/27/04 -0800, you wrote:
> >Stanley and Colleagues:
> >
> >Stanley wrote:
> >
> ><<Thank you for the explanation. Now I think I understand what you are
> >saying.
> >Just clear up one more thing for me and I am with you.
> >It is commonly thought that one of the causes of Morton's neuroma is the
> >weakness of the digital flexors. It is felt that the weakness results in
> >the metatarsal heads dropping and squeezing the intermetatarsal nerve.
The
> >treatment is to use a metatarsal pad to lift and separate the metatarsal
> >heads. How does this fit into your theory of the muscles causing forefoot
> >plantarflexion?>>
> >
> >I don't know if digital flexor weakness is or is not a cause of Morton's
> >neuroma. I have always thought that a metatarsal pad will tend to
> >decrease the pressure on the neuroma by separating the metatarsals away
> >from the neuroma. I don't know if this is readily explained by sagittal
> >plane kinetics of the midtarsal joint. Possibly a transverse plane
> >kinetic analysis of the metatarsal-cuneiform and metatarsal-cuboid joints
> >would be more fruitful in giving an answer as to the etiology and
> >treatment of Morton's neuroma.
> >
> >Sincerely,
> >
> >Kevin
> >
>
>***************************************************************************
*
> >Kevin A. Kirby, DPM
> >Adjunct Associate Professor
> >Department of Applied Biomechanics
> >California School of Podiatric Medicine at Samuel Merritt College
> >
> >Private Practice:
> >107 Scripps Drive, Suite 200
> >Sacramento, CA 95825 USA
> >
> >Voice: (916) 925-8111 Fax: (916) 925-8136
>
>***************************************************************************
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