Kevin et al,
I do agree that we need to establish clear, useful,
and universal terminology for us to collaborate and
communicate effectively. Some of the work I have done
to date has been in conjunction with physicists and
engineers who have no medical training and are not
fluent in the language of medicine. They think and
function in black and white terms, many of which have
evolved over literally thousands of years. Hopefully
we can evolve a bit quicker with discussions like
this.
On the subject of TMT "stiffness", I have an
interesting case that begs some questions regarding
the importance of this term. The patient is a 33 year
old male who presented with a chief complaint of 2nd
metatarsal pain and recurrent stress fracture. On
examination, he did have increased callus under the
2nd MTPJ on the right side and was pronated more so on
that side through mid stance. His history includes a
motorcycle accident 2 years prior where he partially
degloved his right lateral leg sliding across the
pavement. To make a long story short, he has no
muscle function in the lateral compartment, nor does
he have noticeable contracture of the peroneus longus
or brevis. Without stabilization of the medial column
via the peroneus longus, The first ray has assumed a
more dorsiflexed position. Interestingly, it does
have literally the same range of motion and palpable
"stiffness" as the contralateral side. So, for this
individual, how important is "stiffness" in the
absence of supporting muscle function?
While collagen makeup and ligamentous orientation may
help dictate end-ranges of motion, these factors seem
to fade in the light of compromised muscle/tendon
function. My point is that while effective
terminology is critically important, I feel that
identifying the impact of those factors to which we
apply terminology may be of greater necessity.
Note... The patient mentioned above had seen two
orthopods and one other podiatrist, all of whom had
recommended dorsiflexory osteotomy of the second
metatarsal. Needless to say to this audience, his
symptoms resolved 100% with appropriate orthoses and
no unnecessary surgery. Knowing the "why" made all
the difference for this gentleman.
Respectfully,
Jay
--- Kevin Kirby <[log in to unmask]> wrote:
> Jay and Colleagues:
>
> Jay wrote:
>
> <<Just a thought... Maybe we should come up with
> definitions based more upon function. I am certain
> that all those involved with this discussion have
> come across people who seem to have excess motion in
> the
> 1st TMT joint (on the table) who have a functionally
> stable medial column. On the other hand it is not
> unheard of to come across patients whose TMT seems
> stable though they have increased callus under the
> second MTPJ and excessive late pronation. I have
> evaluated function on the basis of common physical
> examination and with F-Scan. Though I have not
> attempted to do so yet, I do believe that a
> functional
> definition could be devised based upon F-Scan or
> similarly derived data. Perhaps some percentage of
> peak 1st MTPJ pressure over total forefoot pressure.
> I do hope that this doesn't complicate the
> discussion
> but it seems to me that overall function is always
> more important than individual findings.>>
>
> Good to see you contributing again, Jay. It is
> always a pleasure to read your thoughtful responses.
>
> A functional description of metatarsal ray function
> will need to include both the parameters of
> metatarsal ray position and metatarsal ray
> dorsiflexion stiffness.
>
> In the patient you describe with a callus under the
> second MPJ, this could be explained either by
> decreased first ray dorsiflexion stiffness (i.e.
> "hypermobility") and/or by increased dorsiflexed
> position of the first ray relative to the second ray
> (i.e. metatarsus primus elevatus). However, in this
> same patient, recent research by Cornwall showed
> that in patients with "first ray hypermobility"
> didn't dorsiflex their first ray any more than
> patients without first ray hypermobility. This can
> be explained quite easily considering the position
> and dorsiflexion stiffness of the first ray compared
> to the second ray, but can not be explained
> considering the concept of "first ray
> hypermobility". A better biomechanical description
> of metatarsal ray function will lead to not only
> improved theory but also to improved functional
> understanding of a multitude of foot pathologies.
>
> Cheers,
>
> 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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