43 year old male with known leg length discrepancy and left sided knee hip and back pain. History reveals a recent weight gain as a result of the knee pain curtailing physical activity.

Exam:
Shows a 1.1 cm leg length discrepancy on scanogram radiograph. The left leg is shorter. His two feet appear very asymmetrical, the left is quite pronated with a resting calcaneal stance position of around 6 degrees everted and a supinated forefoot position. He has a unilateral positive functional hallux limitus on the left side. His maximally dorsiflexed ankle position on the left is 6 degrees of plantarflexion and on the right is 7degrees of dorsiflexion. In addition to high tone of the gastrocnemius tendon there is tightness of the posterior TF and posterior TT ligaments. His knee pain is peri-patellar in nature. I did not specifically examine the hip.

Impression:
Leg length discrepancy with excessive pronation on the left foot. This has created a functional hallux limitus and unstable midfoot on left side. The unstable midfoot has allowed the midtarsal joint to provide much of the necessary dorsiflexion that is required during gait, and an equinus has resulted.

Plan:
He was placed in a bilateral functional orthotic with a medial flange to stop some of the pronation of the rearfoot. This had a neutral rearfoot post with 0 degrees of motion. There was a 4 mm heel skive applied to the device. A P4 Wedge was applied. ART was done over the gastroc and posterior TT abd TF ligaments. He was placed on wall push up stretches. A 1.1 cm. lift was placed in the left shoe.

Disposition:
2 weeks after using the orthotic his Achilles tendon insertion was very tender. ART was done over this area and along with continued stretching the pain there resolved. His knee, hip and back pain disappeared. His knee pain returned 2 years later. Inspection of the orthotic showed that the P4 Wedge had come off the device. The P4 Wedge was replaced, no other treatment was rendered. 2 weeks later the patient states, “his knee pain was completely resolved with the replacement of the P4 Wedge.”

Comment:
Orthotics alone are not capable of dealing with first ray insufficiency entirely. A
P4 Wedge is the best solution to assure the first ray is functioning normally.
This is a small and important device to apply to the orthotic to restore normal function. This is often the missing link to achieve clinical success. The continued prevelance of foot deformity in individuals wearing functional orthotics is a testament that orthotics alone do not adequately control the first ray. This is so important to normal function and prevention of injury and deformity.

A 52 year old male with heel pain, arch pain and forefoot pain.  Diagnosis from outside clinic is plantar fasciitis, Mortons neuroma.  He has a fusion of L4,5 and has had recent discectomy at L5, S1.  He has ongoing pain in the lower back.

Exam:

Shows minor pain to palpation of the lesser MTPJ’s, mainly 3, 4.  There is no pain in the intermetatarsal spaces.  Pain is noted to palpation of the FDB, QP, Lumbricales, Plantar Interossei muscles. Ankle ROM was improved from 5 – 11 degrees  of dorsoflexion with the knee extended after ART of the posterior talo fibular and posterior tibio-talar ligaments.  Pain is noted on the heel plantarly and plantar medially as well as the lateral arch around the cuboid.  Gait pattern is very tentative and apropulsive, no perceptible motion is present at the first MTPJ. Scanogram shows a 2 cm. leg length discrepancy with the right being short.  Radiographs are unremarkable.

Diagnosis:

1. Plantar Fasciitis
2. Myofasciitis of many intrinsic  muscles
3. Equinus
4. Metatarsalgia
5. Faulty gait mechanics
6. Leg length discrepency

Treatment Plan:

ART over the intrinsic muscles affected, and ankle ligaments, posterior TF and posterior TT.

P4 Wedge and Superfeet blue insoles

Gait training in PT to address abducted foot position and tightness of the hip flexors and ankle. Work on bending over the hallux and improving his walking speed.

Lift on Right shoe.

Disposition:

Heel pain resolved within a few weeks and myofascial pains decreased after about 4 ART treatments.  Forefoot pain under mets. 3 and 4 took longer, but resolved as he became more propulsive over the hallux and we corrected the ankle equinus and abducted gait  pattern.  Back pain improved immediately after application of the lift in the right shoe, and improvement of the gait pattern.

Comment:

This cluster of symptoms is very common with functional limitation of motion of the first MTPJ.  Until proper gait mechanics are established, symptoms will persist. The P4 wedge is a big aid in comprehensively addressing the multiple mechanical issues that commonly develop secondary to a dysfunctional first ray.   A custom orthotic was not necessary in this case as his rearfoot position was relatively normal, and after establishing the windlass his midfoot became stable in propulsion.  I find relatively vertical calcaneal positions are present with many patients presenting with forefoot pain.  The dysfunctional first ray is the main problem in these patients.