Metatarsal Bar Research Articles

INVESTIGATING THE EFFICACY OF SURGICAL AND NON-SURGICAL TREATMENT OPTIONS FOR MORTON'S NEUROMA BASED ON THEIR SIZE

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size.A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis.All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars.There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars.A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection.In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size.

Successful Application of an Insole with a Metatarsal Inhibition Bar and Deep Heel Cup for Improving Gait Dysfunction in a Patient with Poor Coordination with Disrupted Corticoreticular Tracts: A Case Report

We report the successful management of gait dysfunction in a patient with coordination problems using an insole with a metatarsal inhibition bar (MIB) and a deep heel cup. Furthermore, we investigated the state of the neural tracts via diffusion tensor tractography (DTT). A 23-month-old boy with gait dysfunction presented with toe walking with a wide base and decreased hip flexion. Motor weakness or spasticity was not observed. Conventional brain magnetic resonance imaging did not reveal any abnormal findings, but DTT revealed disrupted bilateral corticoreticulospinal tracts (CRTs). No abnormalities were observed in the corticospinal tract or the medial lemniscus. We applied a custom-made insole with an MIB and a deep heel cup. Immediately after application, the patient’s gait pattern stabilized significantly and was nearly normalized. Our therapeutic experience indicates that the application of an insole with an MIB and deep heel cups could be beneficial for patients with coordination problems and gait dysfunction. Our DTT results showed that CRTs could be the causative brain pathology for gait dysfunction in patients with coordination problems.

Forefoot disorders and conservative treatment.

Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton’s neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.

Evaluation of orthotic insoles for people with diabetes who are at-risk of first ulceration

ObjectiveThis study focussed on pressure relieving orthotic insoles designed for retail footwear and people with diabetes and at risk of first forefoot ulceration. The aim was to investigate whether the pressure relieving effects of a customised metatarsal bar and forefoot cushioning are sensitive to bar location and shape, and material choice.Research design and methodsPatient-specific foot shape was used to design an orthotic insole, with metatarsal bar location and shape customised according to plantar pressure data. Changes in forefoot plantar pressure were investigated when 60 people with diabetes and neuropathy walked in nine variants of the orthotic insole. These comprised three variations in proximal/distal location of the customised metatarsal bar and three different metatarsal head offloading materials.Results & conclusionsThe most frequent reductions in pressure occurred when the anterior edge of the metatarsal bar was placed at 77% of the peak pressure values, and its effects were independent of the choice of EVA or Poron offloading material. In the flat insole, 61% of participants had one or more metatarsal head areas with pressure above the 200 KPa, reducing to 58% when adopting generic orthotic design rules and 51% when using the best orthotic insole of the nine tested. Our results confirm that plantar pressure relief is sensitive to orthotic insole design decisions and individual patient feet.

Systematic review on the comparative effectiveness of foot orthoses in patients with rheumatoid arthritis

BackgroundFoot orthoses (FOs) are prescribed as an important conservative treatment option in patients with foot problems related to rheumatoid arthritis. However, a broad variation in FOs is used, both in clinical practice and in research. To date, there is no overview on the outcomes of the treatment with different kinds of FOs in patients with rheumatoid arthritis and a specific foot problem. The objectives of the present study were to summarize the comparative effectiveness of FOs in the treatment of various foot problems in patients with rheumatoid arthritis, on the primary outcomes foot function and foot pain, and the secondary outcomes physical functioning, health related quality of life, compliance, adverse events, the costs of FOs and patient satisfaction.MethodsStudies comparing different kinds of FOs, with a presumed therapeutic effect, in the treatment of foot problems related to rheumatoid arthritis were included. A literature search was conducted in The Cochrane Central Registry for Controlled Trials (CENTRAL), PubMed, EMBASE and PEDro up to May 18th, 2018. Data was meta-analyzed, when this was not possible qualitative data analysis was performed.ResultsTen studies were identified, with a total number of 235 patients. These studies made a comparison between different materials used (soft versus semi-rigid), types of FOs (custom-made versus ready-made; total-contact versus non-total contact), or modifications applied (metatarsal bars versus domes). Also, different techniques to construct custom-made FOs were compared (standard custom-molding techniques versus more sophisticated techniques). A medium effect for (immediate) reduction of forefoot plantar pressure was found in favor of treatment with soft FOs compared to semi-rigid FOs (SMD 0.60, 95% CI 0.07–1.14; P = 0.03; 28 participants). Other comparisons between FOs resulted in non-significant effects or inconclusive evidence for one kind of FOs over the other.ConclusionsFoot orthoses made of soft materials may lead to more (immediate) forefoot plantar pressure reduction compared to foot orthoses constructed of semi-rigid materials. Definitive high quality RCTs, with adequate sample sizes and long-term follow-up, are needed to investigate the comparative (cost-) effectiveness of different kinds of foot orthoses for the treatment of foot problems related to rheumatoid arthritis.

A new protocol for the biomechanical evaluation of sport shoes and insoles: Comparison between in-shoe prefabricated and off-the-shelf insoles with metatarsal bar

A new protocol for the biomechanical evaluation of sport shoes and insoles: Comparison between in-shoe prefabricated and off-the-shelf insoles with metatarsal bar

Results of two different surgical techniques in the treatment of advanced-stage Freiberg's disease.

Background:Freiberg's disease is an osteochondrosis most commonly seen in adolescent women and characterized by pain, swelling and motion restriction in the second metatarsal. The early stages of this disease can be managed with semirigid orthoses, metatarsal bars and short leg walking cast. Number of operative methods are suggested which can be used depending on the pathophysiology of the disease, including abnormal biomechanics, joint congruence and degenerative process. We evaluated the outcomes of the patients with Freiberg's disease who were treated with dorsal closing-wedge osteotomy and resection of the metatarsal head.Patients and Methods:16 patients (11 female, 5 male) with a mean age of 24.5 (range 13–49 years) years who underwent dorsal closing wedge osteotomy or resection of the metatarsal head were included in this retrospective study. Second metatarsal was affected in 13 and third metatarsal in three patients. According to the Smillie's classification system, ten patients had type IV osteonecrosis and six patients had type V. The results of the patients were evaluated using the lesser metatarsophalangeal-interphalangeal (LMPI) scale.Results:According to the LMPI scale, the postoperative scores for the osteotomy and excision groups were 86 (range 64–100) and 72.6 (range 60–85), respectively. In the osteotomy group, mean passive flexion restriction was 18° (range 0°–35°) and mean passive extension restriction was 12° (range 0°–25°). Mean metatarsal shortening was 2.2 mm (range 2–4 mm) in the osteotomy group as opposed to 9.8 mm (range 7–14 mm) in the excision group. Significant pain relief was obtained in both groups following the surgery.Conclusions:The decision of performing osteotomy or resection arthroplasty in the patients with advanced-stage Freiberg's disease should be based on the joint injury and the patients should be informed about the cosmetic problems like shortening which may arise from resection.

Effect of the application of a metatarsal bar on pressure in the metatarsal bones of the foot.

[Purpose] The aim of this study was to determine the effect of application of a metatarsal bar on the pressure in the metatarsal bones of the foot using a foot analysis system (pressure on the forefoot, midfoot, and rearfoot). [Subjects and Methods] Forty female university students in their twenties were selected for this study, and an experiment was conducted with them as the subjects, before and after application of a metatarsal bar. The static foot regions were divided into the forefoot, midfoot, and rearfoot, and then the maximum, average, and low pressures exerted at each region were measured, along with the static foot pressure distribution ratio. 1) Static foot pressure: The tips of both feet were aligned to match the vertical and horizontal lines of the foot pressure measuring plate. The subjects were told to look toward the front and not to wear shoes. 2) Distribution ratio: The distribution ratio was measured in four regions (front, back, left, and right) using the same method as used for static foot pressure measurement. [Results] The results of this study showed that the maximum, average, and minimum static pressures in the forefoot were significantly decreased. The minimum static pressure in the midfoot was significantly increased, and the pressure in the other parts was significantly decreased. The maximum and average static pressures in the rearfoot were also significantly decreased. [Conclusion] As reduction of foot pressure with a metatarsal bar results in lowering of the arch and an increased contact surface, the foot pressure was dispersed. These results suggest that wearing shoes with a bar that can decrease the foot pressure is therapeutically helpful for patients with a diabetic foot lesion or rheumatoid arthritis.

Comparison of the pressure‐relieving properties of various types of forefoot pads in older people with forefoot pain

BackgroundPlantar forefoot pain is commonly experienced by older people and it is often treated with forefoot pads to offload the painful area. However, studies have found inconsistent effects for different forefoot pads on plantar pressure reduction, and optimum forefoot pad placement is still not clear. The aim of this study was to compare the effects of different forefoot pads on plantar pressure under the forefoot in older people with forefoot pain.MethodsThirty-seven adults (31 females, 6 males) with a mean age of 73.5 (SD 4.8) participated. Forefoot plantar pressure data were recorded using the pedar®-X in-shoe system while participants walked along an 8 m walkway. Five conditions were tested in a standardised shoe: (i) no padding (the control), (ii) a metatarsal dome positioned 10 mm proximal to the metatarsal heads, (iii) a metatarsal dome positioned 5 mm distal to the metatarsal heads, (iv) a metatarsal bar, and (v) a plantar cover.ResultsCompared to the shoe-only control condition, each of the forefoot pads significantly reduced forefoot peak pressure and maximum force. The metatarsal dome positioned 5 mm distal to the metatarsal heads and the plantar cover were most effective for reducing peak pressure (17%, p < 0.001 and 19%, p < 0.001, respectively).ConclusionsThese findings indicate that forefoot pads are effective for reducing forefoot pressures in older people with forefoot pain, and that the position of the pad relative to the metatarsal heads may be more important than the shape of the pad.

중족골 바 형태의 전족부 라커 신발이 하지 근 활성도 및 족저압력 분포에 미치는 영향

The purpose of this study was to evaluate the effects of forefoot rocker shoes equipped with a metatarsal bar on lower extremity muscle activity and plantar pressure distribution. Ten healthy women in the age of twenties were participated in this study as the subjects. All subjects walked on a treadmill(Gait Trainer, BIODEX, USA) wearing normal shoes and metatarsal bar shoes, during which the plantar pressure distribution and muscle activity were measured. Using Pedar-X system(Novel Gmbh, Germany), the plantar pressure was measured for six regions of the foot: forefoot, midfoot, rearfoot, 1st metatarsal, 2-3th metatarsal, and 4-5th metatarsal, and for each sub-region, 4 features such as maximum force, contact area, peak pressure, and mean pressure were analyzed based on the plantar pressure. EMG(Electromyography) activity was measured by attaching surface electrodes to the rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius medial head, and magnitude of muscle contraction was analyzed in IEMG(Integrated EMG) value. The results show that the maximum force, contact area, peak pressure, and mean pressure in the midfoot all increased while maximum force, peak pressure, contact area, mean pressure in the 1st metatarsal and 2-3th metatarsal all decreased when wearing functional shoes. Also, muscle activities in the four muscles were all decreased when wearing the functional shoes. This paper suggests that forfoot rocker shoes equipped with a metatarsal bar can help disperse the high pressure and absorb the shock to the foot as well as give positive influence on gait pattern and postural stability by reducing muscle fatigue during walking.

Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head

Background The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed. Objective To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head. Method Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements. Results Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control ( P < 0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads ( P < 0.01), and the oblique position of the bars was more effective than the perpendicular one ( P < 0.01). Conclusions The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.

Orthotic management of plantar pressure and pain in rheumatoid arthritis

Objective. To investigate the effectiveness of foot orthoses in the management of plantar pressure and pain in subjects with rheumatoid arthritis. Design. A repeated measures study in which the independent variable was orthosis design. Dependent variables, including pressure, gait and pain parameters, were examined using analysis of variance and correlation statistics. Background. The aim of orthotic management of the rheumatoid foot is to relieve metatarsalgia through the reduction of metatarsal head pressure. Few studies have investigated the relative effectiveness of different orthosis designs. To date, no studies have examined the relationship between plantar pressure and second metatarsal head pain in rheumatoid arthritis subjects. Methods. Twelve rheumatoid arthritis subjects with foot involvement and second metatarsal head pain were tested. Four styles of foot orthosis (prefabricated, standard custom moulded, custom with metatarsal bar, custom with metatarsal dome) were compared to a shoe only control. An EMED Pedar system was used to measure plantar pressure during repeated trials of comfortable cadence walking and quiet standing. Reports of subjective pain were recorded for each orthosis as were orthosis preferences. Results. All orthoses significantly reduced pressure beneath the first and second metatarsal heads compared to the shoes only control. The custom moulded orthosis with metatarsal dome was the most effective orthosis for reducing subjective ratings of pain. A significant correlation ( r=0.562) was found between ratings of pain and average pressure beneath the second metatarsal head. Conclusions. Results from this study suggest that average pressure measurement may be a useful indicator in the management of metatarsalgia in RA. Further study is required to improve understanding of the relationship between rheumatoid foot mechanics and pain. Relevance Appropriate foot orthosis design can substantially improve comfort in RA patients with symptomatic feet. A custom moulded foot orthosis incorporating a metatarsal dome was the most effective design for subjects with painful second metatarsal heads. Foot pressure measurement technology can be a useful adjunct to research and clinical management of the painful rheumatoid foot.

Surgery of the Forefoot in Rheumatoid Arthritis*

Surgery of the Forefoot in Rheumatoid Arthritis*

Dynamic plantar pressure measurement in 49 patients with diabetic neuropathy with or without foot ulcers

Summary We compared plantar pressures under selected areas of the foot in 49 diabetic patients with neuropathy using the F-scan system — in their own shoe (with and without an insole), in a jogging shoe (with and without an insole) and in an extra depth orthopaedic shoe with a small metatarsal bar. Patients with current or previous plantar ulcers ( n =30) were compared to those with no such history ( n =19). There was very little decrease in plantar pressure between the patients' shoes and the jogging shoes, although non-ulcer patients put more weight on the lateral toes and more on the medial side after adjustments. In most cases the orthopaedic shoe increased pressure under the forefoot significantly. Large standard deviations between patients made comparisons between groups impossible. Integrated peak pressure values were not often significantly different from peak pressure values alone, suggesting some compensation of pressure by time. Standard extra depth shoes did not give the reduction of pressure anticipated. Close attention must be paid to the location of the bar. The reliability of the F-scan system allows for variation of up to 30% between different measurements, and calibration is difficult in these patients; this limits its use in scientific studies. The accuracy is adequate for visual appraisals of changes in pressure.

Effect of an external metatarsal bar on plantar forces and surface area in a person with first metatarsal phalangeal joint pain

Effect of an external metatarsal bar on plantar forces and surface area in a person with first metatarsal phalangeal joint pain

Surgical management of foot disorders

Pathologic conditions of the metatarsophalangeal joints comprise the majority of painful conditions of the forefoot. Clinical manifestations commonly include hallux valgus (bunion), bunionette ("tailor's bunion"), and metatarsalgia. Conservative treatment remains the hallmark of initial management of these disorders. Conservative measures emphasize the adequate accommodation of the forefoot within the toe box of the shoe and the even distribution of plantar pressures by various metatarsal pads or bars and soft insoles. Numerous and sometimes controversial surgical procedures have been developed when conservative measures fail to achieve significant pain relief. In general, these procedures can be grouped as 1) soft tissue realignment procedures, 2) bony realignment procedures, 3) combined bony and soft tissue realignment procedures (ie, osteotomy), 4) bony and joint resection, 5) arthrodesis techniques, and 6) Silastic joint replacement techniques.

Common plantar hyperkeratoses.

In general, metatarsal bars have provided a simple method of relieving pain and disability caused by plantar hyperkeratoses over metatarsal heads. By spanning the longitudinal arch, the bars effectively relieve pressure from the middle three metatarsal heads and elevate the distal portion of the metatarsal bones. This often results in favorable repositioning of displaced proximal phalanges and eliminates direct pressure exerted by metatarsal heads. Also, by giving more uniform support to the foot, metatarsal bars rearrange the weight-bearing surface in a more even way, which favors resolution of hyperkeratoses by removal of pressure points. The prescription for metatarsal bars must be written for both shoes. Dual bars provide balanced walking surfaces and do not induce asymmetric motion of the lower spine as a single bar would. They can be applied to moderately high-heeled shoes for women and regular oxfords for men. The leading edge of the bar must be properly skived and tapered to provide an even surface with the forward part of the soles of the shoes. If this is not done properly, the bars may strike against uneven surfaces as the foot slides forward in walking or running. The patient should return to the prescribing physician in two or three weeks after the bars have been worn constantly. By analyzing the scuffed surfaces of the metatarsal bars, the physician can determine whether or not the bars are firm and thick enough and in the proper position to relieve and divert pressure from the metatarsal heads. Perhaps two pair of shoes should be thus altered to provide a change of foot gear for ordinary purposes. Unaltered dress shoes may be worn for short periods of time as party or formal occasions demand. Eventually, when the painful processes have subsided, the patient may resume wearing ordinary shoes and use the modified shoes if symptoms recur from time to time.

Treatment of Undisplaced Toe Fractures with a Metatarsal Bar Made from Tongue Blades

Treatment of Undisplaced Toe Fractures with a Metatarsal Bar Made from Tongue Blades

PLANTAR PRESSURES AND TROPHIC ULCERATION

1. With the object of perfecting the design of footwear for feet anaesthetic from leprosy, pressures on the soles of feet during walking were measured with transducers sufficiently thin to be worn inside ordinary shoes. 2. It was found that anaesthetic feet without deformity or muscle imbalance did not produce significantly higher pressures than normal feet during barefoot walking on a flat surface. The pressure distribution under drop feet with active posterior tibial muscles differed from normal, with increased pressure under the lateral forefoot and decreased pressures elsewhere. 3. Loss of toes or function of the toes results in high, sharp pressure peaks under the anterior end of the foot during push-off. In deformed feet these pressures are usually concentrated at one or two small areas. 4. In anaesthetic feet the prevention of trophic ulceration largely depends on the even distribution of pressure over the sole of the foot. 5. Moulding by carefully placed arch supports or metatarsal bars effectively redistributes plantar pressure. 6. A shoe with a rigid sole pivoting on a rocker near the centre of the foot most effectively reduces pressures under the forefoot of shortened, deformed feet. 7. We recommend the use of insoles made of microcellular rubber (approximately 1 5 degrees shore). 8. The importance of studying each deformed foot for areas of high pressure before fitting shoes is stressed; a pressure-indicating footprint is satisfactory for this purpose.

Orthetics in musculoskeletal disease.

ORTHETICS in the treatment of the patient with musculoskeletal disease and disability may be prescribed for temporary use during rehabilitation or may be permanently needed. In either case, the purpose of orthetics and their areas of usefulness are specific. Orthetic devices may be indicated: (1) for support and protection of musculoskeletal structure, (2) as a functional replacement or assistive device for a functionally inadequate body part, (3) as an efficiency mechanism for the conservation of body energy expenditure, (4) or for multiples of these reasons. An orthetic device may be as simple as a metatarsal rocker bar to protect arthritic metatarsal heads, as mechanically compact and complex as a motorized wheelchair, or as futuristic as an electronic talking machine. Basically, however, regardless of complexity demanded by need, device design should conform to the same rules. They should be maximally efficient, effective, and simple in operation. They should be designed