Management of a patient with forefoot pain: a case report.

Forefoot pain is a common problem seen by physical therapists. In patients with forefoot pain, I frequently find the metatarsophalangeal (MTP) joints restricted in passive dorsiflexion. Although the normal range of MTP joint dorsiflexion is 65 to 70 degrees, [1,2] many of the patients I see with forefoot pain have only 30 to 45 degrees of MTP joint dorsiflexion. The importance of dorsiflexion of the MTP joint in forefoot function has also been reported by Boissonnault. [3] Besides forefoot pain, restricted MTP joint dorsiflexion has also been associated with ulceration of the great toe [4] and plantar fasciitis. [5] If forefoot pain can be relieved by mobilizing the MTP joint, physical therapists could use this technique to treat patients with restricted MTP joint dorsiflexion. The purpose of this case report is to describe the evaluation and successful treatment of a patient with forefoot pain resulting from hallux limitus.

Patient Data

A 16-year-old male long-distance runner with a diagnosis of hallux limitus was referred to physical therapy. Hallux limitus is a condition where the hallux is unable to move through its full range of dorsiflexion at the first MTP joint. [1] The patient complained of pain around the head and proximal one third of his first metatarsal bone. He stated that he frequently had moderate pain and occasionally experienced intense pain during push-off when running. During normal walking, he complained of minimal, but constant, pain. Occasionally during walking, he would complain of an intense pain when pushing off. At rest, he did not complain of pain. Passive dorsiflexion of his first MTP joint was 30 degrees. A firm end-feel was detected when the proximal phalanx was translated anteriorly on the fixed metatarsal bone (Fig. 1). Observation of the plantar plane of the foot with the patient in the prone position revealed the relationship between the rear foot and the forefoot was normal. The patient had 5 degrees of dorsiflexion at the ankle with the knee straight. With the knee bent, he had 15 degrees of dorsiflexion. The subtalar joint had a passive range of 10 degrees of eversion and 20 degrees of inversion when measured with the patient in the prone position.

The invertor, evertor, plantar-flexor, dorsiflexor, and hallux flexor and extensor muscles were able to hold against maximum resistance when manually tested. [6] The length of the invertor, evertor, dorsiflexor, and extensor hallucis longus muscles were of normal length. The flexor hallucis longus muscle was assessed for length to determine whether it was responsible for the limited MTP joint dorsiflexion. A short flexor hallucis longus muscle can reduce the range of MTP joint dorsiflexion when the foot is dorsiflexed and everted and the interphalangeal joints are extended. A short flexor hallucis longus muscle would not reduce the range of MTP joint dorsiflexion when the foot is plantar flexed and inverted and the interphalangeal joints are flexed. The patient's MTP joint dorsiflexion was the same in both positions, indicating that the limited MTP joint dorsiflexion was not the result of a shortened flexor hallucis longus muscle.

Lateral and anterior-posterior radiographs were taken by the referring physician. No abnormality or evidence of arthrosis was seen on either radiograph.

Physical Therapy Plan

The major treatment goal was to restore normal motion to the first MTP joint of the foot and to reduce forefoot pain. I used three treatment procedures to restore MTP joint dorsiflexion: 1) distal distraction. [7] 2) dorsal gliding mobilization, [7] and 3) gentle passive stretching of the MTP joint capsule. Distal distraction of the MTP joint was the first technique used to restore MTP joint dorsiflexion (Fig. 2). Four to five grade [V distractions were performed; the amplitude and vigor of the distractions were reduced if symptoms were considered uncomfortable. The distractions were repeated after a rest period of approximately two minutes. Gliding mobilization of the proximal phalanx in a dorsal direction (Fig. 1) according to the concave-convex rule was also performed. [7] Seven or eight grade Ill and IV mobilizations were performed and then repeated after a brief rest period. The final treatment technique used was a gentle passive stretching of the MTP joint capsule. The passive stretching was performed by stabilizing the metatarsal head firmly and dorsiflexing the proximal phalanx. The MTP joint was dorsiflexed until a slight stretch was perceived around the plantar surface of the MTP joint. The stretch was held constant until the sensation of stretch disappeared (approximately one minute). Once the sensation of stretch disappeared, the phalanx was passively dorsiflexed until a stretch again could be perceived. The patient was also instructed that if he perceived more than minimal discomfort during the stretch, he stretched too far. The stretching involved a total of three successive passive stretches of the MTP joint capsule. The patient was taught how to perform the passive MTP joint stretch. Stretching was performed three times a day. I also taught him how to stretch his gastrocnemius muscle by standing so that 1) the gastrocnemius muscle to be stretched was behind the foot of the opposite limb, 2) his feet were pointed straight ahead, 3) the rear heel was firmly planted on the ground, and 4) the knee was completely extended on the side of the stretch and flexed on the opposite side. Once positioned, I instructed him to bend forward. When the patient felt a small stretch somewhere along the length of his gastrocnemiussoleus muscle or in the Achilles tendon, he stopped stretching and held that position. He held the stretch until it disappeared and then repeated the process two more times. I instructed him to stretch his gastrocnemius muscle at least three times a day.

Results of Treatment

The patient was seen a total of five times during this 17-day treatment program. On his second visit, 3 days (Day 3) after the first visit, he stated he bad only minimal pain on walking (no complaint of the occasional intense pain). He also reported that his pain was half as intense as on his first visit. His passive range of MTP joint dorsiflexion on his second visit was 45 degrees. On his third visit six days later (Day 9), his passive range of MTP joint dorsiflexion was 55 degrees. At that time, he complained of pain only during push-off when walking. By his fourth visit four days later (Day 13), his range of MTP joint dorsiflexion was 65 degrees. When walking, he ambulated comfortably without pain. He had moderate pain on push-off when running at full speed. He reported that he could run at three-quarters speed without pain. The forefoot pain prevented participation in track and risked his chance of receiving an athletic scholarship. I decided to tape his hallux in the hope of facilitating an early return to training. He was allowed to run only if the taping would keep him symptom-free. Running also would be discontinued if his range of MTP joint dorsiflexion had decreased when reexamined.

The goal of taping is to prevent pain by reducing MTP joint dorsiflexion so that the MTP joint capsule is not stretched to its motion barrier. The taping method I used was as follows:

1. I first applied anchors to the distal
   phalanx of the hallux and proximally
   around the midfoot.
2. Three longitudinal strips were then
   applied on the plantar aspect of the
   foot from the proximal to the distal
   anchor.
3. Anchors were reapplied to solidify
   both the proximal and distal
   anchors so that the longitudinal
   strips would not pull away.
4. By placing the patient's MTP joint
   in approximately 15 degrees of
   plantar flexion, I was able to
   reduce his MTP joint dorsiflexion
   to enable him to run without pain
   (Fig. 3).

By his last visit (Day 17), the patient had 70 degrees of MTP joint dorsiflexion and was without pain when walking or running. One month later, he returned to see me and stated that he had a reoccurrence of pain in his forefoot. An examination of MTP joint dorsiflexion revealed 45 degrees of passive movement. When questioned, he reported that he stretched his gastrocnemius muscle only a few times and quit because lie was pain-free. Passive ankle joint dorsiflexion with the knee straight was still only 5 degrees. I reinstructed him on gastrocnemius muscle stretching. Afterward, I explained how a short gastrocnemius muscle can create pronation of the foot during propulsion and reduce MTP joint dorsiflexion. The patient was seen 1 1/2 months later without further complaint of foot pain.

Discussion

I have found that mobilizing the MTP joint restricted in dorsiflexion was a very effective method of reducing forefoot pain in this patient. Reduced dorsiflexion of the first MTP joint hallux limitus) has been shown to be important in the development of forefoot pain. [1] Restoring dorsiflexion to the MTP joint in patients with hallux limitus can provide relief of forefoot pain. [8] Boissonnault has also reported the importance of MTP joint dorsiflexion in the management of foot dysfunction. [3]

A problem I first had in working with patients with forefoot pain was recognizing limited MTP joint dorsiflexion. When measuring MTP joint dorsiflexion, I did not stabilize the metatarsal head with my hand. Consequently, the range of passive MTP joint dorsiflexion appeared limited. Only after firmly stabilizing the proximal metatarsal bone with my hand did I discover that the range of passive MTP joint dorsiflexion was reduced. The method of stabilization is the same as illustrated in Figure 1. If too much pressure was applied to the plantar aspect of the metatarsal head, passive MTP joint dorsiflexion was reduced. Presumably, the excess pressure against the metatarsal bone compressed the flexor hallucis longus tendon against the metatarsal bone and prevented dorsiflexion. The proper assessment of MTP joint dorsiflexion is necessary before treatment.

Metatarsophalangeal joint dorsiflexion restored through mobilization may be only temporary. Any factors that can reduce MTP joint dorsiflexion must also be taken into account. I The reoccurrence of forefoot pain in the case described helps prove this point. During treatment, I inadvertently overlooked reassessing passive ankle joint dorsiflexion with the knee extended. I probably overlooked ankle joint dorsiflexion because the patient was progressing so well. His short gastrocnemius muscle reduced his ankle joint dorsiflexion. Limited ankle joint dorsiflexion is a common cause of pronation during ambulation. [9] Supination of the foot during propulsion is considered necessary for normal MTP joint dorsiflexion. [1] The treatment of most MTP joint problems requires a complete evaluation of the entire foot-ankle complex. The movement of the MTP joint is dependent on the normal function of many of the proximal joints of the foot.

Mobilizing the MTP joint was an effective technique for this patient. The patient in this case was young, and no osteophytes were visible on anterior-posterior or lateral radiographs. Also, his MTP joint exhibited few signs (eg, swelling, redness, heat) that would indicate active arthrosis. The effectiveness of mobilization in patients with osteophytes or intense arthrosis has not been demonstrated.

Reduced dorsiflexion of the first MTP joint has been shown to be an important factor in the development of forefoot dysfunction. [1-4] I have found that reduced MTP joint dorsiflexion may be found in any of the MTP joints of the foot. Besides hallux limitus, I often find reduced MTP joint dorsiflexion in patients with metatarsalgia, Morton's neuralgia, metatarsal stress fracture, and hallux abducto-valgus. The development of forefoot dysfunction probably depends on the combination of many factors including foot type (forefoot rectus or adductus), calcaneal inclination angle, intoeing or outtoeing, variations in the metatarsal formula and shape, and muscle and joint function of the foot.

The intent of this case report was to describe a successful treatment technique I used for forefoot pain. Although case reports are useful in providing new ideas and theories, they cannot prove the effectiveness of this method. I do believe, however, that physical therapists should examine the range of MTP joint dorsiflexion in patients with forefoot pain.

Summary

This case report described a method of evaluating and treating a patient with forefoot pain secondary to restricted MTP joint dorsiflexion. The importance of properly detecting a foot with limited MTP joint motion and eliminating restricted MTP joint dorsiflexion was emphasized.

References

1 Root ML, Orien WP, Weed JH: Normal and Abnormal Function of the Foot. Los Angeles, CA, Clinical Biomechanics Corp, 1977, vol 2, pp 60, 358, 367, 370, 371

2 Bosien-Moller F, Lamoreux L: Significance of free dorsiflexion of the toes in walking. Acta Orthop Scand 50:471-479, 1979

3 Boissonnault WG: The influence of hallux extension on the foot during ambulation. journal of Orthopaedic and Sports Physical Therapy 5:240-242, 1984

4 Birke JA, Cornwall MW, jackson M: Relationship between hallux limitus and ulceration of the great toe. journal of Orthopaedic and Sports Physical Therapy 10:172-176, 1988

5 Creighton DS, Olson VL: Evaluation of range of motion of the first metatarsophalangeal joint in runners with plantar fasciitis. journal of Orthopaedic and Sports Physical Therapy 8:357-361, 1987

6 Kendall FP, McCreary EK: Muscles: Testing and Function, ed 3. Baltimore, MD, Williams & Wilkins, 1983

7 Kaltenborn FM: Mobilization of the Extremity Joints, ed 3. Oslo, Norway, Olaf Norlis Bokhandel, 1980, pp 28,116,117

8 Turek SL: Orthopaedics: Principles and Their Application. Philadelphia, PA, J B Lippincott Co, 1977, p 1310

9 Hunt GC: Examination of lower extremity dysfunction. In Gould JA, Davies GJ (eds): orthopaedic and Sports Physical Therapy. St Louis, MO, C V Mosby Co, 1985, p 417

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