Patient presented for second opinion of her 1st MTPJ pain. This is an athlete with functional foot orthotics. The main question of the patient was whether or not she was “due for a new pair” … as the pain in the big toe wasn’t going away despite efforts to “pad” the pain area.

On evaluation of the patient: minimal hindfoot pronation with a functional hallux limitus and associated medial hallux and 1st MTPJ callusing.

Prior to pulling the orthotic devices out of the shoe, what do we expect to see on the orthotic? This could be a simple orthotic shell with great hindfoot control and a simple top cover and could potentially include a reverse morton extension, as this modification allows plantarflexion of the 1st metatarsal and therefore increased ROM thru the 1st MTPJ during the gait cycle.

Periodically I see addition of padding beneath the 1st MTPJ in an effort to literally pad the painful region. In this particular instance, all this padding does is dorsiflex the 1st metatarsal and create additional jamming of the 1st MTPJ and more limitus, callusing, and pain. In some instances this also creates transfer metatarsalgia. It is important to have patients stand on their devices before and after any modifications are added (or even removed) and make sure that the goal you have for the patient on their devices is achieved BEFORE they leave the office.

In this case, standing on the device with padding beneath the 1st met head, I could not dorsiflex the 1st MTPJ. I actually caused pain to the patient. Removing everything and simply having the patient stand on the shell of the orthotic made it a little bit easier to dorsiflex the hallux. Finally, adding the reverse morton extension (beneath a fresh top cover) not only made it much easier to range the hallux, but also showed the patient how much we can “un-jam” the great toe and she reported comfort.

To best help your patients it is really important to understand the effect any modification you place on an orthotic has on the mechanics of the lower extremity.