Case Study January 2017 – Sports Podiatrist Treats A Painful Bunion

Initial Consultation with Sports Podiartist

A 44-year-old female arrives at the clinic and informs the Sports Podiatrist she has a painful bunion in her left foot that has been aching for 6- 9 months. She reports a mild pain that has existed for approximately 2 years but a more severe pain that started recently. She informs the Sports Podiatrist that she feels an aching sensation and a sharp pain when she walks for more than 5 minutes and a heat / burning sensation when at rest. She has no pain in her right big toe joint. The Sports Podiatrist takes a history and learns that this patient enjoys sports that involve running and is a keen hockey player. She trains once during the week and then plays a competitive match on the weekends when in season. In addition to this, she is a committed runner and covers a 5k run once or twice a week, in approximately 20 minutes. Her running shoes, Asics DS Trainer, are 4 months old with an uneven wear pattern.

At work, she sits down for most of her day and wears a low-heeled office shoe. She informs the Sports Podiatrist that she is comfortable in ballet flats and doesn’t like wearing high heels. She walks to and from her office / train station 4 mornings a week, and works from home one day a week where once again, she is seated for most of her day. This patient, when walking to and from the office, uses her ballet flats / office shoes. The Podiatrist informs the patient that these shoes offer no support and allow the foot to work harder / endure more stress on hard / flat surfaces.

The Sports Podiatrist assesses the patient’s x rays which her GP had arranged. There is a significant angle at the first metatarso-phalangeal joint (big toe joint / bunion) and moderate osteo-arthritis, causing a narrowing of the joint space. In comparison to the right MTPJ which demonstrates minimal angle and very mild arthritis and a well preserved joint space. This lady was advised by the Sports Podiatrist that she does in fact have, what is commonly known, as a bunion in her left foot, with moderate arthritis.

Physical Assessment by Sports Podiatrist

The patient was asked to lie on the treatment table on her back so that the Sports Podiatrist could carry out a physical assessment, which included a range of motion test at the 1^st MTPJ. On assessment, there was a limited range of motion, in particular, reduced dorsiflexion. Movement was measured at approximately 14 – 16 degrees. Normal range would be approximately 70 – 90 degrees. The right foot demonstrated a range of approximately 65 degrees. The bunion was clearly visible and there was osteophytic dorsal lipping. The Podiatrist noted a redness and heat in and around the joint. There was some mild callus formation of the skin around the medial border of the joint and there was tenderness when the joint line was palpated. Forced plantar flexion by the Sports Podiatrist elicited extreme pain.

This patient demonstrated normal ankle joint dorsiflexion in the right leg but stiffness and a reduced range in the left. Sub talar and mid tarsal joints had similar findings. Leg length appeared to be unequal. The left tibia and femur both appearing to measure a total of 12mm less than the right. The Sports Podiatrist explained to the patient that she had a short left leg and this may be a contributing factor in the development of her bunion. The short leg can often lead to an early heel lift which in turn, loads the forefoot sooner that it should, during gait. An overload of pressure leads to an overload of stress on the joint and can cause deterioration.

Biomechanical Assessment By Sports Podiatrist

With the patient in a standing and fully relaxed position, the Sports Podiatrist took measurements of the patient’s feet. Her arch height was within normal range at 25mm left and 26mm right. From behind, the left heel everted slightly and the right a little less – Foot posture index results – 5 degrees left, 3 degrees right. The patient was observed walking on a treadmill without shoes. Her foot function was recorded using digital software on an iPad. During playback, the Sports Podiatrist was able to observe mild pronation in both feet. The patient was advised that her level of foot stability was acceptable – that she did not over pronate. As to be expected, the Podiatrist detected an early heel lift of the left foot, more than likely a result of her short leg. Unsurprisingly, further discussion between the patient and Podiatrist revealed that she has experienced lower back pain for most of her adult life.

Treatment

Primarily, the Podiatrist advised this lady that her footwear must change. Her running shoes were to be upgraded to an Asics 2000 which would offer more support than her DS Trainer. Her current shoes flex easily beneath the forefoot and allow more stress through the bunion. Her ballet flats, the same. She was asked to use a more supportive street shoe, that has a more rigid mid sole, when walking to and from the office. At work, she could change into her ballet flats.

This patient did show some concern for her leg length discrepancy and the Sports Podiatrist quite rightly referred her for a CT scan. The report showed an 8mm shortening of the left tibia and a 5mm short femur. To this end she was given a 7mm heel lift to use in the left shoe, that would be increased over time, as the patient’s back pain was monitored.

After 6 weeks, her painful bunion was approximately 50% better. She was reviewed after 12 weeks and her condition was the same. No further improvement was noted. To this end, this lady was fitted with prescription orthotics with a Morton’s extension under both 1^st MTPJ. These extensions would act as “spring boards” below the joint and reduce the load going through it.

An orthotic review after a further 8 weeks revealed further improvement. The patient was able to run without pain, and would only experience an “awareness” in the bunion for a few hours after the run / hockey. On a day to day basis, and when at work she did not experience pain at all.

She informed the Sports Podiatrist that her back pain while still present, was not as sharp and was definitely improving. Her next step was some remedial massage and stretching to help realign the back and pelvis.

The patient was booked to come back and see the Sports Podiatrist in 12 months for a general review, but to return sooner if she had problems.

PLEASE BE AWARE: The information in this case study is not general advice. If you have back pain or foot pain you should seek the help of a Sports Podiatrist or a suitably qualified practitioner.