Knee Pain - Morton's Toe
Managing knee pain with orthotics
Knee pain is a common complaint of patients. Protocol for physicians often includes X-rays and prescription medications, but if patients’ symptoms are not resolved the practitioner may need to look further than the knee for biomechanical causes.
Because of the anatomic positioning of the knee, looking at all of the relevant structures that affect the knee may reveal deficiencies elsewhere. It is important to note that often referred pain to the knee may originate from the spine, hip, and especially the foot and ankle.
As pedorthists, we treat many referred patients with foot pain diagnosed as pes planus (flat feet), excessive subtalar pronation, tibial torsion, and forefoot varus with secondary complaints of knee pain. With years of observation and experience, patients regularly return to verify that their knee pains have improved, but may need slight adjustments to their orthotic devices for their foot. The most common foot disorder we see when a patient complains of knee pain is forefoot varus when static. About 30% of the population is born with the first metatarsal ray abnormally short. Often this is obvious when the second toe is longer than the hallux (big toe) which is called Morton’s toe syndrome.
In examining the foot for forefoot valgus, the patient should be in the standing position. Observing the subtalar joint, palpate it to neutral, or as close to neutral as possible. If the first metatarsal head is off the floor, the patient has forefoot varus. When ambulating, the motion caused by this foot type excessively pulls the tibialis anterior tendon and can cause genu valgum and lead to patellofemoral pathology or anteriomedial joint pain. To correct this problem, an orthotic device with wedging under the first metatarsal head and the hallux will reduce the pull on the anterior tibialis.
Excessive pronation of the foot can cause genu valgum. A stronger, more supportive shoe combined with over the counter or custom orthotics will reduce the pronation and help to maintain correct knee positioning. Conversely, excessive supination can cause both genu varum and genu valgum. Once again, stronger, more supportive footwear with over the counter or custom orthotic devices are indicated to reduce supination and help maintain correct knee alignment.
When observing the patient’s gait, observe the degree of heel valgus. Situations where medial knee pain is present but forefoot varus or excessive pronation are not apparent, but heel valgus is present, a heel straight (or posting) could be all that is needed to relieve the symptoms. In more severe cases of heel valgus, sole wedging or sole flaring may be added to the patient’s shoes.
Of course, knee maladies are complex and vary extensively. A quick biomechanical exam may reveal that prescribed custom or over the counter orthoses, shoes, or heel wedging are modalities that physicians may utilize to treat early knee symptoms. Patients are generally receptive to conservative treatment and, often health insurance benefits will pay for pedorthic treatment plans.
This foot is incurring forefoot varus during gait without supports and causing tremendous pull on the medial side of the knee. With the correct orthotic device this condition could be corrected.