Foot and Leg Pain Centre

// Surf Life Saving NSW is excited to formally announce the Overall winners of the 2024 NSW Surf Life Saving Championships Point Scores for Masters and Opens, having now collated results across Lifesaving, Surf Boats, and beach and water events.

After initially announcing discipline-specific winners – being related to the point scores accumulated during the beach and water events – following the culmination of both the Masters and Open Championships, SLSNSW has now been able to combine the point scores accumulated through all State Championship events to determine the overall winning clubs.

Bondi Surf Club is the Masters Overall Champion club, beating neighbours, North Bondi SLSC by nine points. Manly LSC is confirmed as the third-place getter.
In the Open Championships, Newport Surf Life Saving Club beat out Wanda Surf Life Saving Club in second and Redhead SLSC in third to be named the Overall Champion club.

SLSNSW is grateful to all competitors and clubs for helping us to run another successful Championships, and looks forward to announcing shortly the dates for the 2025 Champs.

Painful under the pad of he 2nd metatarsal next to the ball of the foot? We can help 😃

Plantar Plate Anatomy: Part 1

The plantar plate is a fibrocartilaginous structure that lies directly plantar to the lesser metatarsal heads and acts as a sesamoid-like mechanism for each lesser metatarsophalangeal joint of the human foot. Functionally, the plantar plate may be considered to act as a distal mechanical extension of the plantar fascia.

In the dissection below (performed by Lawrence Ford, DPM), the plantar plate is shown to be attached proximally to the deep slip of the plantar fascia (i.e. central component of the plantar aponeurosis) and distally to the plantar aspect of the base of the lesser digit proximal phalanx. The plantar plate inserts onto the base of the proximal phalanx via tightly interwoven collagen bundles. The dorsal surface of the plantar plate, which is slightly concave, is in direct contact and congruous with the plantar articular cartilage of the lesser metatarsal head.

The longitudinal orientation of its fibers suggests that the plantar plate is subject to significant tension loading forces from the plantar fascia. In addition, the plantar plate is subject to significant compression loading forces due to the large magnitudes of ground reaction force that act on the plantar metatarsal heads during weightbearing activities.

https://www.hmpgloballearningnetwork.com/site/podiatry/understanding-biomechanics-plantar-plate-injuries #:~:text=Since%20the%20plantar%20plate%20is,at%20the%20proximal%20phalanx%20base.

References:

Kirby KA: Understanding the biomechanics of plantar plate injuries. Podiatry Today, 30(4):30-39, 2017.

Ankle Block Anesthesia

During my first year of surgical residency, from 1983-1984, at the Veteran's Administration Hospital in Palo Alto, California, I was trained on performing local anesthetic ankle blocks by my residency director, Wilfred Laine, DPM. Dr. Laine had us practice the ankle block technique popularized at the time by John Ruch, DPM, from the Podiatry Institute in Georgia. Dr. Ruch demonstrated the technique to anesthetize the whole foot using only 3.0 cc of xylocaine local anesthetic in a video he created at the time. I created this handout in 1984 at the start of my Biomechanics Fellowship at the California College of Podiatric Medicine. This handout was then provided to the CCPM surgery department residents so they could also start teaching Dr. Ruch's ankle block technique to the podiatry students at CCPM.

Merry Christmas!🎄🎅

⚠️ "Pelvic floor dysfunction among athletes is undervalued, underreported, and undertreated" 🏃‍♀️

Have you seen the from the ? 📖

🔟 naked truths about the pelvic floor in athletes👇

https://bit.ly/47P0pfy

Posterior hip pain is complex so I teamed up .hip.physio for his expert input to create this graphic
Pain locations are approximate and will vary between individuals and in case you’re wondering, PHT = Proximal Hamstring Tendinopathy
For more great hip content check out .hip.physio’s Instagram timeline. He has some real gems on there!

Huge thanks to everyone who attended and made the Conference what it was - an environment of collegiality, warmth and knowledge sharing.

The 2024 SMA & ACSEP Australasian College of Sport and Exercise Physicians Joint Conference will be held at the MCG from 16-19 October 2024.
📅 Block your calendar and stay tuned.

Common pain sites in Gluteal Tendinopathy…
Most tendinopathy in the lower limb has quite focal pain that rarely spreads. Think of the Achilles or Patellar tendons, for example. The Gluteal tendon is different! There is likely to be local pain over and around the tendon but there is often a spread of symptoms down the thigh and/ or into the lower back.
This spread down the leg is known as ‘pseudoradicular’ because it’s similar to nerve pain. This makes it easy to misdiagnose! For help with diagnosis see my timeline for a simple test battery for suspected gluteal tendinopathy.
Just to muddy the water a little further, co-existing pain and injuries are common. Woodley et al. (2008) studied a group of patients with lateral hip pain and reported that 50% had a previous lower limb injury. 75% had a past history of lower back pain and 30% currently had back pain at the time of the study.
The are a couple of key take home messages for this post:
1. Consider Gluteal Tendinopathy as a possibility in those that present with back and leg symptoms, especially if they have common tendinopathy symptoms (such as early morning stiffness, a warm up response or delayed pain).
2. Examine the lumbar spine and kinetic chain in patients with gluteal tendinopathy to determine their rehab needs
Please like and share if you’ve found this helpful 😊

Diagnostic test battery for Gluteal Tendinopathy from
Combining patient history and a selection of tests is likely to be more accurate for diagnosis of Gluteal Tendinopathy (GT). We want to see if these tests recreate *their* symptoms i.e. the pain they are presenting to us with rather than an unrelated discomfort (e.g. from a stretch felt during the test). So we ask, “is this bringing on your pain?” and we compare to the test on the unaffected side to show how we might expect it to feel.
In less irritable cases we may need to add resistance to the tests if symptoms aren’t recreated. For example, performing the FADER and resisting internal rotation at the end of range (FADER-R). This loads the tendon in a provocative position and is likely to elicit symptoms in GT.
For more information see the fantastic work of Dr. Alison Grimaldi and colleagues, including the reference below:
Grimaldi A, Mellor R, Nicolson P, et al Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain British Journal of Sports Medicine 2017;51:519-524.

Champions!

A fantastic result for Dural 13 Blue. A nailbiting finish in a local derby Grand Final, breaking a 19-all deadlock in the final moments to end the game up 24-19 versus a strong Hills team who have had a great season.

Hills Junior Rugby Union - It was a challenging and competitive game to the very end. Congratulations on a solid season and the minor premiership; we look forward to seeing you next year.

To our Dural 13 Blue boys, the hard work and effort you've put in to get where you are today is paying dividends. Dural Rugby Club is very proud of your achievements.

so good!!👏

Thank you, Eastwood Rugby and Manly Marlins Rugby Colts, for your recognition of Alfie at TG Millner. The support of the Rugby community in Sydney is quite overwhelming.

Mortons Neuroms are effectively treated conservatively

Effective Treatment of Morton's Neuroma with Custom Foot Orthoses

Thomas George Morton, MD, was a civil war surgeon that was one of the first to describe the most common nerve pathology that occurs within the forefoot, Morton’s neuroma (Morton TG: A peculiar and painful affection of the fourth metatarsophalangeal articulation. Am J Med Sci, 71:37-45, 1876).

Patients with Morton’s neuroma classically describe their discomfort as being a burning, tingling, aching or cramping sensation in the area between the third and fourth metatarsal heads which often radiates toward the distal aspects of the third and fourth digits. Patients often report the pain of Morton’s neuroma as becoming worse when wearing tight shoes or when walking for long distances.

Clinical examination for Morton’s neuroma often reveals a “clicking mass” that is evident with manual side to side compression of the metatarsal heads (i.e. positive Mulder’s sign). Frequently tenderness is present between the plantar aspects of the third and fourth metatarsal heads and there may also be a specific loss of sharp/dull sensation between the plantar aspects of the third digit and fourth digits. Care must be taken during examination to also palpate the plantar plate area of the surrounding metatarsal heads to rule out plantar plate tears or other pathologies of the plantar forefoot.

Patients with Morton’s neuroma often have a history of wearing fashionable dress style shoes for many years. Shoes that are too narrow for the foot will generate significant external compression loading forces on the medial and lateral forefoot which will also be transmitted as a compression force to the intermetatarsal nerves (Fig. 1). Since the intermetatarsal nerves lie plantar to the deep transverse intermetatarsal ligament, the nerve can also be compressed between the ground and the intermetatarsal ligament, especially in shoes with higher heel height (Miller SJ, Nakra A: Morton’s Neuroma. In: Banks AS, Downey MS, Martin DE, Miller SJ (eds): McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Vol. 1, 3rd ed, Lippincott Williams & Wilkins, 2001, pp. 231-252.)

Therefore, it seems likely that any shoe that exerts an excessive compression force upon the medial and lateral forefoot from side to side or any shoe that has a higher heel height may be responsible, over time, for the development of a Morton’s neuroma. Another theory of why the third intermetatarsal nerve is the most common site for an intermetatarsal neuroma is that there may be more frontal plane motion between the third and fourth metatarsal heads since the third intermetatarsal space is the junction between the medial and lateral columns of the foot.

The clinician should spend a considerable amount of time discussing with patients about the types of shoes that they wear for work and leisure in order make certain that their shoe choices are not causing excessive forefoot compression forces and an exacerbation of neuroma symptoms. Initial treatment involves a change to roomier shoes, icing the plantar forefoot twenty minutes once to twice a day, oral non-steroidal anti-inflammatory medicines, metatarsal pads and cortisone injections. My clinical experience has consistently been that even though many patients may improve with my initial treatment plan for neuroma, many patients may also require a custom foot orthosis (CFO) to avoid surgical treatment for the neuroma. Orthoses can be very helpful in treating Morton’s neuroma if they are designed with the specific goal of reducing the abnormal internal forces acting on the nerve within the third intermetatarsal space during weightbearing activities.

First of all, the clinician needs to pay very close attention to the function of the foot during gait. If the patient exhibits late midstance pronation, instead of the more normal slight supination of the foot during late midstance, then this abnormal pronation motion will cause an abnormal dorsiflexion of the medial column relative to the lateral column when ground reaction force (GRF) is at its maximum on the forefoot (Fig. 1). Late midstance pronation is common in patients with Morton’s neuroma and a well-fitted CFO with a standard rearfoot post, minimal medial expansion to increase arch congruity and possibly a slight (e.g. 2 mm) medial heel skive will help reduce late midstance pronation.

Another orthosis modification that is commonly used to treat Morton’s neuroma is a soft metatarsal pad that is sandwiched between the orthosis plate and a topcover. The goal of using a metatarsal pad on a CFO, or by itself in a dress shoe, is to attempt to place sufficient force between the third and fourth metatarsal shafts so that these metatarsals will “spread away” from the neuroma. Unfortunately, patients may have a difficult time with the metatarsal pad as many may feel that it is more of an uncomfortable bump in their arch rather than a valuable part of the orthosis designed to reduce the compression forces acting on their neuroma.

After hundreds of trial-and-error applications of metatarsal pads on orthoses over the last quarter century of treating these patients, I have found that placing the metatarsal pad so that its leading edge is 15 mm anterior to the distal orthosis edge is the position that is most comfortable for the majority of patients. However, I still write in the “special instructions” section of the orthosis order form for the lab to leave the anterior half of the orthosis topcover unglued so that I can more easily move the metatarsal pad to another location on the orthosis if the patient reports that the metatarsal pad “feels that it is in the wrong place” under their foot.

Lastly, it is important that when designing the CFO for a patient with a Morton’s neuroma that the patient understands that any foot orthosis will tend to make their shoe fit tighter which may also tend to increase the internal compression forces acting on their painful neuroma and prevent the orthosis from performing properly. Therefore, patients are informed that unless more roomy shoes can be worn that allow the orthosis to fit their shoes without increasing shoe tightness, that foot orthoses are unlikely to reduce their pain. For patients that do need to wear stylish dress shoes for their work, I often will make both a thin cobra style dress orthosis with metatarsal pad for their dress shoes and a thicker full length orthosis with metatarsal pad for their athletic shoes in order to allow them to benefit from the therapeutic effects of orthoses while at work and while participating in their leisure activities.

[Reprinted with permission from: Kirby KA: Foot and Lower Extremity Biomechanics IV: Precision Intricast Newsletters, 2009-2013. Precision Intricast, Inc., Payson, AZ, 2014. pp. 91-92.]