Case of the Week 8-26-12: First Ray Regional Interdependence | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week 8-26-12: First Ray Regional Interdependence

Today's COTW is a DPT student who approached me at a recent spinal manip course stating she had severe great toe/first ray pain.

Terminology review here!

Subjective: Pt reports an insidious onset if L foot pain approximately 2 months ago and describes it to be the medial mid-foot over the navicular and extends to the first metatarsal. She states over the first month and half it only hurt occasionally but says the past three weeks it hurts every day. Since the onset of pain she states “rolling her ankle” 4-5 times. She reports going to immediate care approximately 2 weeks ago, stating XRAY was negative and given Naproxen for pain. She tried the free chiropractic clinic at school, but was only getting flying 7 manipulations without HEP.
Sx rated 0-7/10 on the VAS. Sx worse with WB and wearing sandals. Sx better with NWB and wearing sneakers. She is a volleyball and basketball player and is unable to participate in either as a result of her foot pain.

Objective: fair sitting posture, moderate forward head
Cervical Extension DN, mild loss
rot and flex Left DN Right DN, B mild loss

MS Flex DN, mod loss
MS Ext DP, mod loss

MSR Left DN, min Right DN, sev
rot in sit Left FN Right FN
rolling prone to supine Left and Right DN

MRE Left FN Right DN, mod loss
LRF Left FN Right FN

Ext Left FN Right DN
Int Rot Left DN, mod Right FN

SLS EC Left DP Right FN
SL swing FN in all tests EO and EC

Myofascia: moderate restrictions in L ITB, R psoas, around bony contours of navicular in L forefoot

MMT: hip abduction Left 3/5, Right 5/5, hip extension Left 5/5, Right 4/5

Day 1: At the end of my course, I performed IASTM to her L ITB and around her bony contours of the Left 1st MTP. I instructed her on repeated hip IR in hooklying and hip abduction in sidelying against a wall.

Day 2: She wasn't able to follow up until 1.5 weeks after the course but she already reported at least a 20-30% improvement in her foot pain. This was when we did the full eval with SFMA listed above. I surmised that the limits in her shoulder MRE, plus trunk rotation right, along with her gluteus medius weakness on the left was causing excessive 1st ray pressure in push off for both walking and running. Despite the patient stating she was worse without arch supportive footwear and better with, I instructed her on progressively wearing flip-flops more often to increase her foot strength and prioprioception of excessive pronation.

Treatment included IASTM as above, along with psoas release on the left and right, STM to her thoracic paraspinals as manipulation prep and supine thrust manipulation to several levels from upper thoracic to lower thoracic spine. After retest, she had increased thoracic rotation to the right.

For HEP, I added prone to supine rolling patterns in both directions, since she had mod difficulty performing both, and open book sidelying trunk rotations to the right with breathing assistance.

Day 3: The patient reports being able to walk and run with at least 70% reduced pain. SFMA testing revealed shoulder MRE still mod loss on the right, MSR was now Left FN, Right DN, mod loss. Treatment as above with added Right pec minor release and FR to improve right shoulder IR, including lateral upper arm release and IASTM to posterior scapular patterns. No change to her HEP, but she said she modified the hip abduction on the wall to more extension because she felt it fired her gluts more.

Day 4: The patient reports she was able to play basketball for 1.5 hours with only minimal great toe "soreness." SFMA testing revealed MSR was now Left FN, Right DN, mild loss, rolling patterns were now FN bilaterally in all directions, glut med strength was Left 4+/5 Right 5/5. SLS was FN in EO, EC and FN for SL swing EO, but mild DN hip swing EC on the Left. I re-instructed her on open book sidelying trunk rotation as she was not performing it correctly. No change in treatment. The patient reported she was very happy with her outcome and had to leave to go out of town. She will call if further appointments are needed or email me for exercise progressions. Of course I stressed HEP and showed her self audits and her baselines to increase or decrease HEP as needed.


The toe bone's connected to the shoulder bone! In the class, I was unsure of her presentation as when someone presents with great toe pain, I expect a loss of ankle df along with great toe extension. These both had full ROM with no pain. Neurodynamics were negative. The second day, I had time for a full eval which brought out more with her SFMA and showed how her walking and running gait could be placing excessive pressure on her left great toe because of her proprioceptive dysfunction in SLS and trunk limits with rotation Right and shoulder limits with MRE on the right. That's how I pictured it in my head anyway, so I improved the DNs and I was actually amazed that she could play basketball so soon after not being able to do it for months!

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