Outpatient Rehabilitation for a Patient with Chronic

OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC

METATARSALGIA

A Doctoral Project A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

Christine Eden-Graves

FALL 2019

Christine Eden-Graves

OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC

METATARSALGIA

A Doctoral Project

Christine Eden-Graves

Approved by:

______, Committee Chair William Garcia, PT, DPT, OCS, FAAOMPT

______, Second Reader Bradley Stockert, PT, PhD

______, Third Reader Bryan Coleman-Salgado, PT, DPT, MS, CWS

______Date

iii

Student: Christine Eden-Graves

I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project.

______, Department Chair ______Michael McKeough, PT, EdD Date

Department of Physical Therapy

Abstract

OUTPATIENT REHABILITATION FOR A PATIENT WITH CHRONIC

METATARSALGIA

Christine Eden-Graves

A 54-year-old man with left foot metatarsalgia was seen for 10 physical therapy treatments at an outpatient pro bono physical therapy clinic. The episode of care began on

06/05/2018 and ended on 07/28/2018. Treatment was provided by a student physical therapist under the supervision of licensed physical therapists.

The patient was evaluated at the initial encounter with gait observation, goniometric measurements, manual muscle testing, single limb stance test, foot squeeze test, tuning fork test, and self-report questionnaires (Lower Extremity Functional Scale and Foot and Ankle Ability Measure). The patient presented with forefoot pain, impaired ankle and foot strength and limited range of motion, decreased ability to balance, a limp, and decreased walking speed. An appropriate plan of care was established following the evaluation. The main goals for the patient were to normalize his gait pattern and gait speed, increase his left foot strength and range of motion, and to improve his static standing balance to regain his functional mobility. The main interventions used were joint and soft tissue mobilizations, therapeutic exercises, and treadmill training.

The patient normalized his gait pattern and gait speed, improved his strength, increased his range of motion, improved his balance and regained his functional mobility to be independent in all activities of daily living. The patient was able to resume participation in his favorite recreational activities and was discharged with a home exercise program.

______, Committee Chair William Garcia, PT, DPT, OCS, FAAOMPT

______Date

ACKNOWLEDGEMENTS

I acknowledge California State University, Sacramento Physical Therapy Pro Bono

Clinic with its knowledgeable clinical instructors for allowing me to learn about and treat a patient with an orthopedic disorder.

vii

TABLE OF CONTENTS Page

Acknowledgements ...... vii

List of Tables ...... ix

Chapter

1. GENERAL BACKGROUND ...... 1

2. CASE BACKGROUND DATA ...... 3

3. EXAMINATION – TESTS AND MEASURES ...... 6

4. EVALUATION...... 11

5. PLAN OF CARE – GOALS AND INTERVENTIONS...... 16

6. OUTCOMES...... 21

7. DISCUSSION ...... 22

References ...... 24

viii

LIST OF TABLES Tables Page

1. Medications ………………… ...... ……………………………….5

2. Examination Data……………………………….…. …………………………10

3. Evaluation and Plan of Care… .. ………….…………………………………. 13

4. Outcomes……………………………….……… ... …………………………. 19

Chapter 1

General Background

Foot pain is a common complaint and affects approximately 1 in 5 middle-aged- to-older people, while forefoot pain occurs at an annual rate of 9.1% in US adults aged

45-64.1,2 Metatarsalgia refers to acute, recurrent, or chronic pain in the forefoot under one or more metatarsal heads. Pain in the metatarsophalangeal joint (MTPJ) can be caused by damage to the anatomical structures that relate to the joint, such as bone, cartilage, capsule, ligaments, tendons, vessels, nerves, bursa, subcutaneous tissue, and skin.3

Metatarsalgia is an umbrella term that encompasses a variety of diagnoses such as

Morton’s neuroma, tarsal tunnel syndrome, stress fractures, Freiberg infarction, and benign skin lesions.4

As a result of metatarsalgia’s complexity, 3 classifications of metatarsalgia exist: primary, secondary, and iatrogenic metatarsalgia.5,6 Primary metatarsalgia pertains to anatomical characteristics of the metatarsals, such as congenital deformities, hindfoot abnormality, pes cavus, fixed equinus of the foot, or tightness of the gastrocnemius.5

These structural anomalies represent 70.8% and functional dysfunction of the foot is seen in 13.6% in all cases of metatatrsalgia.3 Secondary metatarsalgia is characterized by causes such as trauma, overload, or indirect mechanisms of systemic conditions such as chronic synovitis, rheumatoid arthritis, gout, or psoriasis.3,5,6 The systemic disorders represent 15.6% of people with metatarsalgia.3 Secondary metatarsalgia may also be triggered by neurological disorders such as Charcot-Marie-Tooth disease.5 Metatarsalgia caused by iatrogenic etiologies include surgical removal of metatarsal heads or

2 inappropriate osteotomies resulting in shortening of structures, causing overloading of the metatarsal head.5

The clinical impairments associated with metatarsalgia can present as pain, swelling, decreased foot intrinsic muscular strength, limited foot joint range of motion

(ROM), and impaired balance.7 These impairments can lead to functional limitations such as limping, decreased gait speed and impaired endurance, which cause restrictions in patients’ participation in social and recreational activities.3,7 Although there is limited evidence-based research to guide the optimal treatment of metatarsalgia, most patients are managed successfully with conservative care.6 Physical therapy interventions are aimed at pain and edema management, increasing strength and ROM, as well as patient education aimed at self-management skills to improve function so patients can return to previous levels of activities.6

Non-modifiable risk factors for developing metatarsalgia include: advancing age, female sex, osteoarthritis, and the aforementioned etiologies.4,8,9 Modifiable risk factors for developing metatarsalgia include: obesity, diabetes, wearing high-heeled shoes or poorly fitting footwear, and high-impact exercises such as running or jumping.8,9 High impact exercises can generate stress fractures, particularly when intrinsic factors such as race (Caucasian), smoking, and nutritional and menstrual irregularities in women are present.10 Returning to sport and previous activity level is a common rehabilitation goal after an injury. The average time to return to weight-bearing exercise after metatarsal injury is 4-6 weeks.10 The medical management of metatarsalgia and prognosis depend on the etiology, severity, age, gender, and whether surgery is required.11

Chapter 2

Case Background Data

Examination – History

The patient was a 54-year-old male college professor who was self-referred to physical therapy with left (L) foot metatarsalgia that he had sustained while attempting to run in cowboy boots 6 months prior to the initial visit. The patient saw his primary care physician (PCP) approximately 5 months prior to his initial physical therapy evaluation.

The PCP ordered radiographs, which were unremarkable and referred him to a podiatrist.

The podiatrist diagnosed him with metatarsalgia and prescribed a cam boot, recommended rest and elevation. The patient ambulated with a cam boot and a knee scooter for 4 months prior to initiating physical therapy. The patient had returned to the podiatrist for a follow up visit 1 week prior to his initial physical therapy examination, at which time a second set of radiographs were negative for fracture. At that time, heel-toe rocker shoes (Hoka shoes) were recommended for walking instead of the cam boot.

His past medical history included: psoriasis, treated with topical creams since the age of 5; colitis since the age of 20, which required a 3-day hospitalization; 4 occurrences of kidney stones since the age of 26; and insidious onset of low back pain (LBP) at age

53, with an unremarkable MRI. At that time, he was diagnosed with back spasms, with symptoms lasting 3 months. He sought out alternative therapies such as acupuncture and aromatherapy for relief. He was cleared by his PCP to return to previous level of activity

2 days prior to the onset of his current complaint of forefoot pain. The patient denied any

4 lower extremity (LE) symptoms with his episode of LBP. He denied a history of rheumatoid arthritis, osteoarthritis, cancer, or diabetes.

The patient’s chief complaint was L forefoot pain when walking barefoot. The patient described his pain as a mild ache or throbbing pain with short and long-distance walking, respectively. His pain was intermittent and variable, ranging from 0-5/10 on the numeric pain rating scale (NPRS) with weight bearing activities; it was relieved with rest and wearing Hoka shoes. He stated having undisturbed sleep. The patient reported donning his socks and shoes in bed prior to taking the first step in the morning and wearing them all day. He reported having difficulties with running, and with walking at social and work events, which contributed to leading a sedentary lifestyle. His goals were to eliminate his pain, improve his ankle and foot ROM, and return to running. The patient stated a desire to train for a half marathon.

Systems Review

The patient’s cardiopulmonary system was impaired based on objective measurements: a pre-clinical hypertensive resting blood pressure of 128/78 millimeters of mercury, a normal resting heart rate of 77 beats per minute, and an oxygen saturation of

96% at room air. The integumentary system was unimpaired based on observation and patient report at time of initial evaluation, yet, at a later visit the patient revealed psoriatic lesions secondary to a colitis flare up. The patient’s communication, cognition, affect, and learning were unimpaired based on observation and patient report. The neuromuscular and musculoskeletal systems were impaired based on subjective complaints of pain, observation, and examination findings listed in table 2.

Examination - Medications

Table 1

Medications12

MEDICATION DOSAGE REASON SIDE EFFECTS Balsalazide/ 750 milligrams, 3 oral Colitis Headache, abdominal pain, Colazal® (Anti- capsules three times a upset stomach, diarrhea, inflammatory agent) day vomiting, joint pain, difficulty falling or staying asleep, tiredness, gas, runny nose, muscle or back pain, coughing, loss of appetite, urinary tract infection, dry mouth, constipation. Prednisone 10 milligrams, 4 oral Anti-inflammatory Headache, dizziness, (Corticosteroid) tablets once a day for 2 for colitis flare-up difficulty falling asleep or weeks, followed by staying asleep, tapering inappropriate happiness, extreme changes in mood, changes in personality, bulging eyes, acne, thin fragile skin, red or purple blotches or lines under the skin, slowed healing of cuts and bruises, increased hair growth, changes in the way fat is spread around the body, extreme tiredness, weak muscles, irregular or absent menstrual periods, decreased sexual desire, heartburn, increased sweating.

Chapter 3

Examination – Tests and Measures

The patient’s deficits were categorized using the International Classifications of

Functioning, Disability and Health (ICF) Model.13 Tests and measures including the

NPRS, goniometry, and manual muscle test (MMT) were used to identify the patient’s impairments in the body structure and function category. The Lower Extremity

Functional Scale (LEFS) and 10-Meter Walk Test (10 MWT) were used as outcome measures to identify activity limitations. Participation restrictions were assessed with the sport subscale of the Foot and Ankle Ability Measure (FAAM) questionnaire and patient report. The single limb stance test (SLST) served as a prognostic measure to determine fall risk. The foot-squeeze (SQU) and tuning fork test (TFT) were utilized as diagnostic tools for Morton’s neuroma and stress fracture, respectively.

The NPRS is a validated 11-point numerical pain intensity scale ranging from 0 to

10, with 0 indicating no pain, and 10 the most intense pain imaginable.14 The minimal detectable change with a 90% confidence interval (MDC90) is reported as a 3-point change in a population with LE dysfunction.15 The minimal clinically important

16,17 difference (MCID95) is a 1-to 2-point change in patients with musculoskeletal pain.

Since the MDC is greater than the MCID, an improvement of 3 points would be necessary to indicate actual change has occurred not due to an error in measurement.

The standard universal goniometer is a common and valid tool to measure joint

ROM.18 A reliability study of active ankle ROM in individuals with orthopedic disorders

19 provided data to compute an MDC95 of 4 degrees for dorsiflexion. Goniometry has been

7 shown to have good intratester reliability of MTPJ measurements with an Intraclass

Correlation Coefficient (ICC) of 0.91-0.99.20,21 Due to limited psychometrics for MTPJ measurements, a 5 degree-change in MTPJ motion was chosen to avoid measurement error.

The MMT is a reliable and valid procedure used to assess muscular strength.22

The clinician grades muscle strength based on a 6-point ordinal scale where 0 of 5 indicates no contraction, and 5 of 5 indicates normal strength. An article review concluded an improvement of at least 1 full grade must occur to reflect a true change.22

The SLST examines static balance by assessing the length of time (in seconds) an individual can balance on one leg. Excellent inter-rater reliability (ICC = 0.994) has been demonstrated in healthy individuals with a normative value of 41.5 seconds in the 50-59

23 age group. Bohannon reported an MDC95 of 8.3 to 11.6 seconds in lower functioning community-dwelling older females, whose SLST was less than 20 seconds.24 The SLST has shown predictive value in determining injurious falls in older people who are unable to balance for more than 5 seconds.25 It was reported that subjects who were unable to balance on one leg had 2.1 times the risk of incurring an injurious fall.25 Calculated likelihood ratios (LR) are based on a sensitivity of 36% and specificity of 76% (LR+ =

1.50 and LR- = 0.84).25 Therefore, a score of 5 seconds or less, is indicative of a negligible shift in the post-test probability of having an injurious fall.

The LEFS is a validated self-report questionnaire that assesses an individual’s activity limitation due to LE musculoskeletal dysfunction.26 It consists of 20 items, each scored from 0-4, with 0 referring to having ‘extreme difficulty or unable to perform

8 activity’, and 4 indicating ‘no difficulty’ at all in performing the activity. The lowest score is 0, which corresponds with 100% disability, meaning lower scores reflect more

26 activity limitations. The MDC90 and the MCID₉₀ were reported as 9 points each, and were used for appropriate goal setting.

The 10 MWT is a performance measure of self-selected and maximum walking speeds over a short distance. Normative values for a healthy 54 year-old male for self-

24 selected and max speed are 1.39 m/s and 2.07 m/s. The best available MDC95 is 0.17 m/s in patients with hip fracture.27

The FAAM is a validated self-reported questionnaire used to determine physical function of individuals with musculoskeletal disorders of the lower leg, foot, and ankle.28

It consists of two subscales: an activity of daily living (ADL) and a sport subscale. The

28 MDC95 and MCID for the sports subscale are 12.3 and 9 points, respectively.

The SQU test is used as a diagnostic measure to rule in or out Morton’s neuroma pathology.29 The SQU test requires the clinician to compress the metatarsal heads from the sides of the involved foot with one hand. If squeezing the metatarsal heads elicits pain the test is considered to be positive.29 Based on reported pre-test probability of 34%, sensitivity of 41% and specificity of 0%, the positive and negative predictive values were

95% and 0%, respectively.29

The TFT was used as a diagnostic tool to screen for a fracture.30 A 128-Hz tuning fork is applied to the metatarsal head to determine the presence of a stress fracture. If localized pain is elicited by the tuning fork’s vibrations, the test is considered positive.

The reliability of the test to diagnose stress fractures has yet to be determined.31 Values

9 for diagnostic accuracy for stress fractures were reported as LR+ of 2.27 and LR- of 0.37 with a 95% CI.32,33 Given the study’s prevalence of 60 % and the LR+ value, a positive test would lead to a small shift in the post-test probability to 77%. The LR- value with a negative test result would lead to a small shift in the post-test probability to 36%.33

Table 2

Examination Data

BODY FUNCTION OR STRUCTURE Measurement Test/Measure Test/Measure Results Category Used Pain NPRS 3rd MTPJ Intermittent, variable pain: least pain = 0/10; average pain = 2/10 (aching); worst pain = 5/10 (throbbing) Active Range of Goniometry L ankle/foot: R ankle/foot: Motion DF = 0°- 10° DF= 0°- 15° PF = 0°- 28° PF = 0°- 40° Hallux MTP F = 10°- 0 - 2° Hallux MTP F = 0°- 16° Hallux MTP E = 10°- 34° Hallux MTP E = 0°- 38° 2nd MTP F = 0°-20° 2nd MTP F = 0°-25° 2nd MTP E = 0°-36° 2nd MTP E = 0°-55° Strength Manual Muscle L ankle and foot/hip: R ankle and foot/ hip: Test • TA= 5/5 • TA = 5/5 • TP = 5/5 • TP = 5/5 • FL = 4+/5 • FL = 5/5 • EHL = 4+/5 • EHL = 5/5 • FHL = 4-/5 • FHL = 5/5 • FHB = 2+/5 • FHB = 5/5 • EDL = 4+/5 • EDL = 5/5 • FDL= 4-/5 • FDL= 5/5 • FDB = 2+/5 • FDB= 5/5 • ABDH = 1/5 • ABDH = 5/5 • Glut max = 5/5 • Glut max = 5/5 • Glut med = 4+/5 • Glut med = 5/5 Static Balance SLST L leg: 12 seconds R leg: 30 seconds FUNCTIONAL ACTIVITY Measurement Test/Measure Test/Measure Results Category Used Functional Mobility LEFS Score: 46/80 (= 42.5% limited community ambulator) Walking Speed 10 Meter Walk • Self-Selected Walking • Max Walking Test Speed: 0.99 m/s Speed: 1.39 m/s PARTICIPATION RESTRICTIONS Measurement Test/Measure Test/Measure Results Category Used Exercise FAAM- Sports Score: 13/32 (= 59.4% restricted) subscale Participation in Patient Report Patient is limited in walking at work; can only tolerate about Social/Work Events 600 steps at work as measured by pt.’s Fitbit®. Abbreviations: L = left; R = right; MTP = metatarsophalangeal; NPRS = Numeric Pain Rating Scale; DF = dorsiflexion, PF = plantarflexion; F = flexion; E = extension; TA = tibialis anterior; TP = tibialis posterior; FL = fibularis longus; EHL = extensor hallucis longus; FHL = flexor hallucis longus; FHB = flexor hallucis brevis; EDL = extensor digitorum longus; FDL = flexor digitorum longus; FDB = flexor digitorum brevis; ABDH = abductor hallucis; Glut max = gluteus maximus; Glut med = gluteus medius; LEFS = Lower Extremity Functional Scale; SLST = single limb stance test; m/s = meter per seconds; FAAM = Foot and Ankle Ability Measure

Chapter 4 Evaluation

Evaluation Summary

The patient was a 54-year-old male who presented with minimal to moderate L third MTPJ pain and variable irritability, minimal to moderate loss of ankle and toes

ROM, moderate to severe weakness in his lower leg and intrinsic foot muscles, and moderate impairment in balance with standing on his L leg. He had limitations in his daily activities as exhibited by a compensated gait pattern and severely decreased walking speed. Patient reported being unable to run and having moderately reduced social outings. The SQU test and TF test were both negative, which contributed to ruling out the pathologies of Morton’s neuroma and stress fracture, respectively.

Diagnostic Impression

The patient’s medical diagnosis of metatarsalgia was supported by his clinical presentation of pain with walking and having an antalgic gait. The patient’s body structure and function impairment of L forefoot pain, limited ROM, weakness, and balance deficits contributed to activity limitations of decreased walking speed, and a reduced ability to perform ADLs. His limited ability to walk led to restrictions in participation in work and sport related events, social outings and recreational activities.

Prognostic Statement

The patient’s positive prognostic factors to regain mobility included: male gender, a high level of education, socioeconomic status, intact cognitive functioning, his motivation to return to running, and a supportive family.9 Negative prognostic factors

12 included: age, time since the onset of symptoms, wearing a cam boot for several months, having psoriasis34, and an adverse behavioral factor of currently leading a sedentary lifestyle. The prognosis for falls was improved by his SLS time which put him at low risk for injurious falls.25 The patient’s overall rehab potential to regain functional mobility was favorable based on his motivation and desire to return to previous activity levels.

G-Codes

Current with modifier: G8978 CK (based on LEFS Score 46/80; 42.5% impaired)

Goal with modifier: G8979 CJ (based on LEFS Score 55/80; 31.25% impaired)

Discharge Plan

The patient was to be discharged with a home exercise program (HEP) after 7 weeks of physical therapy intervention. He was educated on the importance of continued involvement in the HEP and he was encouraged to resume a regular running program, once he no longer felt pain with weight-bearing exercises. No modifications to his home or environment were needed.

Chapter 5

Plan of Care-Goals and Interventions

Table 3

Evaluation and Plan of Care

PLAN OF CARE Short Term Goals Long Term Goals Planned Interventions (4 weeks) (7 weeks) Interventions are Direct or Procedural unless they are marked: (C) = Coordination of care intervention PROBLEM (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS 3rd MTP Joint Decrease worst Decrease worst Interventions included manual therapy Pain pain during push- pain during push- techniques such as joint mobilizations, off to 3/10 off to 0/10 soft tissue manipulation. Mobilizations were progressed as pain diminished; NPRS: from grade II to grades III and IV, as MDC90: 3 points ROM increased. MCID95: 2 points (E) Ice was recommended to be included as part of HEP. • Distraction of 3rd MTP joint: 3x30 sec, grade III • Anterior and posterior accessory glides of 3rd MTP joint: 2-3x30 sec, grade II-III- Limited L Patient will Patient will Interventions included physiologic and Ankle/Foot demonstrate an demonstrate an accessory mobilizations, stretching, and Active Range increase in L ankle increase in L PNF exercises. of Motion and foot AROM to ankle and foot (E) Instruction in therapeutic stretching the values stated AROM to the exercises and HEP. below: values stated In prone: below: • Talocrural joint distraction: 3x30 sec, grade III DF 0° - 15° Maintain 15°, • Subtalar joint distraction: 3x30 MDC95 = 4° same as R side sec, grade III • AP glide of talus: 3x30 sec, Hallux MTPJ Maintain 17°, grade III F 10° - 0° - 7° same as R side • Physiologic DF mobilization: 3x30 sec, grade III Hallux MTPJ 10° - 48°, same as In supine: E 10°- 41° R side • Distraction of 2nd MTPJ: 3x 30 sec, grade III nd 2 MTP 0° - 55°, same as • AP glides of 1st, 2nd, 3rd MTPJs: E 0° - 44° R side 3x 30 sec, grade III, grade II for 3rd MTPJ

• PA glides of 1st, 2nd, 3rd MTPJs: 3x 30 sec, grade III, grade II for 3rd MTPJ • PNF: contract-relax 6x5 sec • Long sitting DF towel stretch: 3x20 sec Progressed to: • Standing calf stretch w/straight knee against wall: 3x20 sec • Calf stretches off a stair, hold: 3x 20 sec Decreased L Patient will Patient will Interventions included therapeutic Ankle and Foot demonstrate an demonstrate an strength exercises, which were Muscle increase in L ankle increase in L progressed as pt. improved. Strength and foot strength: ankle, foot and (E) Instruction in therapeutic hip strength: strengthening exercises and HEP. Extensor hallucis For initial strength gain and motor longus/brevis = 5/5 control: • Towel crunch: 2-3 min. Flexor hallucis Flexor hallucis • Pencil curling: 2-3 min longus = 4+/5 longus = 5/5 • Isometric toe flexion: 6x5 sec • Long-sitting DF w/red Flexor hallucis Flexor hallucis TheraBand: 3x10 reps brevis = 3+/5 brevis = 5/5 • Long-sitting PF w/yellow TheraBand: 3x10 reps Progressed to: Flexor digitorum Flexor digitorum • Long-sitting DF/PF w/green longus = 4+/5 longus = 5/5 TheraBand: 3x10 reps

• Long-sitting hallux F/E w/red Flexor digitorum Flexor digitorum TheraBand: 3x10 reps brevis = 3+/5 brevis = 5/5 • Seated heel raises: 3x10 reps

• Heel walking: 2x15 feet

Progressed to:

• Bilateral calf raises in standing on blue foam mat: 3x10 reps; progress to unilateral calf raises • Heel walking: 2x20 feet; progressed in distance • Plank hold on blue foam pad: 1-3x10 sec; progressed to 2x 20 sec. Impaired Static Patient will be able Patient will be • SLST: on blue foam mat: 3x5 Balance on L to stand on L LE able to stand on L sec LE for 20 sec on even, LE for 30 sec on Progressed to: increase in time to match stable surface, w/o even, stable R, uninvolved LE. LOB surface, w/o LOB • Bridge on stability ball w/supported head and neck: 3x30 sec hold, progressed to 3x10 heel raises • Lunges: barefoot; 3x10 reps

ACTIVITY LIMITATIONS 42.5 % Patient will Patient will All above treatment interventions helped Impaired demonstrate demonstrate increase ability to perform functional Functional improved improved activities. Mobility (= functional mobility functional Additional interventions included patient limited w/an increased mobility w/an education (E) and HEP to regain community LEFS score of increased LEFS functional mobility. ambulator) 55/80 (independent score of 64/80 c. ambulator) (active c.ambulator) MDC95 = 9 pts. MDC95 = 9 pts. MCID90 = 9 pts. MCID90 = 9 pts. Severely Patient will Patient will Above stretches and Decreased increase self- increase self- strengthening exercises helped Walking Speed selected walking selected walking increase patient’s ability in speed by 0.20 m/s; speed by 0.20 force production for increased as measured by the m/s; as measured walking speed. 10MWT; MDC95 = by the 10MWT; Treadmill training at 1% 0.17 m/s. MDC95 = 0.17 incline; alternate walk and jog Patient will m/s. at self-selected speed. increase fast Patient will walking speed by increase fast 0.20 m/s; as walking speed by measured by the 0.20 m/s; as 10MWT: MDC95 = measured by the 0.17 m/s 10MWT: MDC95 = 0.17 m/s PARTICIPATION RESTRICTIONS 59.4% Impaired No short-term goal Patient will Interventions from body structure and in Participation improve function and activity addressed the in Exercise participation in patient’s goal to walk pain-free, which exercise as increased his ability to participate in measured by an athletic and recreational activities. increased score of 26/32 on FAAM Sport Subscale. (18.75%restricted) MDC95 = 12.3 pts. Moderately Patient will Patient will Interventions from body structure and Limited in improve walking improve walking function and activity addressed the Social/Work- tolerance to 1000 tolerance to 1500 patient’s goal to walk pain-free, which Related Events steps at work. steps at work. increased his ability to participate in social and work-related events. Abbreviations: MTP = metatarsophalangeal; DF = dorsiflexion; PF = plantarflexion; E = extension; F = flexion; PNF = proprioception neuromuscular facilitation; SLST = single limb stance test; LEFS = Lower Extremity Functional Scale; c. = community; FAAM = Foot and Ankle Ability Measure; MDC= minimal detectable change; MCID = minimal clinically important difference; pts. = points; LE = lower extremity; HEP = home exercise program; min. = minute; reps = repetitions; sec = seconds; m/s = meter per second; 10 MWT = 10 Meter Walk Test; HEP = home exercise program; L=left; R=right; w/o LOB = without loss of balance.

Plan of Care – Interventions See Table 3.

Overall Approach

The plan of care relied on an impairment-based approach consisting of multimodal interventions including manual therapy, therapeutic exercise, and treadmill training. More specifically, the treatment plan consisted of joint and soft tissue mobilization, manual stretching; therapeutic exercises focusing on strength, flexibility, and balance; patient education; and home exercise instruction. Due to the patient’s variable irritability and minimal to moderate severity level in experiencing pain with weight bearing, the initial treatment approach focused on joint mobilization such as MTP distraction and accessory mobilizations to modulate pain and to increase ROM.35

Therapeutic exercises such as stretching and strengthening were included from the start and progressed as the patient demonstrated increased ROM and strength. The patient was seen once to twice weekly for 60-minute treatment sessions for 10 visits over a period of

7 weeks. The plan of care and HEP were modified as appropriate.

PICO question

In patients with metatarsalgia (P), is manual therapy (I) more effective than a placebo intervention (C) for decreasing pain? (O)

A randomized clinical trial (RCT; evidence level: 1b)36 by Peterson et al. aimed to investigate the efficacy of ankle and foot manipulations compared to a placebo of ultrasound intervention in the treatment of primary metatarsalgia.37 Primary metatarsalgia was defined as generalized pain under the metatarsal heads of the forefoot.37 The subjects

17 were randomly assigned to the experiment group (Chiropractic Manipulative Therapy

(CMT); n = 20) or the control group (placebo of detuned ultrasound; n = 20). Both groups received treatments twice a week over a 4-week period. The authors gathered subjective data with the short-from McGill Pain Questionnaire, the NPRS-101, which ranges from

0-100; and the Foot Function Index. The 3 self-reported outcome measures were utilized at initial, 2nd, 3rd, and final visits. Objective data was collected with algometer measurements to obtain pain-pressure threshold and tolerance. The results showed there was a statistically significant difference in the scores for the NPRS in terms of worst pain at initial, 2nd, and 3rd visit, and statistically significant difference for least pain at the 2nd,

3rd, and final visit between the groups. There was no statistically significant difference for worst pain at final visit, and no statistically significant difference for least pain at initial visit. The CMT intra-group comparison for scores of worst pain of the NPRS-101 revealed statistically significant differences between treatment sessions, indicating improvements in pain between visits. In terms of least pain, no statistically significant difference was measured between sessions, however, statistically significant difference was seen from initial to final visit; indicating overall improvement from treatments.

The authors concluded that while the placebo group saw a statistically significant difference from initial to final visit, the overall improvement in decreasing pain was greater in the CMT group. The NPRS-101 scores for the CMT group for worst pain was at 20%, and 0% for least pain at final visit.

The findings of this RCT indicated manual therapy to be an effective intervention in the treatment of metatarsalgia when compared to a placebo of detuned ultrasound.

These results provided evidence that supported the implementation of manual therapy into the plan of care for this case study. The patient met the inclusion criteria of experiencing pain with active resistance to flexors or extensors, pain on palpation of the surrounding soft tissue, and being close in age to the average of 49.5 years.

Limitations of this study included: a small sample size, a lack of details describing exact intervention protocols, and no long-term follow-up to assess if forefoot pain resolved. Nevertheless, this study identified support for the use of manual therapy as an intervention for primary metatarsalgia. There is very limited interventional evidence available to guide treatment in patients with metatarsalgia symptoms.

Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up (DC) Change Goal Measure Met? (Y/N) NPRS Worst Pain: 5/10 Worst Pain: 0/10 -5 Y MDC90 = 3 pts. MCID95 = 1-2 pts. Goniometry- DF: NWB 0°-10° DF: NWB 0°-18° + 8° Y L ankle and toes Hallux MTP F = 10°- 0 - 2° Hallux MTP F = 0°- 18° + 6° Y

Hallux MTP E = 10°- 34° Hallux MTP E: 0°- 36° + 12° Y

2nd MTP E: 0°- 36° 2nd MTP E: 0°- 54° + 18° Y MDC95 = 4° DF *MTPJ: 5° MMT-L LE Fibularis Longus = 4+/5 Fibularis Longus = 5/5 + ½ grade Y

Extensor Hallucis Extensor Hallucis Longus/Brevis = 4+/5 Longus/Brevis = 5/5 + ½ grade Y

Flexor Hallucis Longus Flexor Hallucis Longus = 4-/5 = 4+/5 + 1 grade Y

Flexor Hallucis Brevis Flexor Hallucis Brevis = 2+/5 = 4+/5 + 3 grades** Y

Extensor Digitorum Extensor Digitorum Longus/Brevis = 4+/5 Longus/Brevis = 5/5 + ½ grade Y

Flexor Digitorum Flexor Digitorum Longus = 4-/5 Longus = 4+/5 + 1 grade Y

Flexor Digitorum Flexor Digitorum Brevis = 2+/5 Brevis = 4+/5 + 3 grades Y

Gluteus Medius = 4+/5 Gluteus Medius = 5/5 + ½ grade MDC ≥ 1 grade Y SLST on L 12 sec on stable surface 32 sec on stable surface + 20 sec Y LE MDC95 = 8.3 -11.6 sec

ACTIVITY LIMITATIONS Outcome Initial Follow-up (DC) Change Goal Measure Met? (Y/N) LEFS Score = 46/80 Score = 64/80 + 18 pts. Y 42.5% (limited community 20% (active community MDC90 = 9 pts. ambulator) ambulator) MCID90 = 9 pts. 10 MWT Self-selected speed: Self-selected speed: Self-selected speed: • 0.99 m/s • 1.29 m/s • Increased 0.30 m/s N Max speed: Max speed: Max speed: • 1.39 m/s • 2.35 m/s • Increased 0.96 m/s Y

MDC95 = 0.17 m/s PARTICIPATION RESTRICTIONS Outcome Initial Follow-up (DC) Change Goal Measure Met? (Y/N) FAAM Sport Score = 13/32 Score = 18/32 + 5 points N Subscale 59.4% 43.75% MDC95 = 12.3 pts. MCID = 9 pts. Social/Work- Limited ability to Able to walk 15000 14400 steps Y Related participate socially and at steps at State Fair Events work events NPRS = Numerical Pain Rating Scale; MMT = Manual Muscle Test; LE = lower extremity; SLST = Single limb stance test; LEFS = Lower Extremity Functional Scale; 10 MWT = 10 Meter Walk Test; FAAM = Foot and Ankle Ability Measure; NWB = non-weight bearing; L = left; sec = seconds; MTP: metatarsophalangeal; DF = dorsiflexion; E = extension; F = flexion; min = minute; MDC = Minimal Detectable Change; MCID = Minimal Clinical Important Difference; pts. = points; m/s = meter per seconds; Y = Yes; N = No; * = 5 degree of change not based on an MDC or MCID; .≥ = greater and equal than; ** = 1 grade change consists of 2 x ½ grades; example: from 2+/5 to 3/5.

Discharge Statement:

The patient was seen for L foot metatarsalgia in an outpatient pro bono clinic 1 to

2 times a week for 10 visits over a two-month period. At initial examination the patient complained of pain, exhibited an antalgic gait, had decreased strength and ROM, impaired balance, and reduced gait speed. The plan of care included interventions of joint and soft tissue mobilizations, therapeutic exercises, modality application, functional activity exercises, treadmill training, patient education and a HEP. During the episode of care, the patient achieved goals associated with decreased pain, increased ROM, strength,

& balance, improved functional activities, walking, and he was able to resume some of his favorite recreational activities such as jogging. At discharge, the patient’s forefoot pain was eliminated and thereby reaching his goal, and, exceeding the MDC90 of 3 points.

His ankle and foot strength improved, as did his ROM. With these gains he was able to increase his gait speed to match normative values for healthy males in the age range of

50-59 year-olds of 1.38 m/s.38 His LEFS score improved from 46 to 64 points, indicating he changed from a limited community ambulator to an active community ambulator.39

Even though he did not reach the FAAM sport subscale MDC95 of 12.3 points within 7 weeks of physical therapy, he did improve his score by almost 16% as indicated by his ability to jog, and his report of being able to participate in 4 hours of walking at the State

Fair. Patient was discharged with a home exercise program.

DC G-Code with modifier:

G 8980 CJ (based on LEFS Score 64/80; 20% impaired)

Chapter 7 Discussion

The management of this patient with metatarsalgia was conducted based on identified impairments, the patient’s goals, and best available evidence. This resulted in the patient regaining his functional ability and improvements in life participation. While metatarsalgia encompasses all forefoot pain, a thorough examination is essential to identify impairments and to differentiate between possible diagnoses, and for potential referral. Therefore, any individual with forefoot pain needs to be examined carefully.

The patient responded well to manual therapy techniques as measured by increased ROM, and by the patient’s ability to walk pain-free. However, due to the patient’s capricious irritability, he required about half of his visits to gain lasting benefits.

His rehabilitation process was therefore slower due to setbacks of recurrent inflammation, him being overzealous, and due to an episode of a colitis flare-up. Even though the medical treatment for the patient’s colitis and psoriasis flare-ups with glucocorticosteroids could have indirectly supported the healing process, he did not progress as quickly as expected with an orthopedic injury.

The patient acknowledged the patient-centered care he received, which contributed to a successful episode of care; he improved and regained functional mobility over the course of 10 physical therapy visits. Nevertheless, I wish I had done things differently, such as being unbiased before meeting the patient for the first time. Based on the knowledge I had about this patient, I assumed he was going to be using a scooter and wearing a boot. Instead, the patient arrived at the initial encounter walking extremely

23 slowly with an antalgic gait pattern. This resulted in being unprepared for testing his walking speed at the initial encounter. He remarkably improved his gait speed after his first visit, and therefore the 10 MWT did not accurately reflect his initial limitation.

While the change in gait speed was the most noticeable gain he demonstrated, he further improved throughout the course of care. The examination could have been more efficient with more competent goniometric measurements. The evaluation could have been more accurate with the use of a more appropriate prognostic measure, such as the validated dynamic Star Excursion Balance Test (SEBT). Even though the SLS test was challenging for my patient, the SEBT could have provided predictive data for returning to sport.

The experience and knowledge gained from this patient case will improve future care of patients with similar presentation. While this patient was atypical in the sense that wearing a cam boot for 4 months did not improve his condition, his clinical presentation of forefoot pain accompanied by decreased ankle ROM and strength was typical. The diagnostic tests used were appropriate and can be applied to similar patients. However, the use of the Thumb index finger squeeze test is recommended due to better diagnostic accuracy of Morton’s neuroma than the SQU test. The outcome measures used in this patient case are appropriate for patients with similar pathologic conditions. The interventions utilized were appropriate, even if the evidence for metatarsalgia is sparse to support it. While evidence has shown that joint mobilizations are effective in treating pain and ROM, better evidence could have provided more applicable prognostic data to guide treatment expectation. The patient care could have been improved by providing overall more efficient care and by emphasizing the importance of not overdoing it.

References

1. Thomas MJ, Roddy E, Zhang W, Menz HB, Hannan MT, Peat GM. The

population prevalence of foot and ankle pain in middle and old age: a systematic

review. Pain. 2011;152(12):2870-2880.

2. Dufour AB, Broe KE, Nguyen USD, et al. Foot pain: is current or past shoewear a

factor? Arthritis Care & Research. 2009;61(10):1352-1358.

3. Bardelli M, Turelli L, Scoccianti G. Definition and classification of metatarsalgia.

Foot and ankle surgery. 2003;9(2):79-85.

4. Barlow-Kearsley E, Calfas M, Donson L. CRITICAL REVIEW: The assessment

and treatment of lesser/central metatarsalgia. Podiatry Now. 2011;14(7).

5. Besse J-L. Metatarsalgia. Orthopaedics & Traumatology: Surgery & Research.

2017;103(1):S29-S39.

6. Federer AE, Tainter DM, Adams SB, Schweitzer KM. Conservative Management

of Metatarsalgia and Lesser Toe Deformities. Foot and ankle clinics. 2017.

7. Hawke F, Burns J. Understanding the nature and mechanism of foot pain. Journal

of foot and ankle research. 2009;2(1):1.

8. Neely FG. Biomechanical risk factors for exercise-related lower limb injuries.

Sports medicine. 1998;26(6):395-413.

9. Menz HB. Chronic foot pain in older people. Maturitas. 2016;91:110-114.

10. Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and

rehabilitation of stress fractures in the lower extremity in runners. Open access

journal of sports medicine. 2015;6:87.

11. Bielak KM, Pinn TM. Metatarsalgia. In: The 5-Minute Clinical Consult Standard

2016: Twenty Fourth Edition. Wolters Kluwer Health Adis (ESP); 2015.

12. National Library of Medicine (U.S.), National Institutes of Health (U.S.).

MedlinePlus : trusted health information for you. 1998; Web site. Available at:

https://medlineplus.gov/druginfo/meds/a601102.html. Accessed July 19, 2018.

13. Organization WH. International Classification of Functioning, Disability and

Health: ICF. 2001; http://www.who.int/classifications/icf/en/. Accessed 02/16,

2018.

14. Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered

numerical rating scale of acute pain for use in the emergency department.

Academic Emergency Medicine. 2003;10(4):390-392.

15. Stratford PW, Spadoni G. FEATURE ARTICLES-The reliability, consistency,

and clinical application of a numeric pain rating scale. Physiotherapy Canada.

2001;53(2):88-91.

16. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically

important changes in chronic musculoskeletal pain intensity measured on a

numerical rating scale. European journal of pain. 2004;8(4):283-291.

17. Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance

of changes in chronic pain intensity measured on an 11-point numerical pain

rating scale. Pain. 2001;94(2):149-158.

18. Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of

goniometry emphasizing reliability and validity. Physical therapy.

1987;67(12):1867-1872.

19. Youdas JW, Bogard CL, Suman VJ. Reliability of goniometric measurements and

visual estimates of ankle joint active range of motion obtained in a clinical setting.

Archives of physical medicine and rehabilitation. 1993;74(10):1113-1118.

20. Hopson M, McPoil T, Cornwall M. Motion of the first metatarsophalangeal joint.

Reliability and validity of four measurement techniques. Journal of the American

Podiatric Medical Association. 1995;85(4):198.

21. McPoil TG, Cornwall MW. The relationship between static lower extremity

measurements and rearfoot motion during walking. Journal of Orthopaedic &

Sports Physical Therapy. 1996;24(5):309-314.

22. Cuthbert SC, Goodheart GJ. On the reliability and validity of manual muscle

testing: a literature review. Chiropractic & osteopathy. 2007;15(1):4.

23. Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the

unipedal stance test with eyes open and closed. Journal of geriatric physical

therapy. 2007;30(1):8-15.

24. Bohannon RW. Responsiveness of the single-limb stance test. Gait & posture.

2012;35(1):173.

25. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ.

One‐leg balance is an important predictor of injurious falls in older persons.

Journal of the American Geriatrics Society. 1997;45(6):735-738.

26. Binkley JM, Stratford PW, Lott SA, Riddle DL, Network NAORR. The Lower

Extremity Functional Scale (LEFS): scale development, measurement properties,

and clinical application. Physical therapy. 1999;79(4):371-383.

27. Latham NK, Mehta V, Nguyen AM, et al. Performance-based or self-report

measures of physical function: which should be used in clinical trials of hip

fracture patients? Archives of physical medicine and rehabilitation.

2008;89(11):2146-2155.

28. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Swearingen JMV. Evidence of

validity for the Foot and Ankle Ability Measure (FAAM). Foot & Ankle

International. 2005;26(11):968-983.

29. Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic accuracy of clinical

tests for Morton's neuroma compared with ultrasonography. The Journal of Foot

and Ankle Surgery. 2015;54(4):549-553.

30. Mungunthan K, Doust J, Kurz B, Glasziou P. Is there sufficient evidence for

tuning fork tests in diagnosing fractures? BMJ Open. 2014.

31. Muller M. The comprehensive classification of fractures of long bones. Manual of

internal fixation. 1991:118-149.

32. Toney CM, Games KE, Winkelmann ZK, Eberman LE. Using tuning-fork tests in

diagnosing fractures. Journal of athletic training. 2016;51(6):498-499.

33. Lesho EP. Can tuning forks replace bone scans for identification of tibial stress

fractures? Military medicine. 1997;162(12):802-803.

34. Lewinson RT, Vallerand IA, Parsons LM, et al. Psoriasis and the risk of foot and

ankle tendinopathy or enthesopathy in the absence of psoriatic arthritis: a

population-based study. RMD open. 2018;4(1):e000668.

35. Do Moon G, Lim JY, Da YK, Kim TH. Comparison of Maitland and Kaltenborn

mobilization techniques for improving shoulder pain and range of motion in

frozen shoulders. Journal of physical therapy science. 2015;27(5):1391-1395.

36. Howick J, Chalmers I, Glasziou P, et al. OCEBM Levels of Evidence Working

Group. The Oxford 2011 levels of evidence 2011;

https://www.cebm.net/index.aspx?o=5653. Accessed 09/06, 2018.

37. Petersen S BJ, Kretzmann H. The efficacy of chiropractic adjustment in the

treatment of primary metatarsalgia. Euro J Chiropr. 2003;49:267-279.

38. Bohannon RW, Andrews AW, Thomas MW. Walking speed: reference values

and correlates for older adults. Journal of Orthopaedic & Sports Physical

Therapy. 1996;24(2):86-90.

39. Wang Y-C, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of a

lower-extremity functional scale–derived computerized adaptive test. Physical

therapy. 2009;89(9):957-968.