Does the 1st ray complex have super powers? Perhaps Marvel should consider a new superhero “Ray”? We are not sure but here is a story that gets us one step closer to the answer.
While teaching a course this past weekend and doing a teaching case, we examined one of the participants who had high arches, a rigid rearfoot varus, internal tibial torsion, R > L, and foot pain R>L and a dorsal exostosis (growth of extra bone from stress at the base of her 1st metatarsal) where it articulated with the 1st cunieform on the right. No surprisingly, she also had a partially compensated forefoot supinatus on the right. She had increased wear on the lateral aspect of her shoes and a walking strategy which involved hiking the right side of the pelvis during stance phase on the left, and a pelvic shift to the right during stance phase on the right, as well as an inability to get the head of either 1st ray complex to the ground, R > L. It was also determined she had, not surprisingly, locking of the 1st metatarsal cunieform joint on the right and a loss of anterior and posterior shear at the superior tib fib articulation on the right, as well as hypomobility of the right sacoiliac joint. There was weakness of the abdominal external obliques bilaterally and posterior fibers of the left gluteus medius, along with the long toe extensors on the left and short toe flexors, a pattern that we often see clinically.
We then proceeded to treat her tib posterior, peroneus longus and flexor digitorum on the right, all of which have an effect on descending the 1st ray, along with the long extensors on the right, which would effectively raise the distal aspect of the 1st ray, but we thought may provide better eccentric control of the foot from initial contact to loading response, and again from the end of terminal stance and through swing phase. We then mobilized the 1st met cunieform articulation only. Ideally, we should have reassessed after we made EACH change, but due to time constraints, AFTER we had done ALL these things.
Rexamination had better 1st ray motion, restoration of tib fib motion and restoration of R sided SI mechanics. Her 1st ray descended much better, tib fib motion was normalized, L sided hip hiking strategy and R sided pelvic shift were greatly improved. For the 1st time in 10 years, the participant had no foot pain. Coincidence? Perhaps. Placebo? Maybe. You decide.
Sometimes, doing a little of the right thing can be a good thing. Sometimes we overdo. I have to admit, because I am a chiropractor, I would have started with manipulation 1st of all 3 articulations with a recheck immediately post treatment AND THEN treated the other dysfunctions. For those of you who are manual therapists, I am sure you see miraculous things happen when we cavitate joints and change their instantaneous axes of rotation. I can thank Dr Ted Carrick and my good friend and colleague, Dr Paul Chille, for teaching me that. The students, in this case, were driving the bus and I went along with it. I was surprised (though I shouldn’t have been) to see the pathomechanics resolve WITHOUT manipulation, but it got me thinking I should consider treating the muscular dysfunctions 1st, and then recheck and manipulate later. It makes sense that the receptor density of the lower extremity musculature has a much larger population of muscle mechanoreceptors, especially in the foot, since it has a greater cortical representation than the joint mechanoreceptors.
My students never cease to teach me something new...