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which conservative treatment for taylo'r bunion?

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Whats hurting ?

joint on motion
Shoewear pressure

Depends on where the pain is coming from.

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Mike Weber.



Crazy Mary

Related threads:
Other threads tagged with tailors bunion

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Fifth head pain and swelling.
Especially to prevent several bunion deformity

As Mike said: ie is the pain from shoewear pressure or is the pain on joint motion.

Perhaps read this: Presenting Patients for Clinical Advice

pain in shoewear especially

If there's enough room, you can glue a skived piece of 4mm felt into the shoe alongside the fifth metatarsal shaft but not beside the bunion itself. Keep it forward of the base of the 5th met as well. This holds the inflamed joint away from the shoe.

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If the problem is pressure from shoewear, accommodating the bunion with the right type of footwear will help. This is not always easy from the patient to find themselves.

Footwear manufacturers such as Klaveness ( http://www.klaveness.co.uk )can change the side panels of the shoe below to be stretch leather(or neoprene if more relief is required) to accommodate the bunionette. Keeps the shoe looking quite slim rather than a fully accommodative shoe. Apologies for the poor artwork

If you need any information, Winston Johnson who heads up Klaveness in the UK is always very helpful. Other orthopaedic footwear manufacturers can do the same. Their products just don't look as nice.

Hope this helps

Robin

Attached Images

Bunionette Panel.jpg (56.9 KB, 130 views)

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The top three images on this page also have neoprene over the offending area

http://www.mendivil.com/podiabet_se%F1ora_ing.htm

These are good because they are stock shoes so are quick and relatively speaking quite cheap

Robin

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I find that abduction of the fifth ray leading to the taylors bunion is commonly associated with a plantarflexed forefoot or fifth ray which in a relatively flat shoe has to be accommodated by abduction. Ensuring the shoe style has a small heel should reduce some of this abductory stress. Cheers

You might want to check for functional hallux limitus, and make the appropriate accomodation.

Are you sure Cam

Are you really sure Cam care to explain the mechanical reasioning for your statement.

Dont see it myself.

How does increased dorsiflexion stiffness at the 1st cause a tailors bunion at the 5th?

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Mike Weber.



Crazy Mary

some info re tailors bunion ( I always thought it was taylors - Ive learnt something)

A Review of Tailor's Bunion Curtain Uni old Pod dept

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Mike Weber.



Crazy Mary

If there is increased stiffness at the 1st MPJ, the resulting compensation can be a moment of supination at toe-off, resulting in increased pressure on met heads 2-5. We find the Cluffy Wedge to be helpful for many complaining with pain associated with Tailor's bunions, but probably any other accommodation for functional hallux limitus (1st ray cut-out, hallux pad, etc.) might also be helpful.

Re; Cam reply
Surely FHL is an associated deformity of plantarflexed forefoot or plantarflexed Fifth ray. This is a case of chicken or the egg?

What is the most likely cause of increase dorsiflexion stiffness at the 1st mtpj ?

What changes in jt position of the joints of the foot causes the answer to the above to occur?

What does a cluffy wedge help with ie what mechanism ?

What type of moment at the stj will usually occur ( depening on the stj axis position) when the above mechanism occurs ?

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Mike Weber.



Crazy Mary

Anytime the first ray becomes mobile enough to allow the medial collateral ligament to be placed on an obliquity to the ground,, such that the ligament now serves as a tension band to prevent DF of the 1st MTPJ, you will get stiffness of the 1st MTPJ. Pronatory forces on the medial column will over time, elevate the first ray if the foot is functioning in an unstable position in propulsion, due to a failure to engage the windlass mechanism.

This stiffness, as correctly stated by Cam, will result in lateralization of forces to avoid progress moving forward, in some individuals. This is one of several methods of compensation. In those that compensate this way, bunionettes will be developed as lateral column instability (failure to engage the windlass mechanism) will result in a bunionette formation, and continued lateral column overload will result in symptoms.

Addressing the stiffness of the 1st MTPJ is paramount to addressing this entity sucessfully. Applying a slight dorsal displacement to the toe overcomes the oblique orientation to the collateral ligaments and allows unrestricted motion of the 1st MTPJ. Once this is overcome, gait can be normalized and the windlass mechanism can stabilize the foot.

I just don´t see it.

1st I assume since I am guessing your nickname is Cluffy we have the Cluffy wedge. ( Just as if it was Jimmy we would be discussing the Jimmy wedge) - Could be wrong about the nickname thing, but of course you maybe a little Biased re cluffy wedge.

A Functional Hallux Limitus or increased dorsiflexion stiffness at the 1st will most likely come about from increased tension in the plantar fascia, increased tension in the plantar fascia tension can come from many reason including increased tension in the Achilles tendon and Subtalar joint pronation. So why people are compensating for an increased dorsiflexion at the 1st with late stance supination does not make sense to me.

What does make sense to is that the body is finally able to overcome the increased dorsiflexion stiffness of the 1st and engage the windlass mechanism at the 1st MTPJ . ie a delayed windlass.

So pre-loading the Hallux in a dorsiflexed position ie the Cluffy wedge will enable the windlass to engage easier - I agree here , but this will then enable the CoP to progress distally and in most into a more lateral position on the forefoot.

How this helps a tailors bunion I´m really not sure.

The reason I´m not sure is that we have a definitive reason for the formation of a tailors bunion.

I would say that

- lateral pressure on the 5th toe would be the most likely - ie shoewear combined with ligament laxity and unstable joint construction.

- Soft tissue attachments which pull the toe into a tailor bunion position would the other one.

- Ground reaction force which push the 5th into a tailors bunion position would be the other.

When we pre-load the hallux and engage the windlass mechanism at the 1st MTPJ we most likely get some inversion of the forefoot, so we will increase the lateral push from the shoe and change the position of the GRF acting on the 5th to a more lateral position - which may lead to greater deformity.

We also have the anatomy of the plantar fascia with the medial band attaching to the 1st.

Does reducing tension in the medial band increase tension in the rest of the Fascia, if it does and the attachment causes the tailors bunion deformity then again by pre-loading the hallux we have added to the problem.

For these reading who want some reading re the fascia see below.

Plantar aponeurosis and internal architecture of the ball of the foot*
FINN BOJSEN-M0LLER AND K. E. FLAGSTAD

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Mike Weber.



Crazy Mary

Regarding footwear to accomodate painful bunions please have a look at http://www.meanfeet.co.uk

The site features the Austian comfort brand Fidelio 's range of bunion shoes and sandals which have a soft pouch incorporated into the design at exactly the area where the bunion sticks out. This design helps alleviate pain and pressure and also improves the look of the foot radically, reducing the visible "bulge". Please take a look and tell us what you think. We are recommended and endorsed by a large number of podiatrists who either stock our brand or refer their patients to us directly as we really do seem to provide a great solution for painful bunions. Please contact us for a brochure if you are interested.
Thanks, Meanfeet

Good product - we've discussed it on this forum before.

However, the OP was requesting information on a Tailors bunion - 5th MPJ. Can the hallux range have a lateral pocket?

Robin

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I do not believe that I have ever referred to the Cluffy Wedge in my posts. I refer to pre-stressing the hallux in dorsiflexion, as I am not trying to build the Cluffy Wedge brand with these posts, but to contribute to an educational forum. I am indeed biased about the Cluffy Wedge, as I have considerable clinical experience with this device and have seen the tremendous clinical outcomes that one can achieve with this. (The Cluffy Wedge has been developed to provide the correct size, elevation and durometer of material to provide the optimal correction for different body weights, and is cosmetically pleasing for application in open toed shoes.) Functional stiffness of the big toe joint is probably the most under-appreciated clinical entity that I see based on my independent research that I plan to publish shortly. I think this is responsible for the greatest array of clinical pathologies we see in the foot.

What information are you relying on to state that FHL is the result of increased tension in the plantar fascia? I am not familiar with this hypothesis, but on the surface I would tend to disagree. I think the opposite is more likely true, that functional stiffness of the first MTPJ will likely result in tightness of the plantar fascia. My work in surgery has shown that stabilization of the medial column or sectioning of the medial collateral ligament will eliminate functional stiffness of the first MTPJ. I have no experience with sectioning of the plantar fascia ,as I never need to do this in isolation.

My clinical experience is in line with this video which shows premature loading of the lateral forefoot with FHL, and improvement in this pathology with the use of a wedge to elevate the hallux. http://www.youtube.com/profile?user=...11/MxK5YH9SylM
Ongoing research is also showing increased pressures under mets 2-5 with FHL, which is reduced with increased loading of the first met. with a wedge under the hallux. This research project has not yet concluded.
Lateral overload of the forefoot is clearly a compensatory strategy for a stiff first MTPJ. As you mention, overload of the fifth ray is a mechanism for developing a tailors bunion. This is consistent with the co-morbidity of FHL and tailors bunions, which is high. If you read my research article in JAPMA, The Etiology of Hallux Valgus Clough,J; Marshall, H. Journal of the American Pod Med Association, 75, 238-244, 1985., my conclusion on the etiology of bunions at the time was that shoe gear was not the cause of this deformity. I would suggest the same is true with bunionettes.
In my clinical experience, which, by the way, is the way most of us make our clinical decisions, I have seen some people with functional stiffness of the first MTPJ have a delay in the engagement of the windlass mechanism, and some do not engage this at all. It depends on the compensatory strategies employed.
When you engage the windlass mechanism by dorsiflexing the hallux, the first met. will plantarflex, not dorsiflex. This reduces the inverted forefoot position and will result in a more lateral transfer of weight after heel lift and into propulsion. This lateral forefoot load occurs as the foot stabilizes into the close-packed position obtained by dorsiflexing the hallux, as described in this study. Bojsen-Moller, F.: Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J. Anat. 129: 165, 1979.
Loading of the forefoot prematurely as with a stiff first MTPJ will result in forefoot deformity as the foot is not stable at this time.
Do a simple test to convince yourself this is correct. Preload the hallux with a wedge, and have your patient take a longer stride length and walk faster. They will engage the windlass, the first met will plantarflex and the pressures will almost immediately be reduced on the lateral forefoot, as reported by your patients. See this article: Clough, J.G.: Functional Hallux Limitus and Lesser Metatarsal Overload. JAPMA 95: 593, 2005.
I have treated a number of bunionettes successfully in the same way. I believe many lateral foot complaints are rooted in stiffness of the first MTPJ. Anyone interested in a study on this? My results would be viewed with too much bias.

I was just pointing out who you are, it not a negative but just as if you produced a paper re the cluffy wedge you would have to declare bias it not a negative

I would have thought the best way to optimize the size of the cluffy wedge it would be more important to look at dorsiflexion stiffness as well.

Sagittal plane progression is an important factor is understanding gait I agree. Maybe it is in the States but the windlass mechancism is very important in my discussions with Pods, but maybe that based to much on Podiatry Arena.


Hopefully soon there will be some more evidence but here some threads where it has been discussed, with some references. And Eric Fullers paper on the windlass mechanism.

Does Arch Flattening Cause Functional Hallux Limitus or Vice Versa?

The windlass mechanism of the foot. A mechanical model to explain pathology

Functional Hallux Limitus

I leave it there but there is evidence. There has been many cause or result discussions. I believe that dorsiflexion stiffness occurs from increased tension in the plantarfascia not the other way around.

Try increasing tension in the Achilles tenson and see what happens to dorsiflexion stiffness on the 1st MTPJ -

Also try pronating the foot and see what happens to dorsiflexion stiffness of the 1st MTPJ - it goes up right, many things have changed when we increase the tension of the tendon and pronate the STJ, especially tension in the plantarfascia.


If the CoP is lateral there will be a pronation moment at the STJ axis - pronation - lowering of the arch - increased tension of the plantarfascia- increased dorsiflexion stiffness of the 1st MTPJ.


I believe Shoe gear is 1 of the predisposing features of Hallux Valgus and Tailors Bunion so we will have to agree to disagree here.



I agree here due to the longer time and effort required to overcome the dorsiflexion stiffness of the 1st MTPJ to engage windlass at that Joint.


I´m not saying that windlass will not cause a more lateral transfer of CoP while it moves distially but -

See where this gets confusing.

1st you are saying that there is more lateral pressure with people who have increased dorsiflexion of the 1st MTPJ , but then go on to say that by preloading the Hallux to engage windlass you get - This reduces the inverted forefoot position and will result in a more lateral transfer of weight after heel lift and into propulsion..

Im not saying that when the windlass mechanism is engaged there mostly will be a lateral transfer of weight ( depending on the position of the STJ axis and MTJ axis) I agree and thats why I´m suggesting that it is not the most appropriate form of treatment of a tailors bunion to use a cluffy wedge.


1st if we take the Tailors Bunion - there needs to be a paper written re the aetiology - As I stated I can not find one, if we we discussing dorsiflexion stiffness and plantar fascia tension at the 5th MTPJ I might agree, but not at the 1st MTPJ as a cause

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Mike Weber.



Crazy Mary

Your evidence to explain FHL based on a tight plantar fascia is weak. How do you explain how this can be normalized with sectioning of the medial collateral ligament?

Quote:
//If the CoP is lateral there will be a pronation moment at the STJ axis - pronation - lowering of the arch - increased tension of the plantarfascia- increased dorsiflexion stiffness of the 1st MTPJ.//

I would agree with you on this FHL will not allow the foot to supinate properly in propulsion. This is because of a lack of plantarflexion of the first metatarsal head. Tension builds in the plantar fascia without movement of the first MTPJ and is a primary cause of Plantar Fasciitis.


Quote
// I believe Shoe gear is 1 of the predisposing features of Hallux Valgus and Tailors Bunion so we will have to agree to disagree here.//

There is no support in the literature for this. Why don’t all people with shoes have Bunionettes, and why do some patients with a history of use of poor shoes not have the pathology? Read some of the references in the article, particularly looking at the incidence of forefoot deformity in shoe wearing and non shoe wearing populations, they are the same. The shoe wearers are just more symptomatic.

About the lateral transfer of weight, the key here is that this occurs into propulsion and not before. This is the supination you need for stabilization of the foot structure in propulsion.

I will maintain that the Cluffy Wedge is indeed a very effective treatment for symptomatic tailors bunions with an FHL. I have used this frequently with success in clinical practice, some patients experiencing immediate relief of symptoms. It will not work if there is a varus heel from a variety of etiologies. In this case , the lateral overload is structural and not functional.

James I think we should just agree to disagree we can go around and around here.

Hopefully the evidence you require to re plantar fascia tension will start being seen more soon or soonish .

I beleive there are many reasons for a tailors bunion just as with Hallux Valgus pointy toed shoes will be one ,Davis law.

But like I said maybe it is best we agree to disagree.

Have a nice weekend.

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Mike Weber.



Crazy Mary

The evidence I have for this, and it happens in my own feet as well as many others, is that when you palpate the arch in a foot with functional hallux limitus you can feel the fascia is tight. When you attempt to dorsiflex the toe in stance, you can feel the fascia get tighter.

When you section the medial collateral ligament, how much dissection do you do before you get to it? In the cadaver work that I've done, I've increased dorsiflexion range of motion by cutting the plantar structures, which include the distal attachment of the plantar fascia at the base of the proximal phalanx. The medial collateral ligament of the 1st MPJ is not in position to limit dorsiflexion. To limit dorsiflexion you need a plantar flexion moment. The force couple from the proximal pull of the stuff attached to the sesamoids and the distal force from the metatarsal head create a force couple that creates a plantar flexion moment on the proximal phalanx. The medial collateral ligament is in line with the force from the metatarsal head and has no leverage to create that force couple. Well, the most plantar part of the collateral ligament might, but it does not have the leverage that the plantar structures do. (Pictures are in my paper that was linked in one of the above posts.)

Also, it's hard to believe that the metatarsal can evert enough to make the collateral ligament become plantar.


Mike, you have to be careful looking just looking at the location of center of pressure. One scenario is that to avoid high medial pressures, the person subconsciously chooses to increase posterior tibial activity to the point that there will be a lateral movement of the center of pressure. Yes, there will be a higher pronation moment from the ground, but that will be countered, or caused by, the supination moment from the PT tendon.

I believe that the reason that you see functional hallux limitus at the same time that you see lack of resupination is that there is a high pronation moment from the ground. Often, with STJ pronation, there will be high medial forefoot pressures. It's the high medial forefoot pressures that prevent the metatarsal from plantarflexing. In fact the high plantar pressures under the first met, cause a dorsiflexion moment of the metatarsal and the fascia gets tighter to keep the the met from dorsiflexing more.


There is support for increased incidence of bunions (HAV) with shoes. I beleive the author was named Stone, in the 1960's reported a population of the coast of England (genetically isoloated) where half the population wore shoes and half did not. Those that wore shoes got more bunions, but both groups got bunions. So, shoes are a factor, but not the only factor. People who do not wear shoes get bunions.


I believe that the Cluffy wedge might work. I disagree with some of your explanations of how it works.

Eric